|Year : 2016 | Volume
| Issue : 1 | Page : 67-68
Treatment of retained placenta with sublingual misoprostol: A case report
Rashmi Bala, Sumit Shukla Das, Laiphrakpam Ranjit Singh
Department of Obstetrics and Gynecology, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, India
|Date of Web Publication||5-Feb-2016|
Department of Obstetrics and Gynecology, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Retained placenta is a common complication of the third stage of labor. It can be due to an atonic uterus, a trapped placenta, or an adherent placenta. The most common source of a trapped placenta is from a partial closure of the cervix and/or a contracted lower uterine segment. We present an unusual case of a trapped placenta managed by Misoprostol [prostaglandin (PG) E1] administered sublingually with spontaneous expulsion of the placenta on the 21 st day after delivery.
Keywords: Misoprostol, prostaglandin (PG) E1, retained placenta, trapped placenta
|How to cite this article:|
Bala R, Das SS, Singh LR. Treatment of retained placenta with sublingual misoprostol: A case report. J Med Soc 2016;30:67-8
| Case Report|| |
We present a case of a 30-year-old secundigravida at 39 weeks, 5 days of gestation with asymmetrical intrauterine growth restriction (IUGR). The patient had a history of medical termination of pregnancy (MTP) at 3 months of gestation 2 years back.
She went into spontaneous labor and delivered a live female baby weighing 1.5 kg. The umbilical cord was fragile and got separated from the placenta during controlled cord traction followed by spontaneous closure of the cervix and the placenta was retained. Twenty units of Syntocinon in one unit of Ringer's lactate at a rate of 15 drops/min intravenously and injection methyl PGF2 alpha (PGF2α) 0.3 cc intramuscularly for three doses at 15 min intervals were administered. The patient was shifted to the operation theatre after 30 min for manual removal under general anesthesia after the abovementioned treatment failed. However, the cervix could not be dilated and as there was no further bleeding per vaginam and the patient was stable, the procedure was withheld and the patient was shifted to the ward for further management. Ultrasound of the abdomen was done that showed a nonadherent placenta trapped behind the cervix.
Keeping in view of the patient's desire to maintain fertility and unwillingness to undergo another operative procedure, a trial of Misoprostol tablet was started with a dose of 200 μ sublingual twice daily along with other supportive measures for a period of 2 weeks. Informed consent was taken from the patient and she was additionally explained the need for hysterotomy/hysterectomy on the 14 th day after delivery, if the treatment failed.
On the 13 th day, the patient developed high-grade fever and the procedure was postponed. She was managed with intravenous antibiotics. The patient became afebrile on the 17 th day. Hysterotomy/hysterectomy was tentatively planned on the 21 st day of delivery in consultation with the physician and the anesthesiologist and Misoprostol was continued in the same dosage.
The placenta was expelled spontaneously on the 21 st day of delivery. The condition of the patient improved rapidly thereafter. Repeat ultrasound showed only bits of membranes. The patient was discharged on request on the 25 th day with advice to attend the outpatient department (OPD) after 1 week with a repeat ultrasound report. The patient, however, did not turn up and was lost in the follow-up.
| Discussion|| |
The incidence of the retained placenta varies greatly around the world and affects around 0.1-3.3% of vaginal deliveries.  At our institution we follow the definition of a retained placenta as the nonexpulsion of the placenta even with active management of the third stage till after 30 min of delivery. The definitive management of retained placenta is manual removal under general anesthesia. Other options such as umbilical vein PG injection or facilitating uterine relaxation with nitroglycerin have been mentioned in literature as well.  Preliminary evidence had suggested that PGs such as Misoprostol may expel the placenta and reduce blood loss in women with retained placenta. In our institute this is the first case of its type, where, though the treatment was done over such a prolonged period, it had led to the expulsion of the placenta and hence, a successful outcome.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Weeks AD. The retained placenta. Best Pract Res Clin Obstet Gynaecol 2008;22:1103-17.
Nardin JM, Weeks A, Carroli G. Umbilical vein injection for management of retained placenta. Cochrane Database Syst Rev 2011:CD001337.