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Retained Placenta and Postpartum Haemorrhage

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Retained Placenta and Postpartum Haemorrhage Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1077 Retained Placenta and Postpartum Haemorrhage JOHANNA BELACHEW ACTA UNIVERSITATIS UPSALIENSIS ISSN 1651-6206 ISBN 978-91-554-9182-6 UPPSALA urn:nbn:se:uu:diva-246185 2015 Dissertation presented at Uppsala University to be publicly examined in Rosénsalen, Ing 95/96, Akademiska sjukhuset, Uppsala, Thursday, 23 April 2015 at 13:15 for the degree of Doctor of Philosophy (Faculty of Medicine). The examination will be conducted in Swedish. Faculty examiner: Professor Kjell Å Salvesen (Lunds Universitet). Abstract Belachew, J. 2015. Retained Placenta and Postpartum Haemorrhage. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1077. 59 pp. Uppsala: Acta Universitatis Upsaliensis. ISBN 978-91-554-9182-6. The aim was to explore the possibility to diagnose retained placental tissue and other placental complications with 3D ultrasound and to investigate the impact of previous caesarean section on placentation in forthcoming pregnancies. 3D ultrasound was used to measure the volumes of the uterine body and cavity in 50 women with uncomplicated deliveries throughout the postpartum period. These volumes were then used as reference, to diagnose retained placental tissue in 25 women with secondary postpartum haemorrhage. All but three of the 25 women had retained placental tissue confirmed at histopathology. The volume of the uterine cavity in women with retained placental tissue was larger than the reference in most cases, but even cavities with no retained placental tissue were enlarged (Studies I and II). Women with their first and second birth, recorded in the Swedish medical birth register, were studied in order to find an association between previous caesarean section and retained placenta. The risk of retained placenta with heavy bleeding (>1,000 mL) and normal bleeding (≤1,000 mL) was estimated for 19,459 women with first caesarean section delivery, using 239,150 women with first vaginal delivery as controls. There was an increased risk of retained placenta with heavy bleeding in women with previous caesarean section (adjusted OR 1.61; 95% CI 1.44-1.79). There was no increased risk of retained placenta with normal bleeding (Study III). Placental location, myometrial thickness and Vascularisation Index were recorded on 400 women previously delivered by caesarean section. The outcome was retained placenta and postpartum haemorrhage (≥1,000 mL). There was a trend towards increased risk of postpartum haemorrhage for women with anterior placentae. Women with placenta praevia had an increased risk of retained placenta and postpartum haemorrhage. Vascularisation Index and myometrial thickness did not associate (Study IV). In conclusion: 3D ultrasound can be used to measure the volume of the uterine body and cavity postpartum, but does not increase the diagnostic accuracy of retained placental tissue. Previous caesarean section increases the risk of retained placenta in subsequent pregnancy, and placenta praevia in women with previous caesarean section increases the risk for retained placenta and postpartum haemorrhage. Keywords: postpartum haemorrhage, retained placenta, secondary postpartum haemorrhage, retained placental tissue, threedimensional ultrasound, previous caesarean section Johanna Belachew, Department of Women's and Children's Health, Akademiska sjukhuset, Uppsala University, SE-75185 Uppsala, Sweden. © Johanna Belachew 2015 ISSN 1651-6206 ISBN 978-91-554-9182-6 urn:nbn:se:uu:diva-246185 (http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-246185) To Yosef List of Papers This thesis is based on the following papers, which are referred to in the text by their Roman numerals. I Belachew J, Axelsson O, Mulic-Lutvica A, Eurenius K. Longitudinal study of the uterine body and cavity with three- dimensional ultrasonography in the puerperium. Acta Obstet Gynecol Scand. 2012 Oct; 91:1184-90. II Belachew J, Axelsson O, Eurenius K, Mulic-Lutvica A. Three- dimensional ultrasound does not improve diagnosis of retained placental tissue compared to two-dimensional ultrasound. Acta Obstet Gynecol Scand. 2015 Jan; 94:112-6. III Belachew J, Cnattingius S, Mulic-Lutvica A, Eurenius K, Axelsson O, Wikström AK. Risk of retained placenta in women previously delivered by ceasarean section: A population-based cohort study. BJOG. 2014 Jan;121(2):224-9. IV Belachew J, Eurenius K, Mulic-Lutvica A, Axelsson O. Placental location, postpartum haemorrhage and retained placenta in women previously delivered by caesarean section: a prospective cohort study. Submitted. Reprints are made with permission from the respective publishers. Contents Abbreviations .................................................................................................. 9 Introduction ................................................................................................... 11 Postpartum period and uterine involution ................................................ 11 Secondary postpartum haemorrhage and retained placental tissue .......... 11 Ultrasound postpartum ............................................................................. 12 3D ultrasound ........................................................................................... 12 Caesarean section ..................................................................................... 13 Complications following caesarean section in previous pregnancy ......... 14 Postpartum haemorrhage .......................................................................... 14 Retained placenta ..................................................................................... 15 Abnormal invasive placentation ............................................................... 16 Ultrasound and abnormal invasive placenta ............................................. 16 Aims of the studies........................................................................................ 18 General aim .............................................................................................. 18 Specific aims ............................................................................................ 18 Study I .................................................................................................. 18 Study II ................................................................................................ 18 Study III ............................................................................................... 18 Study IV ............................................................................................... 18 Material and methods .................................................................................... 19 Study populations and settings ................................................................. 19 Studies I and II ..................................................................................... 19 Study III ............................................................................................... 20 Study IV ............................................................................................... 20 Methods .................................................................................................... 21 Studies I and II ..................................................................................... 21 Study III ............................................................................................... 21 Study IV ............................................................................................... 24 Statistical analysis .................................................................................... 26 Studies I and II ..................................................................................... 26 Study III ............................................................................................... 26 Study IV ............................................................................................... 27 Ethical considerations .............................................................................. 27 Results ........................................................................................................... 28 Studies I and II ......................................................................................... 28 Study III ................................................................................................... 34 Study IV ................................................................................................... 35 Discussion ..................................................................................................... 39 Studies I and II ......................................................................................... 39 Studies III and IV ..................................................................................... 41 Strengths and limitations .......................................................................... 43 Clinical implications ................................................................................ 44 Conclusions ................................................................................................... 46 Future studies ................................................................................................ 47 Sammanfattning på svenska – Summary in Swedish .................................... 48 Studie I och II ..........................................................................................
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