Maayan Bas-Lando, Lior Drukker, Rivka Farkash, Arnon Samueloff, Sorina Grisaru Granovsky
Shaare Zedek Medical Center, Hebrew University Medical School, Jerusalem
Introduction: The third stage of labor is a major source to maternal morbidity and mortality. We aimed to determine the maternal risks associated with a third stage uterine revision procedure due to retained placental fragments (3rd SRPF).
Materials & Methods: Cohort of women, 2005 -2014, based on a validated computerized database at a single center. Women with vaginal delivery (VD) and 3rd SRPF were compared to women with spontaneous VD and normal third stage, controls. Main outcome: puerperal febrile morbidity and maternal blood transfusion. Department protocol for the procedure: sterile procedure field preparation, prophylactic antibiotics (1 gr Cefazoline IV), appropriate anesthesia/ analgesia, VD to procedure interval 0-40 minutes. Comparisons as appropriated and adjusted multivariate model produced OR (95%CI), p <0.05
Results: During the study 101,185 women had a VD; 3297 (3.3%) had revision of the uterine cavity due to 3rd SRPF. All women had the management protocol implemented as registered in the real time database. Groups characteristics in Table. Women with 3rd SRPF as compared to controls had a significantly increased rate of postpartum febrile morbidity 15(0.5%) vs 111 (0.1%) p<0.0001, hemorrhage control interventions [Bakry 4(0.0012%), hysterectomy 11 (0.334%)] p<0.00001, blood products transfusion 298 (9%) vs 507 (0.5%), p<0.0001. Furthermore, a multivariate analysis adjusted for potential confounders: maternal age>35years, epidural, past CS, ART, preterm<37weeks, primiparity, SGA, preeclampsia, induction of labor, instrumental delivery, newborn gender: 3rd SRPF emerged as a significant risk for febrile morbidity OR 3.4(2.41-4.90) p<0.0001, hemoglobin drop [>3 g%] OR 8.18 (7.45-8.98), p<0.0001 and blood products transfusion OR 17.66 (15.13-20.61) p<0.0001.
Conclusions: Strict implementation of a 3rd SRPF uterine revision management protocol is nonetheless associated with severe maternal morbidity. The prospective evaluation of an improved approach to 3rd SRPF is crucial for maternal health.
Demographic and labor group characteristics
| 3rd SRPF | Control | P value | |
| Age (years) (mean, SD) | 28.3±5.6 | 29.0±5.7 | P<0.0001 |
| Age> 35 years (N, %) | 514 (15.6%) | 12,280 (12.5%) | P<0.0001 |
| Past CS (N, %) | 335 (10.2%) | 7,114 (7.3%) | P<0.0001 |
| Preeclampsia
(N, %) |
57 (1.7%) | 784 (0.8%) | P<0.0001 |
| ART (N, %) | 208 (6.3%) | 2,668 (2.7%) | P<0.0001 |
| Induction of labor (N, %) | 402 (12.2%) | 7,950 (8.1%) | P<0.0001 |
| Instrumental delivery (N, %) | 313 (9.5%) | 5,400 (5.5%) | P<0.0001 |
| Epidural analgesia (N, %) | 2,129 (64.6%) | 51,168 (52.3%) | <0.0001 |
| Primiparity (N, %) | 792 (24%) | 23,594 (24.1%) | P=0.915 |
| Preterm delivery <37weeks (N, %) | 276 (8.4%) | 3,348 (3.4%) | P<0.0001 |
| SGA (N, %) | 272 (8.2%) | 6,580 (6.7%) | P<0.0001 |
| Prior >3 miscarriages | 173 (5.2%) | 3,364 (3.4%) | P<0.0001 |
| Newborn gender, female (N, %) | 1,789 (54.3%) | 47,583 (48.6%) | P<0.0001 |
| Fever (N, %) | 15 (0.5%) | 111 (0.1%) | P<0.0001 |
| Hysterectomy
(N, %) |
11 (0.334%) | 0 (0%) | P<0.00001 |
| Transfusion of blood products
(N, %) |
298 (9%) | 507 (0.5%) | P<0.0001 |
| Prolonged hospitalization (>3days) | 690 (21%) | 11,102 (11.4%) | P<0.0001 |