Retained placenta
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"retained placenta" management
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Now I have comprehensive information from multiple authoritative textbooks. Here is a complete overview of retained placenta:
Retained Placenta
Definition
Retained placenta is failure of the placenta to deliver within 30 minutes after birth of the baby (some definitions use 60 minutes). It is one of the "four Ts" of postpartum hemorrhage — specifically under Tissue — and accounts for up to 10% of postpartum hemorrhages.
Mechanism of Normal Placental Separation
Following fetal delivery, myometrial contractions shear the placenta from the implantation site; the spiral arteries are mechanically constricted by uterine contraction. Retained placenta prevents this constriction, leading to ongoing hemorrhage.
Risk Factors
- Maternal age > 30 years
- Preterm delivery (24–26 weeks gestation has the highest risk compared to term)
- Stillbirth
- Multiparity
- Prior uterine surgery / cesarean section
- Placenta previa
- History of uterine curettage
- Uterine anomalies
- Succenturiate (accessory) placental lobes — any defect in the delivered placenta may signal a retained cotyledon
Causes
| Cause | Mechanism |
|---|---|
| Adherent placenta (most common) | Defective decidua basalis — chorionic villi attach to or invade myometrium |
| Placenta accreta | Villi adhere to myometrium without invading decidua basalis |
| Placenta increta | Villi extend into myometrium |
| Placenta percreta | Villi penetrate full myometrial thickness |
| Trapped/incarcerated placenta | Cervical closure before placental expulsion |
| Retained cotyledon/membrane | Incomplete delivery — fragment remains after main placenta delivered |
The current incidence of placenta accreta is approximately 3/1,000 deliveries, with a strong association with prior cesarean delivery.
Clinical Consequences
- Primary postpartum hemorrhage (within 24 hours)
- Secondary postpartum hemorrhage (24 hours to 6 weeks)
- DIC — retained products contain excess thromboplastin, which can precipitate disseminated intravascular coagulation
- Endometritis / sepsis — retained tissue is a nidus for infection
- Uterine subinvolution
Always inspect the delivered placenta for missing cotyledons or a ragged maternal surface, which indicates retained fragments.
Management
Step 1 — Initial Stabilisation
- IV access (large-bore), fluid resuscitation
- Monitor vital signs, Foley catheter (decompresses bladder, monitors output)
- Cross-match blood; have blood products available
- Administer tranexamic acid 1 g IV
Step 2 — Attempt Placental Delivery
- Controlled cord traction + uterine massage (Brandt–Andrews manoeuvre)
- Oxytocin — 10 units IM after delivery, or 5–10 units IV followed by infusion up to 40 units total
- Consider misoprostol in low-resource settings when oxytocin is unavailable
Step 3 — Tocolysis + Manual Removal (if placenta undelivered after 30 min)
Manual removal under regional or general anaesthesia is standard.
Nitroglycerin is particularly useful as a tocolytic to relax the uterus:
- Translingual spray: 400-μg pre-metered spray, 1–2 sprays every 3–5 min (maximum 3 doses in 15 min)
- IV injection: 50–150 μg, repeated in 30–60 seconds if blood pressure is stable
Manual Removal Technique:
- Trace the umbilical cord through the cervical os to the placental margin
- Digitally perforate the placental membranes
- Gradually separate the placenta from the myometrium using blunt dissection
- Explore the uterus for retained cotyledons after removal
- Curettage by an obstetrician for remaining fragments
- Stimulate uterine contraction: massage + oxytocin + prostaglandins
⚠️ Placenta accreta, increta, and percreta are not digitally dissectible — attempting forced removal risks catastrophic hemorrhage.
Step 4 — Management of Abnormally Invasive Placenta (Accreta Spectrum)
- If placenta cannot be manually removed → suspect accreta spectrum disorder
- Hysterectomy is usually required to avoid catastrophic haemorrhage
- Conservative approach (only if fertility preservation is paramount):
- Curettage of retained placenta, OR suturing of the bleeding site (at cesarean)
- Prophylactic selective uterine artery embolisation — described for diagnosed cases before delivery
- Must be prepared to proceed to hysterectomy if bleeding is not promptly controlled
Step 5 — Adjuncts for Uncontrolled Bleeding
- Pelvic vessel embolisation (interventional radiology): reported success 95–100%; preserves fertility
- Uterine packing (gauze or Foley catheter): temporising measure when embolisation/hysterectomy unavailable
- Recombinant factor VIIa: used in severe, refractory postpartum haemorrhage
Antibiotics
Prophylactic antibiotics at the time of manual placental removal have been debated; a 2024 Cochrane systematic review evaluated this specifically. Their role is not firmly established by current evidence for routine use, though they are widely given in practice given the infection risk.
Key Points Summary
| Feature | Detail |
|---|---|
| Time threshold | > 30 minutes after delivery |
| Contribution to PPH | ~10% of cases |
| Uterotonic of choice | Oxytocin (IV/IM); misoprostol in resource-limited settings |
| Tocolytic for manual removal | Nitroglycerin (IV or translingual) |
| Anaesthesia for manual removal | Regional or general |
| When to suspect accreta | Placenta non-dissectible on manual removal |
| Definitive treatment for accreta | Hysterectomy |
Sources:
- Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice, Chapter 40
- Rosen's Emergency Medicine, Chapter on Postpartum Hemorrhage
- Pfenninger and Fowler's Procedures for Primary Care, Maternal Complications
Recent evidence (2024 Cochrane reviews):
- Uterotonics for retained placenta management [PMID: 39465684]
- Prophylactic antibiotics for manual removal of retained placenta [PMID: 39474979]
Anemia mukth bharat
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Anemia Mukt Bharat programme India details 2025
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Anemia Mukt Bharat 6x6x6 strategy beneficiaries targets
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Anemia Mukt Bharat 6 institutional mechanisms 6 interventions complete list IFA schedule
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https://nhm.gov.in/images/pdf/Nutrition/AMB-guidelines/Anemi…
Here is a comprehensive overview of Anemia Mukt Bharat (AMB):
Anemia Mukt Bharat (AMB)
Background
- Launched in 2018 by the Ministry of Health and Family Welfare (MoHFW), Government of India
- Builds upon earlier programmes: National Iron Plus Initiative (NIPI, 2013) and Weekly Iron Folic Acid Supplementation (WIFS)
- Implemented under POSHAN Abhiyaan (National Nutrition Mission)
- Integrated with the School Health Programme and National Deworming Day
- Implemented across all villages, blocks, and districts in all States/UTs
Burden of Anemia in India (NFHS-5, 2019–2021)
| Population Group | Prevalence |
|---|---|
| Children (6–59 months) | 67.1% |
| Adolescent girls | 59.1% |
| Women of reproductive age | ~57% |
| Non-pregnant women | ~30% (539 million) |
| Pregnant women | ~37% (32 million) |
| 3 in 4 Indian women | Low dietary iron intake |
Goal
Reduce anemia prevalence by 3 percentage points per year across all target groups, following a life cycle approach.
Reach approximately 450 million beneficiaries — nearly 50% of India's population.
The 6×6×6 Strategy
The core framework of AMB consists of 6 beneficiary groups × 6 interventions × 6 institutional mechanisms.
1️⃣ Six Target Beneficiary Groups
| # | Group | Age |
|---|---|---|
| 1 | Pre-school children | 6–59 months |
| 2 | School-age children | 5–9 years |
| 3 | Adolescent girls and boys | 10–19 years |
| 4 | Women of reproductive age (non-pregnant, non-lactating) | 15–49 years |
| 5 | Pregnant women | — |
| 6 | Lactating mothers | — |
2️⃣ Six Interventions
| # | Intervention |
|---|---|
| 1 | Prophylactic Iron and Folic Acid (IFA) Supplementation |
| 2 | Periodic Deworming |
| 3 | Intensified year-round Behaviour Change Communication (BCC) Campaign (including assured delayed cord clamping) |
| 4 | Testing of anemia using digital non-invasive haemoglobinometers + point-of-care treatment |
| 5 | Mandatory provision of IFA-fortified foods in government-funded public health programmes |
| 6 | Addressing non-nutritional causes of anemia in endemic pockets (malaria, haemoglobinopathies, fluorosis) |
IFA Supplementation Schedule (Colour-Coded)
| Group | Formulation | Frequency | Colour |
|---|---|---|---|
| Children 6–59 months | IFA syrup (1 mL) | Bi-weekly (2×/week) | — |
| Children 5–9 years (WIFS-Junior) | IFA tablet | Weekly | Pink |
| Adolescents 10–19 years | IFA tablet | Weekly | Blue |
| Women of reproductive age (20–49 yrs) | IFA tablet | Weekly | Red |
| Pre-conception / 1st trimester | Folic acid tablet | Daily | — |
| Pregnant women (from 2nd trimester) | IFA tablet | Daily | — (continues 6 months postpartum) |
| Lactating women | IFA tablet | Daily (for 6 months) | — |
3️⃣ Six Institutional Mechanisms
| # | Mechanism |
|---|---|
| 1 | Strengthening procurement and supply chain for IFA supplements |
| 2 | Capacity building and training of all stakeholders |
| 3 | Inter-ministerial convergence (MoHFW + Ministry of Education + Ministry of Women & Child Development + Ministry of Food & Supplies) |
| 4 | AMB Dashboard/Digital Portal — real-time tracking of anemia screening, IFA supply and distribution |
| 5 | Demand generation through community mobilisation (ASHA, AWW, ANM) |
| 6 | Monitoring, reporting, and review mechanisms (AMB Scorecard with key performance indicators) |
Digital Tools
- AMB Dashboard: tracks real-time data on IFA supply, distribution, screening coverage at national, state, district, and block levels
- Digital haemoglobinometers: non-invasive point-of-care testing at schools and health facilities
- States use the AMB scorecard to finalize budgets and procurement plans
Recent Progress (2024–25)
- 15.4 crore (154 million) children and adolescents received IFA supplements in Q2 FY 2024–25
- Significant improvement in IFA coverage among children, lactating mothers, and pregnant women (2018–19 to 2022–23)
- Programme is being continuously evaluated through the AMB Index — a composite state-level performance ranking
Key Programme Mnemonics
| AMB Tool | Full Form |
|---|---|
| TEST | Screen with haemoglobinometer |
| TREAT | Point-of-care treatment for anemia |
| TALK | BCC — counselling and awareness |
| SUPPLY | IFA supply chain management |
| DASHBOARD | Real-time digital monitoring |
Challenges
- Irregular IFA supply at district/block level
- Poor compliance due to side effects (nausea, GI upset)
- Non-nutritional causes (malaria, thalassaemia, fluorosis) not addressed by IFA alone
- Gaps in coverage of out-of-school adolescents
- Data quality issues in reporting
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