Maayan Bass-Lando, Itay Zmora, Rivka Farkash, Arnon Samueloff, Alex Ioscovitch, Faiz Hatib,  Sorina Grisaru-Granovsky

Hebrew University Faculty of Medicine, Jerusalem, Israel Shaare ZedeK MC

Introduction: The third stage of labor is a major determinant of early and late maternal morbidity and a source of costly mother and infant hospital readmissions. MaRUC is performed to treat and prevent these maternal risks.

Aim: To determine the early and late maternal complications associated with MaRUC due to suspected retained placenta/ fragments (3rd SRPF) using a strict departmental protocol.

Methods: Cohort study of all women with a vaginal delivery (VD); 2005-2014, in a single center based on computerized database. Women that underwent MaRUC due to SRPF (study group) were compared to women with VD and normal 3rd stage (controls). MaRUC strict protocol: initiated if separation of placenta not observed 40` after delivery, SRPF with/without PPH, under regional analgesia/ general anesthesia, prophylactic antibiotics (2nd generation cephalosporins IV),sterile field preparation. Main outcome: Maternal complications: (1) Early: puerperal febrile morbidity, prolonged maternal hospital stay (>72h) and maternal blood loss (blood transfusion and Hb drop > 3grams%]; (2) Late: hospital readmission within 6 weeks from delivery due to uterine/pelvic febrile morbidity or vaginal bleeding.

Statistics: Maternal and labor characteristics: descriptive (%, means ± SD and/or medians with IRQ ranges). Analyses: 1.Univariate: Chi2; T-test or Mann-Whitney as appropriate; 2. Multivariate backward, stepwise logistic regression model to identify risk factors associated with MaRUC; OR (95% CI).

Results: During the study 101,185 women had a VD; 3297 (3.3%) had MaRUC due to SRPF. The MaRUC group significantly differed: older maternal age (>35), nulliparity, assisted reproductive technology (ART),  induction of labor ,VBAC, instrumental delivery, epidural, preterm labor, SGA and male neonatal gender. MaRUC group (vs controls) had significantly higher risk of early puerperal fever 1.1% vs 0.3%,  blood loss 9.0% vs 0.5%,  prolonged hospital  stay 21.0% vs 11.4%, (all p<0.0001). Overall 335 women (0.33%) were readmitted; the readmission risk was significantly higher within the MaRUC group  0.819% vs 0.315%, p<0.0001 . MaRUC independent predictors for readmission were ART OR 1.80 95%CI [1.15-2.83] p=0.010, p<0.0001, gestational diabetes mellitus OR 1.89 95% CI [1.07-3.32], p=0.027 and Hb drop OR 2.73 95%CI [1.93-3.85] & blood loss OR 1.71 95%CI [1.05-2.78] p=0.031.

Conclusion: MaRUC is the delivery room “alarm bell” for early and late postpartum maternal complications and should not be regarded as a solution but rather the start of a chain of events, albeit a strict protocol. The prospective evaluation of performance/follow up MaRUC is crucial for improvement of maternal health and reduction of costly readmissions.