Journal of Obstetrics and Gynaecology (1997) Vol. 17, No.

3, 245247
OBSTETRICS
Retained placenta and associated risk factors
M. H. SOLTAN and T. KHASHOGGI
Department of Obstetrics and Gynaecology, King Khalid University Hospital, King Saud
University, Riyadh, Saudi Arabia
Summary
In a retrospective study, the factors that might inuence the
retention of placenta such as age, parity, antenatal abnor-
malities, labour onset and duration, history of uterine
surgery and previous retained placenta, were studied in 146
patients with retained placenta. Three hundred women who
were delivered vaginally without retained placenta were
similarly evaluated under the same conditions. The results
showed (in descending order of signicance), history of
retained placenta, previous uterine surgery, preterm deliv-
ery, age above 35 years, placental weight less than 601 g,
pethidine use in labour, labour induction and parity of more
than ve to be associated with retained placenta. The
existence of some or all these risk factors in a pregnant
woman should alert the obstetrician about the possibility of
retained placenta in labour.
Introduction
Retained placenta is an important risk factor associ-
ated with obstetric haemorrhage in low risk patients
(Stones et al., 1993), and it is the second major
indication for blood transfusion in the third stage of
labour, after uterine atony (Kamani et al., 1988).
Postpartum haemorrhage increases three times, when
the placenta is retained compared with normal deliv-
ery of placenta (Hall et al., 1985; Kamani et al.,
1988).
Risk factors associated with retained placenta are
not well highlighted in the literature. Romero et al.
(1990) reported signicant increase in the rate of
retained placenta in preterm labour, with no differ-
ence between those with and those without associated
rupture of the membranes. A history of retained
placenta increases the relative risks of postpartum
haemorrhage and retained placenta in a subsequent
birth about 24 times compared with women without
such history (Hall et al., 1985). Furthermore, changes
in the use of oxytocics and active management of the
third stage of labour may affect the rate of retained
placenta Thornton et al., 1988, Hammer et al., 1990).
The aim of the present study was to analyse the
risk factors associated with retained placenta in
women who were delivered at King Khalid Univer-
sity Hospital (KKUH).
Materials and methods
During the six year period (January 1990 to Decem-
ber 1995), in the obstetric unit at KKUH, there were
146 cases of retained placenta. Cases of retained
placenta were the ones that were retained for more
than 60 minutes after delivery and required manual
removal. Three hundred patients who were delivered
vaginally within 24 hours of the case study, and under
similar conditions, were taken as controls. Each case
of retained placenta was matched with two controls.
Pertinent data relating to age, parity, gestation age at
delivery, antenatal complications, ultrasound localisa-
tion of placenta, onset of labour, length of labour in
different stages, type of analgesia in labour, placental
weight, fetal sex and weight, history of previous
caesarean section, dilatation and curettage (D&C), as
well as history of retained placenta in previous deliv-
eries, and histopathology nding of placental tissue,
were extracted. Data collected were coded, and
analysed using Stat Pack Gold statistical package and
EPI INFO program. Chi-squared test was used to
assess the statistical signicance of retained placenta
in relation to other variables. Corneld s odds ratio
was used to estimate the relative risk of retained
placenta in the different categories of the variables.
Results
During the study period, there were 146 cases of
retained placenta and the total number of deliveries
was 26 315, making the incidence of retained pla-
centa in KKUH 055%.
The ages of the patients with retained placenta
ranged from 1642 years, with a mean age of
2836 659 years and their parity varied from nulli-
para to para 9, with a mean of 303 6266. Statisti-
cally signicant differences were noted between the
cases and the controls with regards to patient s age
(P 500003) and parity (0004). The odds of having
retained placenta were about 2 and 5 for the age
groups 2134 and > 35 years respectively, and 2 and
3 for women s parity less than or equal to ve and
more than ve respectively. It doubled with age for
the women 2134 years and women with 15, while
it increased almost ve fold with age above 35 and
more than three fold with parity above ve.
There were statistically signicant differences
between the retained placenta cases and controls in
respect to preterm labour (P 500004), induction of
labour (P 50005), use of pethidine (P 5000009)
and placental weight less than 601 g (P 50000006).
The odds of having retained placenta were about 5 for
preterm labour, 3 for induced labour, 3 for women
Correspondence to: M. H. Soltan, Department of Obstetrics and Gynaecology, King Khalid University Hospital, P. O. Box 2925,
Riyadh 11461, Saudi Arabia. Fax: 966-1-467-1993.
0144-3615/97/030245-03 $9.50 Institut e of Obstetrics and Gynaecology Trust, 1997
M. H. Soltan and T. Khashoggi 246
Table I. Risk factors associated with retained placenta
Patients Controls
Risk factor n 5 146% n 5300% P value OR 95% CI
Previous retained 12 (82% ) 0 (0) 0000004** 2898 391, 12309
placenta
Previous D&C 40 (274% ) 12 (40%) 0000006** 906 439, 1902
Previous caesarean section 17 (116% ) 7 (23% ) 00001* 552 209, 1507
Preterm delivery 20 (137% ) 9 (30% ) 00004* 513 215, 1255
( , 37 weeks)
Age
. 35 years 28 (192% ) 26 (86% ) 00013* 477 203, 1137
2134 years 104 (712% ) 212 (707%) 0019* 217 112, 427
, 21 years 14 (96% ) 62 (207%)
Placental weight 98 (671% ) 120 (40%) 0000006* 342 218, 536
( # 600 g)
Pethidine use in labour 33 (226% ) 28 (93% ) 000009* 336 177, 642
Induced labour 15 (103% ) 10 (33% ) 0005* 332 136, 820
Parity
. 5 24 (164% ) 28 (93% ) 0003 305 143, 655
15 97 (665% ) 183 (610%) 0018* 189 110, 324
NIL 25 (171% ) 89 (297%)
*Statistically signicant at 5% level of signicance.
**Computation were based on adjusted values.
of unbooked patients in the Indian study was high
(89%), and home deliveries in the Scottish study was
unstated, but presumed to be high, while the number
of unbooked cases in this study was very low
(801%). The higher incidence in the above studies
may be due to delay in management of the patient s
third stage of labour.
The risk of having retained placenta increases with
age and parity. Chang et al. (1977) reported com-
moner incidence of retained placenta in grandmulti-
para although they did not state the magnitude of this
increase. The increased risk of retained placenta with
preterm labour in this study was ve fold. This ts
well within the range of three- and nine-fold reported
by Romero et al. (1990) and Combs and Laros
(1991). The risk factors which lead to preterm labour,
may cause abnormal adherence of the placenta. Such
examples include infarcts or brinoid degeneration of
decidual arterioles, acute atherosclerosis which often
accompany preterm labour, stillbirth and intrauterine
growth retardation (Altshuler, 1986).
Induction of labour signicantly contributed to the
increased incidence of retained placenta in this study.
It raised the rate of retained placenta by more than
three-fold. To our knowledge, no reported data in
literature is available to compare our ndings. Placen-
tal retention may be the result of uterine atony caused
by uterine muscle exhaustion sometimes encountered
in cases of induced labour.
Smaller placental size was signicantly associated
with retained placenta. This is an interesting associ-
ation and it may be that in the smaller placenta, the
more chorionic tissues are replaced by brous or
infarcted tissue, and this results in non-physiological
attachment to decidua basalis, or the myometrial sur-
face. Perhaps an ultrasound determination of placen-
tal size antenatally may allow a cautiously better
management of labour in these patients.
Pethidine, among various types of analgesia used
in labour, was associated with 35-fold increase in
retained placenta. When phenergan, an antihis-
taminic, was added to pethidine, or with the use of
who used pethidine only in labour and 3 for women
who delivered with placental weight less than 601 g,
compared with term delivery, spontaneous labour
onset, use of other analgesics in labour and women
who delivered placenta weighing more than 600 g
respectively. History of previous caesarean section,
D&C, and previous retained placenta were all
signicantly associated with retained placenta
(P 500001, ,0000006 and ,0000004 respect-
ively) (Table I).
Antenatal complications such as threatened abor-
tion, antepartum haemorrhage, chorio-amnionitis,
polyhydramnios, and hydrops fetalis were recorded in
10 cases and two controls and they were signicantly
related to retained placenta (P value 50048). How-
ever, multiple pregnancy, ultrasound placental locali-
sation, premature rupture of membranes, prolonged
labour, fetal weight and sex were not found to be
signicantly associated with retained placenta.
Abnormal histopathology ndings were found in
eleven cases. These were mostly decidual tissue
degeneration, polymorphism, chorioamnionitis, focal
degeneration, calcication, infarction and haemor-
rhagic decidua.
Discussion
Postpartum haemorrhage remains an important cause
of maternal mortality and morbidity, and retained
placenta is the second leading cause for postpartum
haemorrhage (Hall et al., 1985). Incidence of postpar-
tum haemorrhage is said to remarkably increase (up
to 213% of cases) when the condition is compounded
with retained placenta (Hall et al., 1985). Therefore,
it is important to explore factors that are associated
with retained placenta.
The incidence of retained placenta obtained in this
study was low (055%) compared with Indian (38%)
and Scottish (21%) studies (Begum, 1993; Hall et al.,
1985). This could be explained by the restriction of
our denition in this study, as well as the types of
patients assessed in the various studies. The number
Retained placenta and associated risk factors 247
entonox, the retained placenta was not signicantly
increased. It may be that pethidine not only depresses
the central nervous system but also the autonomic
nervous system, and therefore myometrial contrac-
tions.
History of previous retained placenta increased the
chances of having retained placenta by 29-fold in a
subsequent birth. This is much higher than the risk of
24-fold reported by Hall et al. (1985). This high
gure may be predicated on the chance ndings that
none of the controls in this study had history of
previous retained placenta. Barss and Misch (1990)
went even further to incriminate a previous history of
retained placenta to be associated with placenta acc-
reta. It is possible that the risk factors that were
responsible for the previous retained placenta may
persist in subsequent pregnancies.
Uterine surgery in the form of caesarean section or
D&C are signicantly associated with retained pla-
centa. It may be that implantation of the ovum in
these conditions have occurred in an area of the
uterus with decient or damaged endometrium. This
will probably lead to the chorionic villi readily pene-
trating the endometrium, and reaching the surface of
the myometrium, resulting in non-placental separ-
ation (Beazley, 1986).
The presence of some or all of these risk factors
antenatally, should alert the obstetrician of the possi-
bility of retained placenta in labour and all prepara-
tions to deal with retained placenta should be
undertaken, in order to avoid increased morbidity.
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