Retained Placenta and Postpartum Hemorrhage

A report describes a case of a 32-year-old female, gravida 4 para 3, who presented at 39 weeks and four days for induction of labor. She reported three previous normal spontaneous vaginal deliveries (NSVD) and received a diagnosis of chronic hypertension during this pregnancy. She denied any history of abortion, miscarriage, or any other medical history, including complications in previous pregnancies or deliveries. She reported treatment for chlamydia in the remote past and documented screened positive for group B streptococcus (GBS) in the third trimester. 

The patient was admitted to labor and delivery for labor induction due to chronic hypertension and was started on penicillin for GBS treatment.

After Labor induction, she showed a normal labor curve, and after 13 hours of labor, she delivered via normal spontaneous vaginal delivery. After cutting the umbilical cord, the surgeons maintained gentle traction for 15 minutes to deliver the placenta; however, it did not deliver. Following delivery, the patient received IV oxytocin continuously. Traction for an additional 15 minutes caused only partial separation of the placenta from the uterine fundus. Moderate bleeding prompted manual delivery of the placenta after administering 4 mg of morphine, which also caused the removal of only two-thirds of the placenta, with the remaining third still adhered to the fundus. Given the severe hemorrhage risk, the patient consented to a suction curettage with a possible hysterectomy. 

The surgeons then inserted a 12 French curved suction curette gently into the fundus and used multiple passes of suction curette with ultrasound guidance to remove the retained products of conception. The patient received 800 mcg of rectal misoprostol, 50 units of IV oxytocin, 250 mcg of subcutaneous carboprost, and two IV doses of 1 g of tranexamic acid intra-operatively to control postpartum hemorrhage. Her vaginal bleeding significantly reduced after clearing the uterus from the placenta and products of conception and administering numerous intravenous uterotonics. 

The patient lost 1667 mL of blood and received three units of packed red blood cells (pRBCs), 1 unit of fresh frozen plasma (FFP), and 1 unit of platelets. The recovered placental pieces were sent to pathology for analysis. 

The patient showed stable condition with minimal vaginal bleeding or hemorrhage during the next two days post-surgery. The patient got discharged on the third day with her neonate, both in stable condition.

The fetal membranes of the placenta did not show any pathological features. It showed areas of umbilical vessel hemorrhage, likely due to umbilical cord traction during attempts to deliver the placenta. A diagnosis of the morbidly adherent placenta (specifically placenta accreta or increta) could not be made since the placenta came in several pieces, and it was impossible to find the placenta's adherence point to the fundus during microscopic analysis. Thus, the final diagnosis of retained placenta with multiple small infarcts less than 10% of the placental volume was made.

Lekuikeu LT, Moreland C. Retained Placenta and Postpartum Hemorrhage: A Case Report and Review of Literature. Cureus.2022; 14(4): e24389. doi:10.7759/cureus.24389