PLACENTAL FRAGMENTS

Examining the placenta for completeness is part of the after-delivery routine. If substantial fragments remain in the uterus, late hemorrhage and/or infection may be serious and even require hysterectomy.

In cases coming to malpractice litigation, there are often indicators of a rather casual approach to retained fragments after delivery of the placenta. The American College of Obstetricians and Gynecologists recommends[1] more circumspect and aggressive management of unusually heavy bleeding immediately after delivery, including routine examination for retained fragments.

PRACTICE POINT In cases involving Delayed Post Partum Hemorrhage, administering Oxytocin after delivery may have masked signs that placental fragments remained.

Surgical treatment of later hemorrhage can cause infertility. A recent paper[2] echoes the oft-repeated message that Dilatation and Curettage in the month after delivery is the commonest cause of Asherman's Syndrome. In this condition, the cavity of the uterus is obliterated by pathological attachments (adhesions) of the lining.

Standard textbooks[3] ,[4] first recommend non-surgical techniques for dealing with delayed Post Partum Hemorrhage. If curettage is essential during this critical period, it should be gentle and with a blunt instrument[5]. Though this disease is rare, it may be serious and is largely preventable.

PRACTICE POINT Trauma from curettage (scraping) of the lining of the uterus in pregnancy, or during the first month after delivery, preceded Asherman's Syndrome in 9 out of every 10 cases.

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