Original Article Singapore Med J 2008; 49(7) : 532 Risk factors for retained placenta in southwestern Nigeria Owolabi A T, Dare F O, Fasubaa O B, Ogunlola I O, Kuti O, Bisiriyu L A ABSTRACT Keywords: grand multiparity, previous caesarean Introduction: This study aimed to determine the section, previous retained placenta, retained incidence of, and identify independent risk factors placenta to retained placenta in Ile-Ife, southwestern Singapore Med J 2008; 49(7): 532-537 Nigeria. INTRODUCTION Methods: This was a prospective case-control study Retained placentas affect 0.5%–3% of women following involving 120 women with retained placenta after delivery, and is a major factor in the cause of maternal vaginal birth at the Obafemi Awolowo University death from postpartum haemorrhage (PPH) and puerperal Teaching Hospital, Ile-Ife, southwestern Nigeria sepsis.(1,2) About 25% of maternal deaths in Africa and over a period of seven years. Two consecutive Asian countries are due to haemorrhage during pregnancy, normal deliveries after each retained placenta served as controls. Following a bivariate analysis, birth or postpartum period. Of these, almost 30% are Department a multivariate logistic regression model was contributed by PPH. A further 15%–20% of these PPH of Obstetrics, maternal deaths are due to retained placenta.(3) After uterine Gynaecology and constructed in order to define independent risk Perinatology, factors for retained placenta while controlling for atony, retained placenta is the second major indication for College of Health (4) Sciences, confounding variables. blood transfusion in the third stage of labour. Obafemi Awolowo Appropriate management of the third stage of labour University, Ile-Ife, Results: During the study period, there were 120 can help to reduce complications associated with this stage Osun 220005, cases of retained placenta, and the total number Nigeria of labour, including retained placenta. Retained placenta of deliveries was 6,160, making the incidence 1.9 is a potentially preventable cause of PPH. Although some Owolabi AT, MBBS, percent. Independent risk factors associated with MCommH, FWACS factors that predispose a pregnant woman to retained Senior Lecturer and retained placenta include non-use of antenatal placenta have been identified, there is no consensus on its Consultant care (Odds-ratio [OR] 22.71, 95 percent significance and relative importance. For example, some Dare FO, MBBS, confidence interval [CI] 10.5–49.12, p-value FWACS authors have reported a significant increase in the incidence Consultant and is less than 0.000), previous retained placenta Professor (OR 15.22, 95 percent CI 3.30–70.19, p-value is of retained placenta due to factors such as preterm labour, Fasuuba OB, BSc, less than 0.000), previous caesarean section (OR grandmultiparity and in some deliveries initiated by MBChB, FWACS 12.00, 95 percent CI 2.05–70.19, p-value is less labour induction, while others have not reported such an Consultant and (5-9) Professor than 0.006), maternal age 35 years or more (OR increase. A controlled study by Soltan and Khashoggi Ogunlola IO, MBBS, 7.10, 95 percent CI 1.5–32.40, p-values is less than showed, in descending order of significance, history of FWACS, FMCOG 0.012), grand multiparity (OR 6.63, 95 percent CI retained placenta, previous uterine surgery, preterm Lecturer and Consultant 1.88–23.40, p-value is less than 0.003), previous delivery, age above 35 years, placental weight less than Kuti O, MBBS, dilatation and curettage (OR 4.44, 95 percent CI FWACS, FMCOG 601 g, pethidine use in labour, labour induction and 1.69–11.63, p-value is less than 0.002), preterm Senior Lecturer and parity of more than five, to be associated with retained Consultant delivery (OR 3.12, 95 percent CI 1.12–8.68, p-value placenta.(10) However, in another controlled study, Titiz Department of is less than 0.029) and placenta weight less than et al found that only previous history of retained placenta Demography and 501 g (OR 2.91, 95 percent CI 1.34–6.32, p-value Social Statistics and a history of preterm delivery to be significantly related is less than 0.007). Bisiriyu LA, BSc, MSc to retained placenta in the current pregnancy, while age, Lecturer Conclusion: Women with identifiable risk factors parity, and gravidity did not influence the incidence of Correspondence to: retained placenta.(11) Dr Alexander Tuesday should be targeted for the prevention of retained Owolabi placenta. There is a need for the training of birth Clearly, it would be relevant to investigate and Tel: (234) 803 715 1125 Fax: (234) 36 230 705 attendants in the proper conduct of delivery and identify independent risk factors for retained placenta Email: third stage of labour to prevent placenta retention alexandrerowolabi before applying the risk approach for its prevention in @yahoo.com and postpartum haemorrhage. any community. This will help to increase the sensitivity Singapore Med J 2008; 49(7) : 533 and specificity of the method and selected risk factors in Table I. Complications associated with retained placenta. preventing retained placenta. The aim of the present study Characteristics No. (%) was to determine the incidence and identify independent Incidence of primary PPH > 500 ml 58 (48.33) risk factors for retained placenta among pregnant women Incidence of anaemia on in Ile-Ife, southwestern Nigeria. Information obtained will admission (% PCV) be used in formulating policies and programme for the 6–19 23 (19.17) 20–25 24 (20.00) reduction of retained placenta. 26–29 16 (13.33) 30–38 57 (47.50) METHODS Condition on admission In state of shock* 47 (39.17) This study was conducted at the Obafemi Awolowo In stable state 73 (60.83) University Teaching Hospital Complex (OAUTHC), Incidence of blood transfusion 48 (40.00) Mismanagement of third stage of labour 27 (22.50) Ile-Ife, Nigeria, between January 1999 and December 2005. During the seven-year period, 120 cases of retained PPH: postpartum haemorrhage; PCV: packed cell volume * Patient was in a clinical state of shock due to hypovolaemia, as placenta were prospectively studied. 240 women who had a result of moderate to severe haemorrhage. singleton normal vaginal delivery within 24 hours of the case study, were taken as controls. Each case of retained placenta was matched with two controls. instituted with the administration of intravenous infusion The management of third stage of labour in this of dextrose solution, crystalloids and plasma expanders study involved both passive and active management. with administration of oxygen to patients in shock. All the women were residents of the Ife/Ijesa health Attempts to deliver the placenta by CCT were made before administrative area. Most women routinely received one resorting to manual removal of the placenta. Simple dose of ergometrine or ten units of oxytocin after delivery sedation or general anaesthesia was used, depending on as standard treatment. In some high-risk women, the third the clinical situation of the patient. Following removal stage was actively managed, as prophylaxis treatment of the placenta, continuous oxytocin infusion was added against the development of PPH. The active management for 1–2 hours to ensure sustained uterine contraction. of the third stage involved the administration of oxytocic Broad-spectrum antibiotics were administered to control agent intravenously (ten units of oxytocin or 0.25–0.50 or prevent infection. mg of ergometrine) at the delivery of the anterior shoulder Informed consent was obtained from each woman with early cord clamping and cutting. recruited into the study. Ethics and research committee Following uterine contraction, gentle cord traction in approval was obtained. Data was collected by the use of the axis of the birth canal was then applied. The uterus a standardised questionnaire, which was administered to was at the same time manually controlled above the level the cases and controls through interviews, in addition to of the symphysis with countertraction (Brandt-Andrews a thorough review of the clinical records. Data obtained manoeuvre or controlled cord traction [CCT]). In the included age, educational status, occupation, marital expectant management, no oxytocic was given before the status, parity, gestational age at delivery, antenatal delivery of the placenta (but intramuscular injection of ten complications, booking status, placental weight, foetal units of oxytocin or 0.25–0.5 mg of ergometrine was given sex and weight. Other data included history of previous after delivery of the placenta). The cord was clamped and dilatation and curettage (D&C), caesarean section, cut immediately after delivery of the baby; no CCT was myomectomy and retained placenta, as well as history of performed until signs of separation of the placenta were use and non-use of oxytocic agent in the current delivery. noticed. All the cases of retained placenta that occurred Presence or absence of PPH was ascertained. in our delivery suites was diagnosed within 30 minutes The data was coded and input into the computer using of the delivery of the baby. All cases of retained placenta the Statistical Package for Social Sciences version 11.0 referred to us (unbooked women from other healthcare (SPSS Inc, Chicago, IL, USA). Frequency tables were facilities and those delivered at home, at faith clinics and then computed for all variables separating the cases from at herbal homes) had retained their placenta for more than the controls. Continuous variables such as age and parity 60 minutes before presenting to us. were categorised, and obstetrical history was treated as All women with retained placenta was managed individual elements and then as combined summary according to the departmental protocol. The patients measures. The presence of an association between the had an urgent packed cell volume done, with grouping hypothesised risk factors and retained placenta were tested and cross matching of appropriate units of blood for using bivariate analysis.