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Retained Placenta After Termination of Pregnancy Requiring Hysterotomy in a Patient with Large Uterine Fibroids
Abstract Number: RF7A10-298
Abstract Type: Case Report Case Series
Introduction: Retained placenta complicates 2-3% of vaginal deliveries, leading to an increased incidence of postpartum hemorrhage and endometritis. Abnormal uterine anatomy is a risk factor for retained placenta.
Case: A 40 year old G2P0 with multiple leiomyomata, and no other significant medical history, presented for induction of labor for termination of pregnancy at 16 weeks EGA for suspected Trisomy 21. Labor progressed unremarkably, however delivery of the fetus was complicated by retained placenta. Multiple maneuvers to deliver the placenta manually were unsuccessful as a ten centimeter cervical leiomyoma obscured access to the uterine cavity. Twenty-four hours after delivery, the patient was taken to the OR for ultrasound-guided dilation and extraction of the placenta via transcervical approach under general anesthesia. Neuromuscular blockade and a high end-tidal concentration of sevoflurane optimized pelvic floor and uterine relaxation. Unfortunately, the uterine cavity could not be accessed vaginally. Expectant management was continued with the placenta in situ until forty-eight hours after delivery when the patient developed fever, leukocytosis, and uterine tenderness concerning for endometritis and worsening anemia from ongoing vaginal bleeding. To avoid morbidity anticipated with a hysterectomy, and to accommodate the patient’s desire to preserve fertility, a transuterine suction curettage via mini laparotomy was planned. The patient was transferred to the main hospital and taken to the OR. In anticipation of significant hemorrhage and potential emergent hysterectomy, blood products were made available, and two large bore IVs were inserted after induction of general anesthesia with propofol, succinylcholine, and fentanyl. Because the patient was hemodynamically stable, a central venous catheter (CVC) was not placed, though equipment for CVC placement and vasoactive medications to manage septic shock were available. Broad spectrum antibiotics were continued intraoperatively. Fortunately, the placenta was evacuated uneventfully with minimal blood loss. Postoperatively, the patient was counseled extensively about her risk of serious morbidity with future pregnancies. The patient is considering a hysterectomy on an elective basis.
Discussion: This report describes a unique case of retained placenta due to mechanical obstruction from uterine leiomyomata. Despite optimization of pelvic floor and uterine relaxation with general anesthesia, the placenta could not be extracted via the cervix, and was ultimately removed via an uncommon transuterine approach. Though preparations were made to treat severe hemorrhage and septic shock, placental extraction via hysterotomy proceeded uneventfully and the patient’s postoperative course was uncomplicated.
1. Coviello EM. AJOG 2015;213:864.e1-11.
2. Bjurstrom J. Arch Gynecol Obstet 2018; 297:323-332.