Retained placenta and postpartum hemorrhage: time is not everything

Abstract

Purpose: Postpartum hemorrhage is the major cause of maternal mortality worldwide. Retained placenta accounts for nearly 20% of severe cases. We investigated the influence of the time factor and retained placenta etiology on postpartum hemorrhage dynamics.

Methods: Our retrospective study analyzed a single-center cohort of 296 women with retained placenta. Blood loss was measured using a validated and accurate technique based on calibrated blood collection bags, backed by the post- vs pre-partum decrease in hemoglobin. We evaluated the relationship between these two blood loss parameters and the duration of the third stage of labor using Spearman rank correlation, followed by subgroup analysis stratified by third stage duration and retained placenta etiology.

Results: Correlation analysis revealed no association between third stage duration and measured blood loss or decrease in hemoglobin. A shorter third stage (< 60 min) was associated with significantly increased uterine atony (p = 0.001) and need for blood transfusion (p = 0.006). Uterine atony was significantly associated with greater decrease in hemoglobin (p < 0.001), higher measured blood loss (p < 0.001), postpartum hemorrhage (p = 0.048), and need for blood transfusion (p < 0.001).

Conclusion: Postpartum blood loss does not correlate with third stage duration in women with retained placenta. Our results suggest that there is neither a safe time window preceding postpartum hemorrhage, nor justification for an early cut-off for manual removal of the placenta. The prompt detection of uterine atony and immediate prerequisites for manual removal of the placenta are key factors in the management of postpartum hemorrhage.

Keywords: Manual removal of the placenta; Postpartum hemorrhage; Retained placenta; Third stage of labor; Uterine atony.

Fig. 1

a Correlation of duration of the third stage of labor with MBL (ml), all patients (n = 296), r = −0.06, p = 0.311. b Correlation of duration of the third stage of labor with ∆-hemoglobin (g/l), all patients (n = 296), r = −0.04, p = 0.497

Fig. 2

a–d Correlation analysis between the duration of the third stage of labor and measured blood loss (MBL) (ml) of: a patients with a third stage of labor < 60 min, b patients with a third stage of labor ≥ 60 min, c patients with uterine atony, d patients without uterine atony). a Correlation of duration of the third stage of labor with MBL (ml), in patients with third stage duration < 60 min (n = 93), r = −0.14, p = 0.178. b Correlation of duration of the third stage of labor with MBL (ml), in patients with third stage duration ≥ 60 min (n = 203), r = −0.14, p = 0.178. c Correlation of duration of the third stage of labor with MBL (ml), in patients with uterine atony (n = 81), r = −0.06, p = 0.311. d Correlation of duration of the third stage of labor with MBL (ml), in patients without uterine atony (n = 215), r = 0.05, p = 0.470