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J. Obstet. Gynaecol. Res. Vol. 37, No. 9: 1203–1207, September 2011
Intraumbilical injection of three different uterotonics in the management of retained placenta
Rany Harara1, Sherif Hanafy1, Mahmoud Saad Alsayed Zidan2 and Medhat Alberry1,3
1 Ain-Shams University Maternity Hospital, Cairo and 2Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt; and 3Luton and Dunstable Hospital, NHS Foundation Trust, Luton, UK
Aim: The aim of this work was to compare the effect of intraumbilical injection of three different uterotonic solutions in the management of retained placenta. Materials and Methods: This study was conducted in Ain-Shams University Maternity Hospital, Cairo, Egypt. A total of 78 women with retained placenta (>30 min after delivery of the fetus) were included in the study and subdivided into three groups. Each group was injected with a different type of uterotonic into the umbilical vein after clamping it using the Pipingas technique. Uterotonics used were either 20 IU oxytocin dissolved in 30 mL saline (n = 26), ergometrine 0.2 mg dissolved in 30 mL saline (n = 27) or misoprostol 800 mg dissolved in 30 mL saline (n = 25). Results: The overall success rate of spontaneous placental separation within 30 min after intraumbilical injection of uterotonics was 56/78 (71.79%). The success rate was higher with misoprostol when compared to oxytocin and ergometrine but the difference was not signiﬁcant (20/25 [80%], 19/26 [73.08%], 17/27 [62.96%], respectively, P > 0.05). The injection-to-separation interval was signiﬁcantly shorter in the misoprostol group than in the oxytocin and ergometrine groups (7.0 Ϯ 2.2 min, 13.14 Ϯ 3.76 min, 22.5 Ϯ 4.37 min, respectively, P < 0.001). Conclusion: Intraumbilical injection of uterotonics, namely oxytocin, ergometrine and dissolved misoprostol in saline, are closely effective in the management of retained placenta, with misoprostol being slightly more effective. This method may have a role in minimizing the need for manual removal of the placenta and its adverse sequelae. Key words: obstetric complications, obstetrics diagnosis, placental pathology, post-partum care, post-partum hemorrhage.
Postpartum hemorrhage (PPH) is one of the most common causes of maternal mortality worldwide and remains as the commonest cause of maternal mortality in developing countries, including Egypt. The World Health Organization (WHO) estimated that 25% of 585 000 maternal deaths worldwide were due to severe peripartum hemorrhage, with a further 20 million mothers per year suffering signiﬁcant morbidity from this cause.1
The third stage of labor lasts 10–15 min on average, and is generally considered to be prolonged after 30 min. Even with active management of the third stage, about 3% of cases have a prolonged third stage of labor.2,3 Retained placenta may result from simply adherent placenta or various forms of morbidly adherent placenta, including placenta accreta, increta, or percreta. All forms of simply or morbidly adherent placenta have been observed in association with intrauterine adhesions, endometritis, previous uterine operations or abnormalities of the uterine cavity.3 Active management
Received: June 23 2010. Accepted: October 18 2010. Reprint request to: Mr Medhat Alberry, Luton and Dunstable Hospital, Luton LU4 0DZ, UK. Email: email@example.com
© 2011 The Authors Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology
the preparation of solutions under aseptic conditions and their injection only onto the umbilical cord makes transmission of infection to the mother unlikely.2 g (range: 1000– 4000 g).) after delivery of the anterior shoulder. hypertensive disorders with pregnancy. Results The mean age of included women was 23. and group III (n = 25) received misoprostol 800 mg dissolved in 30 mL saline. the catheter was retracted by 1–2 cm and then advanced as far as possible. manual removal of the placenta was performed. of the third stage of labor.4 Manual removal of retained placenta appears to be the management of choice for retained placenta. Gentle uterine massage is performed routinely after delivery of the fetus. The diagnosis of retained placenta was made when signs of spontaneous placental separation had not occurred within 30 min after delivery of the fetus. anova was used to compare the means of the three groups. Misoprostol tablets were highly soluble in saline. median and interquartile range were used for non-parametric data. by injecting 5 IU of oxytocin or 0. mean and standard deviation were used as descriptive statistics for parametric data. Median parity was 1 (range: 0–4. Deliveries less than 20 weeks’ gestation. probably because of the lack of a large randomized controlled trial to determine which uterotonic to use and at what dosage. Range. Recent studies have shown that uterotonic agents administered via umbilical vein injection may be effective in management of retained placenta7 and a WHO publication even recommended this treatment as a ﬁrst line of treatment for retained placenta. despite administration of uterotonics (5 IU of oxytocin + 0. A total of 2512 women between 18 and 40 years of age were recruited into the study over a 12-month period (April 2008 to March 2009). When spontaneous separation of the placenta had not occurred within 25 min. it is associated with higher risk of endometritis. the solution for injection was prepared in the last 5 min. A size-10 nasogastric suction catheter was inserted along the umbilical vein.m. If placental separation spontaneously occurred in the last 5 min the solution was discarded. If spontaneous placental separation failed to occur within 30 min after injection. interquartile range: 0–2). Randomization was performed using a computergenerated randomization system. The prepared solution was then injected after clamping of the cord.8 Despite this recommendation. range.2 mg methyl ergometrine [ergometrine] i. The 78 included women were randomly divided into three groups: group I (n = 26) received 20 IU oxytocin in 30 mL saline. The primary outcome was the success of spontaneous separation or expulsion of the placenta.12 cm (range: 1204 © 2011 The Authors Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology .6 Oxytocin. has resulted in a signiﬁcant reduction in incidence of retained placenta and a signiﬁcant decrease of early and late post-partum hemorrhage and in total maternal peripartum morbidity and mortality. The mean catheter tip-to-placenta distance was 10. The mean cord length was 51. and prostaglandins are all capable of inducing sustained myometrial contractions. A total of 78 cases had a prolonged third stage of labor. The mean placental weight was 482 Ϯ 53. the method is yet to make its way into routine practice. In addition. hemorrhage and traumatic perforation of the uterine wall.7 cm (range: 45–55 cm).2 g (range: 280–550 g). Harara et al.8 The latest Cochrane Review concluded that ‘umbilical vein injection of saline solution plus oxytocin appears to be effective in the management of retained placenta’.43 Ϯ 3. Mean gestational age was 38. We used the Pipingas technique10 for injection of the uterotonics in the umbilical vein.3 weeks (range: 26–42 weeks). and vaginal birth after cesarean were excluded.23 Ϯ 438. before a diagnosis of retained placenta is made.2 mg methyl-ergometrine intramuscularly after shoulder delivery. Collected data were spread on an Excel sheet. ergometrine. group II (n = 27) received ergometrine 0.R. Patients’ characteristics are shown in Table 1. Statistical analysis was performed using spss. or signiﬁcant bleeding occurred. multiple pregnancies. The c2-test was used to compare the categorical data of the three groups.3 Ϯ 2.5 Effective medical treatment of the retained placenta is based on stimulating contraction of the underlying myometrium that has sufﬁcient strength to induce separation of the placenta.34 years (range: 18–35 years).23 Ϯ 2.2 mg in 30 mL saline. Misoprostol tablets are supplied in blister packs and whilst not sterile. The mean birthweight was 3020.3 The number of cases with successful placental separation in each group and the injection–separation time interval were recorded. However. it requires the use of either general or regional anesthesia. If resistance was felt.02 Ϯ 2.9 Methods This study was conducted at Ain-Shams University Maternity Hospital (18 000 deliveries/year).
2 min.05 NS >0.3 P* >0.8 1 (0–2) 1 (0–1) 32–41 39.1 280–550 477 Ϯ 84.2 350–550 473 Ϯ 73. None of the Figure 1 Difference between study groups concerning injection-to-spontaneous separation interval. while manual removal of the placenta was indicated in 22 (28.96%) Misoprostol group (n = 25) 20 (80%) P* >0. spontaneous placental separation occurred in 56 (71.37 min.05 NS *Analysis using one-way anova. Oxytocin group (n = 26) 19 (73.4 Ϯ 3.6 Ϯ 5.001 8–12 cm). Women in the misoprostol treatment group had the highest success rate compared to women in either the oxytocin or ergometrine groups (20/25 [80%]. NS.9 Ϯ 2.3 Ϯ 5.6 Syntocinon group (n = 26) 19–35 25.79%) women.96%]. Those parameters and the number of previous uterine evacuations or curettages in the three groups were not signiﬁcantly different.76 Ergometrine group (n = 17/27) mean Ϯ SD 22.2 P* Injection-to-spontaneous separation interval (min) *Analysis using anova.1 Misoprostol group (n = 25) 18–35 26. of women Spontaneous placental separation n (%) *Analysis using c2-test.3 350–550 495.14 Ϯ 3. SD.6 8–12 10 Ϯ 2.2 8–12 9. Table 2 Difference between study groups concerning successful spontaneous placental separation No. This difference was not statistically signiﬁcant.08%) Ergometrine group (n = 27) 17 (62. Data presented as range.37 Misoprostol group (n = 20/25) mean Ϯ SD 7. not signiﬁcant.21%) women.5 Ϯ 4.0 Ϯ 2.2 1000–4000 2990 Ϯ 996.1 Ϯ 3.001) as shown in Table 3 and Figure 1.05 Table 3 Difference between study groups concerning injection-to-separation interval Spontaneous placental separation Oxytocin group (n = 19/26) mean Ϯ SD 13. standard deviation.05 NS >0.Medical management of retained placenta Table 1 Difference between study groups concerning women’s characteristics Methergine group (n = 27) Age (years) Parity No.1 1 (0–3) 1 (0–2) 26–42 37.7 48–55 51.4 48–54 51. 13.0 Ϯ 2.05 NS >0. P < 0.7 9–12 10.05 NS >0. The mean injection-to-separation time interval was signiﬁcantly shorter in the misoprostol group compared to the oxytocin and ergometrine groups (7. respectively. Overall.9 Ϯ 2.1 1750–4000 3201 Ϯ 827.7 Ϯ 6. 19/26 [73. © 2011 The Authors Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology 1205 .5 Ϯ 54.5 Ϯ 4.2 Ϯ 2.8 45–55 50.2 Ϯ 2.05 NS >0. 22. <0.09 Ϯ 2. mean Ϯ standard deviation or median (range).05) (Table 2). of previous uterine curettages Gestational age (weeks) Fetal weight (g) Placental weight (g) Cord length (cm) Catheter tip to placenta (cm) 18–30 22.7 2200–3800 3520 Ϯ 484. respectively.2 1 (0–4) 1 (0–2) 32–42 38.0 Ϯ 4.4 Ϯ 2.05 NS >0.05 NS >0.76 min.08%]. P > 0. 17/27 [62.
ergometrine 0.10 to 76%. 15: 138–142. Practical recommendations for umbilical vein injection for management of retained placenta. Am J Obstet Gynecol 1995. Obstet Gynecol 1995. 114–119.9 Ergometrine was tested in a number of trials.14 This relatively wide range is probably related to the variable sample sizes. Several studies achieved a success rate of placental separation ranging between 77% and 100% using different types of prostaglandins. 5. namely oxytocin. Vol. trophoblastic or amniotic ﬂuid embolism. 2001. effective. Rijhsinghani A.4 The efﬁcacy of oxytocin was evident in a number of other trials. both dissolved in 20 mL saline (n = 8).CD001337. Purwar MB. There were no cases of maternal side-effects after administration of any of the three uterotonic agents.5 mg) on women with retained placenta was compared on a larger sample of 75 women. and of ergometrine to be 0/4 (0%). Discussion Manual removal of the placenta is associated with lacerations of the genital tract.10 The intraumbilical injection of uterotonics is a non-invasive. In 2001.3. Habek D. methergine and dissolved misoprostol saline. They found that the success rate with oxytocin injected intraumbilically was 41/54 (76.13 The effect of oxytocin. studied 31 women with retained placenta. 86: 48–54. uterine perforation. 7. Habek et al.2%). Franicevic D. with misoprostol being slightly more effective. 1206 © 2011 The Authors Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology .55%. Geneva: World Health Organization. Bowdler NC et al. Avoiding manual removal of placenta: Evaluation of intra-umbilical injection of uterotonics using the Pipingas technique for management of adherent placenta. 4. Bottoms SF. Int J Gynecol Obstet 2007. In: Gulmezoglu AM. and postpartum hemorrhage. They found the efﬁcacy of oxytocin to be 13/19 (68. 3. Acta Obstet Gynecol Scand 2007. Baschat AA. Ultrasound Obstet Gynecol 2000. comparing the efﬁcacy of oxytocin 20 IU (n = 19). Eur J Obstet Gynecol Reprod Biol 1996. Bider D. However.5%). and complications of general or regional anesthesia. of saline alone to be 1/8 (12. Intraumbilical vein injection of prostaglandin F2alpha in RP. such as oxytocin. methyl-ergometrine and possibly prostaglandins suspended in saline solution may provide a suitable alternative. surgical intervention remains an important line of management of retained placenta. and clinically safe method of shortening the third stage of labor in women with retained placentas. Gray scale and color Doppler sonography in the third stage of labor for avoiding manual removal of placenta 53 early detection of failed placental separation. 9. Geneva: World Health Organization. 172: 1279–1284. are comparable to our work. and that of carboprost tromethamine was 6/7 (85.7%). WHO. The association between manual removal of the placenta and postpartum endometritis following vaginal delivery. Krapp M. Obstetrics: Third stage of labor: Analysis of duration and clinical practice.12 This work showed that various intraumbilical injections of uterotonics (misoprostol 800 mg dissolved in 30 mL saline. References 1. This method causes potent uterine contractions.2 mg in 30 mL saline) were comparably effective in treating retained placenta. Dulitzky M. 86: 1002–1006.1002/14651858.4%). 64: 59–56.13 Intraumbilical injection of prostaglandins was also shown to be a promising technique in the management of retained placenta. showing a lower efﬁcacy compared to oxytocin. The WHO Reproductive Health Library. 2. included women had a morbidly adherent placenta or postpartum hemorrhage. Villar J (eds). The misoprostol group had a signiﬁcantly shorter mean injection-to-separation time interval compared to the other two groups. 8. to saline alone. Rhesus alloimmunization. Cochrane Database Syst Rev 2001.7 58. Rogers MS. 1996. seem to have close efﬁcacy in the management of retained placenta. 99: 105–109. This method may have a role in minimizing the need for manual removal of the placenta and its adverse sequelae. Misoprostol had a relatively higher success rate. Intraumbilical injection of uterotonics. Harara et al. 6. Goldenberg M et al. (4): CD001337.2 mg (n = 4). Wong S. Carroli and Bergel in a Cochrane systematic review of 12 trials showed that oxytocin has signiﬁcantly higher efﬁcacy when compared to saline alone. to some extent. Even the theoretical risk of closure of the uterine cervix and its subsequent entrapment of the placenta was not encountered in any of the included cases. The results of this study. Only one trial showed that ergometrine is not effective in treating retained placenta. Umbilical vein injection for management of retained placenta (Review).R. Dombrowski MP. the success rate of ergometrine was 9/14 (64. DOI: 10. Yuen PM.11 Intraumbilical injection of uterotonics. Revised 1990 Estimates of Maternal Mortality: A New Approach by WHO and UNICEF. Carroli G. Saleh AAA et al. with a range of efﬁcacy of 54. 4. ergometrine and synthetic prostaglandin (carboprost tromethamine 0. Morbidly adherent placentae are usually resistant to this line of management. Bergel E. Intraumbilical injection of uterotonics for retained placenta. Other complications include infections. resulting in the separation of the placenta.9%). More work looking into the costeffectiveness of its use will be required. Ely JW. oxytocin 20 IU in 30 mL saline and ergometrine 0.3%.7. Hankeln M et al.
Huber MGP. Umbilical vein administration of oxytocin for the manage- ment of retained placenta: Is it effective? Am J Obstet Gynecol 1991. Hofmeyr GJ. Mitri FF. Weeks A. 164: 1216–1219. 123: 415–417. Gulmezoglu AM. Habek D. Hrgovic Z. Removing a placenta by oxytocin: A controlled study. Treatment of a retained placenta with intraumbilical oxytocin injection. 161: 155–156. 71: 396–397. Nielsen MD. Wildschut HI. Strom V. Wilken-Jensen C. Mirembe FM. Kleiverda G. Eur J Obstet Gynecol Reprod Biol 2002. 14. Umbilical vein injection for retained placenta: Clinical feasibility study of a new technique. 11. 13. East Afr Med J 1994. Hoek FJ. 12. The retained placenta – new insights into an old problem. Rosenkilde-Gram B. 102: 109–110. Zentralbl Gynakol 2001. Am J Obstet Gynecol 1989. Boer K. Pipingas A. Delmis J. Ivanisevic M. © 2011 The Authors Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology 1207 .Medical management of retained placenta 10.
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