Placental Extraction Research Articles

Uterine Sacculation With Entrapped Placenta After Delivery.

Uterine sacculation refers to a temporary pouch or sac within the uterus that may contain the placenta or fetal parts and that may be diagnosed antepartum or after delivery. There is very limited published information about this rare condition and its management. We report two cases of uterine sacculation with entrapped placenta diagnosed immediately postpartum, managed with two different approaches. In one case, the patient underwent immediate laparotomy and placental extraction. In the second case, the patient was managed conservatively but ultimately developed signs of infection and underwent laparotomy. Uterine sacculation with entrapped placenta is a rare condition that is a potential etiology of retained placenta. Obstetric clinicians should be aware of this diagnosis and the management strategies available.

A comparison of the effect of placental extraction from exteriorized versus non-exteriorized uterus on blood loss during caesarean section in Nigerian women.

The purpose of this study was to determine the effect of placenta extraction from exteriorized uterus versus placenta extraction from non- exteriorized uterus on blood loss during caesarean section (CS). It was a randomized control study in which 98 women undergoing caesarean section were allocated randomly to either the placental delivery from exteriorized uterus or placental delivery from non-exteriorized uterus. The main outcome measure was intraoperative blood loss, and Intention to treat analysis was used. More participants in the non-exteriorized placenta removal group had blood loss ≥500mls (P-value <0.001). Logistic regression showed about 5times likelihood of having blood loss of 500mls or more in the non-exteriorized group (P< 0.001; OR: 5.67; 95%CI: 2.38-13.40). The mean estimated blood loss was 54.1mL less in exteriorized placenta removal group (476.12±160.86 versus 530.20±145.18; P-value = 0.084). The mean changes in haemoglobin concentration in exteriorized and non-exteriorized groups were 0.68±0.19g/dL and 0.74±0.20g/dL; P = 0.131) respectively. This study showed statistically significant difference in blood loss of 500mls or more in the placenta delivery from non-exteriorized compared to the exteriorized group. However, there was no significant difference in the mean blood loss, duration of surgery, and change in haemoglobin between the two groups.

Characterization of a human placental clearance system to regulate serotonin levels in the fetoplacental unit

BackgroundSerotonin (5-HT) is a biogenic monoamine with diverse functions in multiple human organs and tissues. During pregnancy, tightly regulated levels of 5-HT in the fetoplacental unit are critical for proper placental functions, fetal development, and programming. Despite being a non-neuronal organ, the placenta expresses a suite of homeostatic proteins, membrane transporters and metabolizing enzymes, to regulate monoamine levels. We hypothesized that placental 5-HT clearance is important for maintaining 5-HT levels in the fetoplacental unit. We therefore investigated placental 5-HT uptake from the umbilical circulation at physiological and supraphysiological levels as well as placental metabolism of 5-HT to 5-hydroxyindoleacetic acid (5-HIAA) and 5-HIAA efflux from trophoblast cells.MethodsWe employed a systematic approach using advanced organ-, tissue-, and cellular-level models of the human placenta to investigate the transport and metabolism of 5-HT in the fetoplacental unit. Human placentas from uncomplicated term pregnancies were used for perfusion studies, culturing explants, and isolating primary trophoblast cells.ResultsUsing the dually perfused placenta, we observed a high and concentration-dependent placental extraction of 5-HT from the fetal circulation. Subsequently, within the placenta, 5-HT was metabolized to 5-hydroxyindoleacetic acid (5-HIAA), which was then unidirectionally excreted to the maternal circulation. In the explant cultures and primary trophoblast cells, we show concentration- and inhibitor-dependent 5-HT uptake and metabolism and subsequent 5-HIAA release into the media. Droplet digital PCR revealed that the dominant gene in all models was MAO-A, supporting the crucial role of 5-HT metabolism in placental 5-HT clearance.ConclusionsTaken together, we present transcriptional and functional evidence that the human placenta has an efficient 5-HT clearance system involving (1) removal of 5-HT from the fetal circulation by OCT3, (2) metabolism to 5-HIAA by MAO-A, and (3) selective 5-HIAA excretion to the maternal circulation via the MRP2 transporter. This synchronized mechanism is critical for regulating 5-HT in the fetoplacental unit; however, it can be compromised by external insults such as antidepressant drugs.

DermabondTM PrineoTM skin closure system in caesarean section: Preliminary experience and review of the literature

Background: Caesarean Section is one of the commonest abdominal surgeries performed worldwide. The reported incidence of surgical site infection in this procedure ranges between 1 and 21%. Four items have been found to have an impact on this problem: skin disinfection, antibiotic prophylaxis, placental manual extraction and skin closure technique. Concerning this last item, a new closing system, Dermabond™ Prineo™, has become available recently. We wanted to test, in a preliminary study on a high-risk group patients, whether this system could be introduced in our surgical routine comparing it to the gold standard (subcuticular stitches).Methods: We randomly selected thirteen high-risk women undergoing both elective and urgent c-section from January to June 2022. To reduce variability all the skin closures were performed by the same surgeon (ADP), an experienced obstetrician. Wounds were checked the day after intervention (C1), on patient discharge (third day after c-section, C3), ten days after surgery (C10) and twenty days after surgery (C20) by an external physician. A cost analysis was also performed.Results: All but one case did not develop SSI at C10 (7.7% incidence). The only case resulted in a complete healing after a 7-day course of antibiotic therapy. Four cases presented with minimal diastasis requiring no further treatment. The reduced operating time resulting from the use of this device resulted in a saving of nearly 200€ per patient. Conclusion: Our preliminary results show that this skin closure system has a potential application for abdominal wall closure in case of C-section. It is at least equivalent of the gold standard suture method but, being undoubtedly faster it resulted in cost saving. Further studies with a higher number of patients are needed to confirm these preliminary observations.

Serotonin homeostasis in the materno-foetal interface at term: Role of transporters (SERT/SLC6A4 and OCT3/SLC22A3) and monoamine oxidase A (MAO-A) in uptake and degradation of serotonin by human and rat term placenta.

Serotonin is crucial for proper foetal development, and the placenta has been described as a 'donor' of serotonin for the embryo/foetus. However, in later stages of gestation the foetus produces its own serotonin from maternally-derived tryptophan and placental supply is no longer needed. We propose a novel model of serotonin homeostasis in the term placenta with special focus on the protective role of organic cation transporter 3 (OCT3/SLC22A3). Dually perfused rat term placenta was employed to quantify serotonin/tryptophan transport and metabolism. Placental membrane vesicles isolated from human term placenta were used to characterize serotonin transporters on both sides of the syncytiotrophoblast. We obtained the first evidence that serotonin is massively taken up from the foetal circulation by OCT3. This uptake is concentration-dependent and inhibitable by OCT3 blockers of endogenous (glucocorticoids) or exogenous (pharmaceuticals) origin. Population analyses in rat placenta revealed that foetal sex influences placental extraction of serotonin from foetal circulation. Negligible foetal serotonin levels were detected in maternal-to-foetal serotonin/tryptophan transport and metabolic studies. We demonstrate that OCT3, localized on the foetus-facing membrane of syncytiotrophoblast, is an essential component of foeto-placental homeostasis of serotonin. Together with serotonin degrading enzyme, monoamine oxidase-A, this offers a protective mechanism against local vasoconstriction effects of serotonin in the placenta. However, this system may be compromised by OCT3 inhibitory molecules, such as glucocorticoids or antidepressants. Our findings open new avenues to explore previously unsuspected/unexplained complications during pregnancy including prenatal glucocorticoid excess and pharmacotherapeutic risks of treating pregnant women with OCT3 inhibitors.

Antibiotics for 3rd and 4th Degree Vaginal Lacerations, Uterine Tamponade, and Manual Placental Extraction.

Trends in use of antibiotics during delivery hospitalizations complicated by (1) 3rd/4th degree vaginal lacerations, (2) manual placenta extraction, and (3) uterine tamponade are not well characterized. The objective of this study was to analyze trends in antibiotic use during vaginal delivery hospitalizations complicated by these three clinical scenarios. An administrative inpatient database was used to perform a serial cross-sectional analysis of antibiotic administration during delivery hospitalizations in the United States from January 2006 to March 2015. The primary outcome was receipt of antibiotics during vaginal delivery hospitalizations complicated by (1) 3rd and 4th degree vaginal lacerations, (2) manual placenta extraction, and (3) uterine tamponade. Patients with other indications for antibiotics were excluded. The Cochran-Armitage test was used to assess trends. Adjusted log linear regression analyses including demographic, hospital, and obstetric factors were performed to analyze factors associated with antibiotic receipt for each of these three clinical scenarios in both primary and sensitivity analyses. From 2006 to 2015 the rate of antibiotic administration during delivery hospitalizations decreased from 43.1% in 2006 to 25.5% for 3rd and 4th degree lacerations and from 59.6% to 49.2% for manual extraction (p < 0.01). Administration of antibiotics in the setting of uterine tamponade decreased from 48.6% in 2006 to 27.6% in 2009 before rising to 62.5% in the first quarter of 2015. In adjusted analyses, comparing the first quarter of 2015 to 2006 adjusted risk ratios for antibiotic administration were 0.61 (95% confidence interval [CI] 0.56-0.66) for 3rd and 4th degree vaginal lacerations, 0.76 (95% CI 0.53-1.09) for manual placental extraction, and 0.83 (95% CI 0.76-0.92) for uterine tamponade. Antibiotics are not used consistently during vaginal deliveries complicated by 3rd/4th degree lacerations, manual placenta extraction, and uterine tamponade. These findings support that a significant opportunity exists for comparative effectiveness research to assist in characterizing best practices.

Implementation of Evidence-Based Cesarean Section (CS) Technique [10H

INTRODUCTION: Despite evidence supporting specific CS operative techniques, usage is poor. We aimed to observe the effect of a QI initiative on evidence-based operative techniques uptake and its impact on postoperative pain, operative time and estimated blood loss (EBL). METHODS: Literature review identified blunt fascial dissection, lack of bladder flap, passive placental delivery, no peritoneal closure, and sutured skin closure as best practice operative techniques. The QI initiative identifying these practices was disseminated through written communication and large group discussion, including both faculty and trainees. Chart review abstracted demographic data, adherence to evidence-based techniques, operative time, post-operative pain scores at 48 hours, and pre- and post-operative hemoglobin for the 6 months before and after the QI initiative. RESULTS: 509 cases met inclusion criteria; 256 prior to QI and 203 following. After QI, blunt facial dissection increased (13.4 to 41.6%, p=0.00), bladder flap creation decreased (25.4 to 12.3%, p=0.0002), manual placental extraction decreased (75.6 to 48.2%, p=0.00), peritoneal closure decreased (46.5 to 32.8%, p=0.0016), and subcuticular skin closure increased (77 to 89.7%, p=0.0001) (all controlled for baseline differences between groups). Operative time, postoperative pain measures, and EBL did not change after the QI initiative. Controlling for all other factors, blunt fascial dissection was associated with decreased operative time (p=0.00) and increased post-op pain at 48 hours (p=0.01). CONCLUSION: Dissemination of recommendations from a QI initiative resulted in increased uptake of best practice operative techniques, although with varying effects on measured operative outcomes. Our project demonstrates the need for continued efforts in standardization of operative technique.

817: Previable “provoked” fetomaternal hemorrhage may represent insensible cell exchange

To quantify spontaneous and provoked maternal fetal cell exchange in the first half of pregnancy. Transfer of fetal red blood cells (FRBCs) into the maternal circulation during the previable period is poorly characterized but of clinical relevance for miscarriage management and invasive procedures. Prospective, descriptive cohort study of women presenting for surgical termination of pregnancy with sonographically confirmed gestational age (GA). Pre-procedural (1-2 days prior to procedure) and post-procedural (5 minutes after placental extraction) blood samples were collected to characterize both spontaneous and provoked cell exchange. Samples were analyzed via flow cytometry to quantify FRBCs present in the maternal sample with a sensitivity to 4.3 FRBCs per 10,000 maternal red blood cells. A total of 78 patients at 6-22 weeks GA contributed 156 matched pre- and post-procedural samples. FRBCs were identified in 48 patients (62%) including 3 (4%) who exhibited FRBCs pre-procedure only and 5 (6%) post-procedure only, for a total of 45 patients (58%) having post-procedural FRBCs. Of all the patients with FRBCs following their procedure, the majority (n=40, 89%) also exhibited evidence of cells before the procedure with only 5 patients (11%) exhibiting FRBCs only after. Of the 40 concordantly positive patients, 24 (60%) demonstrated an increase in the cell count, 14 (35%) demonstrated a decrease in the cell count, and 2 (5%) demonstrated an equivalent value (Figure 1). No dose-response relationship was appreciable between GA and FRBC count (Figure 2). Following all patients undergoing disruption of the placenta with instrumentation, just over half of patients had detectable FRBCs in the maternal circulation following their procedure but—among those that did—the majority were also present prior to the procedure. This leads to further questions regarding the relationship between risk events and alloimmunization potential in the first half of pregnancy as the rate of spontaneous transplacental cell exchange may be underappreciated and the magnitude of provoked transfer may be overestimated.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Perinatal Outcomes Associated With Isolated Velamentous Cord Insertion in Singleton and Twin Pregnancies.

To evaluate perinatal outcomes in singleton and twin pregnancies with pathologically confirmed velamentous cord insertion without vasa previa. This retrospective case-control study included all nonanomalous singleton and twin pregnancies with pathologically confirmed velamentous cord insertion delivered in a single institution between January 1, 2005, and July 1, 2015, and having an ultrasound examination by maternal-fetal medicine. For each case, the next 2 consecutive deliveries matched for gestational age at delivery ± 1 week and, in twins, amnionicity and chorionicity served as controls. Primary outcomes included surgical delivery for a nonreassuring intrapartum fetal heart rate tracing, umbilical arterial cord pH of less than 7.2, 5-minute Apgar score of less than 7, birth weight below the 10th percentile, neonatal intensive care unit admission, fetal or neonatal death, and cord avulsion necessitating manual placental extraction. Outcomes were available for 53 singletons with 103 matched controls and 33 twin pregnancies with 65 matched controls. In singletons, velamentous cord insertion was associated with cord pH of less than 7.2 (odds ratio [OR] 3.5; 95% confidence interval [CI], 1.1-11.2; P = .039), 5-minute Apgar score of less than 7 (OR, 5.3; 95% CI, 0.99-28.1; P = .045), and cord avulsion requiring manual placental extraction (7.5% versus 0%; P = .012). Associations were suggested with increased surgical delivery for a nonreassuring intrapartum fetal heart rate tracing (OR, 2.4; 95% CI, 0.9-6.9; P = .14), birth weight below the 10th percentile (OR, 2.1; 95% CI, 0.8-5.9; P = .21), and fetal or neonatal death (3.8% versus 0%; P = .11). Velamentous cord insertions were also associated with placental abruption in singletons (7.5% versus 0%; P = .013). Among twins, velamentous cord insertion was associated with fetal or neonatal death (9.1% versus 0%; P = .036). Isolated confirmed velamentous cord insertion is associated with adverse perinatal outcomes in singleton and twin gestations.

An effective placental cotyledons proteins extraction method for 2D gel electrophoresis.

Effective protein extraction is essential especially in producing a well-resolved proteome on 2D gels. A well-resolved placental cotyledon proteome, with good reproducibility, have allowed researchers to study the proteins underlying the physiology and pathophysiology of pregnancy. The aim of this study is to determine the best protein extraction protocol for the extraction of protein from placental cotyledons tissues for a two-dimensional gel electrophoresis (2D-GE). Based on widely used protein extraction strategies, 12 different extraction methodologies were carefully selected, which included one chemical extraction, two mechanical extraction coupled protein precipitations, and nine chemical extraction coupled protein precipitations. Extracted proteins were resolved in a one-dimensional gel electrophoresis and 2D-GE; then, it was compared with set criteria: extraction efficacy, protein resolution, reproducibility, and recovery efficiency. Our results revealed that a better profile was obtained by chemical extraction in comparison to mechanical extraction. We further compared chemical extraction coupled protein precipitation methodologies, where the DNase/lithium chloride-dense sucrose homogenization coupled dichloromethane-methanol precipitation (DNase/LiCl-DSH-D/MPE) method showed good protein extraction efficiency. This, however, was carried out with the best protein resolution and proteome reproducibility on 2D-gels. DNase/LiCl-DSH-D/MPE was efficient in the extraction of proteins from placental cotyledons tissues. In addition, this methodology could hypothetically allow the protein extraction of any tissue that contains highly abundant lipid and glycogen.

Postpartum Hemorrhage and Active Management of the Third Stage of Labor (AMTSL) in a Sub-Saharan Africa Maternity

Objective: To assess why the prevalence of postpartum hemorrhage still high while applying active management of the third stage of labor procedure. Material and methods: It was a retrospective comparative study that lasted for forty-two months period, from July 1st, 2011 to December 31, 2014 about 7466 deliveries. We divided the patients into 2 groups. The case group encompassed all patients for whom the AMTSL procedure was executed. The control group was made of patients who did not receive AMTSL procedure. Results: During the study period, we registered 7466 vaginal deliveries. The prevalence of postpartum hemorrhage reached 3.7%. For the population that benefited from controlled cord traction for placental extraction, the prevalence was 2.9% whereas those who have not benefited from controlled cord traction presented a postpartum hemorrhage in 09.76% therefore three times higher (p<0.00001). The most represented age group was 20-34 years old (76.7% for cases and 74.5% for controls). The nulliparous constituted 32.6% of cases while the multiparous were 32.2% of controls. In over half of the cases, they have been referred (56.5% for cases and 52.9% of controls). The delivery delay was inferior to 5 minutes with 71.75% of cases against 33.35% of controls (p<0.00001). Atony was the prevailing etiology in both groups (78.8% for cases and 65.5% for controls). Postpartum haemorrhage was lethal in 3.2% of cases with controlled cord traction against 17.2% without controlled cord traction making 5 times higher (p<0.00001). The main etiology of death was coagulopathy.

Risk Factors for Retained Placenta

(Am J Obstet Gynecol. 2015;213:864.e1–e.11) According to the World Health Organization, in developing countries, postpartum hemorrhage is the primary cause of maternal mortality, responsible for 25% of maternal fatalities. About 2% to 3% of vaginal deliveries are complicated by postpartum hemorrhage for which the treatment includes manual or operative placental extraction and this often results in increased risks of hemorrhage, infection, and prolonged hospital stays. The objective of this study was to evaluate the risk factors for retained placenta (defined as &gt;30 min between the delivery of the fetus and placenta).

Placental Pathologic Associations with Morbidly Adherent Placenta: Potential insights into Pathogenesis

The pathology that underlies morbidly adherent placenta (MAP) is poorly understood. The objective of this study was to describe the placental pathology, especially implantation site pathology, associated with MAP. This was a single institution, retrospective case-control study design examining placentas of patients who delivered between January 2008 and September 2013. MAP cases were defined by the need for clinical intervention at delivery beyond spontaneous placental delivery or simple manual extraction of the placenta. Controls consisted of patients with placentas sent for examination due to a history of maternal malignancy with no clinical suspicion of accreta. Placental pathologic findings of maternal vascular underperfusion (MVU), acute inflammation, chronic inflammation, fetal vascular obstruction and hemorrhage were recorded and compared using bivariable and multivariable analyses. Three categories of pathologic changes were seen more commonly in MAP placentas (N=101) than control placentas (N=110): chronic basal inflammation, villous changes of MVU and retromembranous and retromembranous/intervillous hemorrhage. In multivariable analyses adjusted for confounders, chronic basal villitis (aOR 5.6, 1.73-18.18), plasma cell deciduitis (aOR 2.63, 1.08-6.39), increased syncytial knots (aOR 3.92, 1.57-9.75), villous agglutination (aOR 24.85, 2.78-221.75), increased perivillous fibrin (aOR 5.08, 1.49-17.34), and the presence of subchorionic/intervillous thrombi (aOR 4.01, 1.63-9.86) remained associated with MAP. MAP is highly associated with evidence of intraparenchymal placental hemorrhage villous changes of MVU, and a lymphoplasmacytic infiltrate at the implantation site. The contribution of this basal chronic inflammatory infiltrate to MAP requires further investigation.

Model Assessment and Development of Risk Stratification of Surgical Site Infection Following Cesarean Delivery for a High-Risk, Urban Population

Background: Surgical site infection (SSI) remains a major cause of morbidity despite efforts aimed at prevention and treatment. Risk stratification tools identify patients at greatest risk of SSI. Two models of stratification are: 1) the Centers for Disease Control and Prevention’s National Healthcare Safety Network SSI Risk Index (NHSN), which assigns risk based on surgery duration, surgical wound contamination and physical status; and 2) the New Risk Stratification Schema (NRSS). The NRSS aimed to improve upon NHSN by incorporating five variables: diabetes control, body mass index (BMI), chorioamnionitis, methods of placental extraction and skin closure.

Is there an association between assisted reproductive technologies and time and complications of the third stage of labor?

To determine if vaginal deliveries exposed to assisted reproductive technologies (ART) are associated with an increased time between delivery of the neonate and placenta and select complications. A retrospective cohort of patients enrolled in an infertility practice who had term, singleton, vaginal deliveries at two academic hospitals from 2008 to 2013 was analyzed. Controls were patients with spontaneous conceptions after infertility consultations. The exposure groups were patients with controlled ovarian hyper-stimulation (COH) with in vivo fertilization, COH with in vitro fertilization and fresh embryo transfer (COH/IVF), and frozen embryo transfer or oocyte donation recipients without COH (non-COH ET). Multiple gestations and stillbirths were excluded. Median time of third stage was compared using the Mann-Whitney U test. Secondary outcomes of retained placenta, manual placental extraction, and post-partum hemorrhage (PPH) were compared using Chi-square or Fisher's exact analyses. A total of 769 patients met criteria and were analyzed. While there were no differences in time of third stage of labor, retained placenta, or PPH, manual extraction was significantly more common among non-COH ET [age-adjusted OR 5.6 (95% CI 2.2-13.8); p<0.001]. Patients who conceived after non-COH ET were at increased risk for manual placental extraction. This association was not influenced by age differences between groups. Further research must be done to determine which elements of the ART process are responsible for these differences.

Risk factors for retained placenta

Retained placenta complicates 2-3% of vaginal deliveries and is a known cause of postpartum hemorrhage. Treatment includes manual or operative placental extraction, potentially increasing risks of hemorrhage, infections, and prolonged hospital stays. We sought to evaluate risk factors for retained placenta, defined as more than 30 minutes between the delivery of the fetus and placenta, in a large US obstetrical cohort. We included singleton, vaginal deliveries ≥24 weeks (n = 91,291) from the Consortium of Safe Labor from 12 US institutions (2002-2008). Multivariable logistic regression analyses estimated the adjusted odds ratios (OR) and 95% confidence intervals (CI) for potential risk factors for retained placenta stratified by parity, adjusting for relevant confounding factors. Characteristics such as stillbirth, maternal age, race, and admission body mass index were examined. Retained placenta complicated 1047 vaginal deliveries (1.12%). Regardless of parity, significant predictors of retained placenta included stillbirth (nulliparous adjusted OR, 5.67; 95% CI, 3.10-10.37; multiparous adjusted OR, 4.56; 95% CI, 2.08-9.94), maternal age ≥30 years, delivery at 24 0/7 to 27 6/7 compared with 34 weeks or later and delivery in a teaching hospital. In nulliparous women, additional risk factors were identified: longer first- or second-stage labor duration, whereas non-Hispanic black compared with non-Hispanic white race was found to be protective. Body mass index was not associated with an increased risk. Multiple risk factors for retained placenta were identified, particularly the strong association with stillbirth. It is plausible that there could be something intrinsic about stillbirth that causes a retained placenta, or perhaps there are shared pathways of certain etiologies of stillbirth and a risk of retained placenta.

Is There an Association Between Pregnancies Conceived Through Assisted Reproductive Technologies and Time and Complications of the Third Stage of Labor? [164

INTRODUCTION: To determine whether vaginal deliveries exposed to assisted reproductive technologies (ARTs) are associated with an increased time between delivery of the neonate and placenta and select complications. Whether these risks are attributable to method of ART or are intrinsic to infertile populations is unknown. Assisted reproductive technologies are known risk factors for abnormal placentation. METHODS: A retrospective cohort of patients in an infertility practice who went on to have term, singleton, vaginal deliveries at two hospitals from 2008 to 2013 were analyzed. The control group consisted of patients with spontaneous conceptions after infertility consultations. Exposure groups were patients with controlled ovarian hyperstimulation with in vivo fertilization, controlled ovarian hyperstimulation with in vitro fertilization and fresh embryo transfer, and frozen embryo transfer or oocyte donation recipients in whom the endometrium was not exposed to controlled ovarian hyperstimulation. Multiple gestations and stillbirths were excluded. The median time of the third stage of labor was compared using the Mann-Whitney U test. Secondary outcomes of retained placenta (time greater than 30 minutes), manual placental extraction, and postpartum hemorrhage (estimated blood loss greater than 500 g or using uterotonics) were compared using the χ2 or Fisher's exact analyses. RESULTS: A total of 769 patients met criteria. There were no differences in time of the third stage of labor, retained placenta, and postpartum hemorrhage between the exposure and control groups. Manual extraction was significantly more common among frozen embryo transfer (age-adjusted odds ratio 5.6, 95% confidence interval 2.2–13.8; P<.001). CONCLUSION: Patients who conceived after frozen embryo transfer were at increased risk for manual placental extraction. This association was not influenced by age differences between groups.

The Effect on Perioperative Bleeding of Placental Extraction From an Exteriorized Uterus During Caesarean Section

ObjectiveTo evaluate the effect on perioperative bleeding of an alternative technique for Caesarean section, in which placental extraction is performed while the uterus is exteriorized. MethodsWe performed a retrospective matched cohort study using data obtained through chart review. Group 1 included women who had CS performed using the technique of placental removal while the uterus was exteriorized, and group 2 included women who had CS performed using the conventional method of placental removal from a non-exteriorized uterus. Women in each group were matched for number of previous Caesarean sections, indications for CS, and gestational age. The primary outcome was the difference between preoperative and postoperative hemoglobin concentrations. Secondary outcomes included the incidence of blood transfusion, estimated blood loss (EBL), operative time, the incidence of postoperative endometritis, and length of hospital stay. ResultsA total of 90 charts were reviewed (45 per group). Baseline clinical characteristics were similar in both groups. The mean decrease in hemoglobin concentration was 22% less in women who had placental extraction from an exteriorized uterus than in those who had the conventional placental extraction (13.2g/L vs. 16.9g/L, P=0.016). Among secondary outcomes, women in group 1 had a lower mean EBL (531.1mL vs. 691.1mL, P<0.05) and a shorter mean duration of surgery (28.0 minutes vs. 40.5 minutes, P<0.05). ConclusionExteriorizing the uterus prior to removal of the placenta during CS may decrease intraoperative and immediate postoperative bleeding compared with the conventional technique. Further studies on this technique are indicated.

The 100th volume of “Archives” appeared 100 years ago

And the journal has survived since then. In 1913, ‘‘Archiv fur Gynakologie’’ celebrated the print of its 100th volume. At that time, the journal has been edited by Ernst Bumm, Berlin, and Ernst Wertheim, Vienna (Fig. 1). The leading article was contributed by the pathologist Robert Meyer under the title ‘‘About the relations of the ovarian cell and the impregnated ovarian cell to the follicular system as well as the corpus luteum to menstruation’’ [1]. The paper followed a lecture given by Meyer before the Berlin Society of Gynecology and Obstetrics on 28 February 1913. His concluding remarks were: ‘‘Anatomy can only hint on single causal connections, chemistry will have the last word’’. How prophetic at that time! There were nine beautiful drawings added, done by the author himself (Fig. 2). The 100th volume contains further articles about ovulation, radiation in genital cancers, chondrodystrophy, bacteraemia in the placenta, peritonitis in uterine rupture, endometrial cancer, endometritis or menstrual desquamation (by Hitschmann and Adler [2]), gonorrhoea, malignancy of the chorionic epithelium, disinfection in the puerperium, umbilical rupture and first investigations of the effects of placental extraction to the sexual organs of the female [3]. The leading researchers did not publish much, but when writing, they were scrupulous to put every detail into their paper. Articles spreading about more than 100 pages were not unusual. The entire spectre of the scientific approach at that time could be presented in that single volume. That tradition has been maintained up to the present and the translation of the journal into English in 1978 did not alter the concept.

Labor analgesia and anesthetic management during emergency cesarean section of parturient with spinal cord injury (SCI)

Labor analgesia and anesthetic management during emergency cesarean section of parturient with spinal cord injury (SCI)