retained placenta/PPH surgical and lab reports - interested?

[because]

I'm going to post the timeline and excerpts from the birth of DS in Dec 2005. He was born at 38w6d (I'm SURE of conception date) in a very fast planned homebirth, followed by an emergency transport for retained placenta and hemorrhage.

I assume this is interesting to professionals and students, so I want to make it available. I would also LOVE to have someone interpret it for me (as I am not a medical person...) and help me to understand what happened and what my future risks are, etc. Just your opinions, I have a consult with a high-risk doc next month but I'm curious what mother-friendly providers around here think.

Here you go:

8:00pm Early labor signs but nothing serious.

10:00-10:30pm Labor becoming active.

11:30pm water breaks with meconium present.

11:40pm 7#, 8 oz 20" boy born, cord tears at delivery, baby pale, limp, and quiet then grunty. Midiwife had not arrived yet.

12:05am midwife arrives and assesses. Doesn't seemed concerned about baby's condition at this point or meconium, etc. Bleeding normal at first then heavier, pass small pieces of placenta, becoming pale and dizzy, hard contractions and uterus not clamping down.

1:14am call 911

1:20am EMTs arrive

1:43am arrive at ER: "OB/GYN at bedside attempted to remove
the retained products, but there is still retained products and the
patient was transferred emergently to the OR in critical condition.
The patient was rushed to the OR within 17 minutes of her presentatin.
She had critical care time while she was there. The fluid infused
was warmer. She had warm blanket;"

2:15am Transfer to OR for retained products, hypotension, anemia.
"PREOP DX:
1. retained products of conception
2. hemorrhage
POSTOP DX:
1. retained products of conception
2. hemorrhage
OPERATION:
1. Manual removal of retained products of conception
2. Dilation and curettage.
ANESTHESIA: IV sedation
SPECIMENS: Placenta
DRAINS: none
EST. BLOOD LOSS: 100cc
IV FLUIDS: 3500cc
URINE OUTPUT: 22cc via straight cath.
COMPLICATIONS: None. The patient tolerated the procedure well.
PROCEDURE: After coming to the ER with postparum hemorrhage with
retained products of concetption, the patient was given informed
consent and taken to th eoperating room secondare to hemorrhage. The
patient was prepped and draped in the normal sterile fashion. A
sterile speculum was placed in the vagina and the cervix was noted to
be completely dilated with no laceration and the products of
conception were visible. Manual removal of the placenta was then
obtained without difficulty. The cervix was then grasped with a ring
forceps in order to observe and report any cervical laceration, non
were found. The vagina was then inspected for any lacerations. A
small left periurethral tear was noted, but was not bleeeding an
therefore, do not need to be sutured. A horseshe curettage was then
used very gently to curette the uterus to assure no products of
cenception were left behind. There was minimal bleeding. The patient
tolerated the procedure well, and the patient was taken to the
recovery room in stable conditio, and to Pathology, products of
conception."

SURGICAL PATHOLOGY FINAL REPORT
"FINAL DIAGNOSIS: Third trimester fragmented, 499 gram placenta -
meconium-stained fetal membranes.

COMMENT: umbilical cord was not identified in the specimen.

MICROSCOPIC DESCRIPTION: Microscopic examination has been performed
and corresponds to the Final Diagnosis.

CLINICAL INFORMATION: Retained products of conception and placenta.

GROSS DESCRIPTION: "Retained products of conception/placenta."
Received in formalin is a 499 gram fragmented placenta. Upon partial
reconstruction the placental disc is ovoid and is 23.0 x 15.0 x 4.0
cm. There is a scant rim of opaque membranes which have a bright
green hue. A segment of umbilical cord i* not recognized on the
placental disc or separate within the specimen container. It appears
to insert in a velamentous fashion as there are several large caliber
vessels within the extraplacental membranes and a* insertion site is
not identified on the placental disc. The fetal surf**** is a light
blue with a dark green hue and the amnion is partially strip****.
Approximately 25% of the maternal surface is torn and friable with
poss*** areas of missing cotyledons. There is a diffuse layer of
calcifications. Cut surfaces are pale pink and spongy and contain
diffuse layer of intraparenchy*** calcification. Focal abnormalities
are not recognized. Representative sections are submitted in three
cassettes."

(my copy of the report has missing letters on the right margin, hence the **)

Thank you for any translation you can provide!

Also, I would be happy to share actual copies of these reports for educational purposes (with identifying info removed) if you pay copying and postage.

[mendomidwife]

Did you deliver the placenta spontaneously ?
The procedure they performed is pretty straight forward and it seems you tolerated it well - minimal blood loss, etc.
There is evidence of meconium stained tissue. Your placental tissue was friable (mushy), and there were calcifications - this is sometimes from being post dates or from smoking or from nothing. Some women with poor diets have friable placental tissue, but healthy women have it too.
There was evidence of velamentous cord insertion - this is when cord inserts on the margin of the placenta and the vessels are not protected. Occurs in 1% in singletons. There are risks to the baby - fetal hemorrhage because the cord vessels are unprotected. Sometimes associated with diabetes, smoking, fetal malformations, single vessel cord.
You don't want to put any traction on these types cords....they tear easily.
There were no focal abnormalities - that is good.
Pretty straight forward overall....
I'm glad you are both OK...

Carla

[Reha]

Originally Posted by because

1:43am arrive at ER: "OB/GYN at bedside attempted to remove
the retained products, but there is still retained products and the
patient was transferred emergently to the OR in critical condition.

Originally Posted by because

PROCEDURE: After coming to the ER with postparum hemorrhage with
retained products of concetption, the patient was given informed
consent and taken to th eoperating room secondare to hemorrhage. The
patient was prepped and draped in the normal sterile fashion. A
sterile speculum was placed in the vagina and the cervix was noted to
be completely dilated with no laceration and the products of
conception were visible. Manual removal of the placenta was then
obtained without difficulty. The cervix was then grasped with a ring
forceps in order to observe and report any cervical laceration, non
were found. The vagina was then inspected for any lacerations. A
small left periurethral tear was noted, but was not bleeeding an
therefore, do not need to be sutured. A horseshe curettage was then
used very gently to curette the uterus to assure no products of
cenception were left behind. There was minimal bleeding. The patient
tolerated the procedure well, and the patient was taken to the
recovery room in stable conditio, and to Pathology, products of
conception."

This is what has me confused. When you 1st arrived at the hospital, it says they attempted to remove the placental fragement, but weren't able to. Then, they took you to the OR, inserted the speculum, and were able to see the placental pieces and, it says, they were easily removed 'without difficulty'. I am wondering...WHY? Why was it suddenly easier to remove it in the OR? : Anyone have any ideas about this?

I am very glad that both you and your baby are ok. It must have been scary when his cord broke!

[NightWalker]

"This is what has me confused. When you 1st arrived at the hospital, it says they attempted to remove the placental fragement, but weren't able to. Then, they took you to the OR, inserted the speculum, and were able to see the placental pieces and, it says, they were easily removed 'without difficulty'. I am wondering...WHY? Why was it suddenly easier to remove it in the OR? Anyone have any ideas about this?"


This is what I am wondering, too. Particularly if you were still fully dilated as it states--why the need for the OR at all?

Also, was this ER docs or L&D triage? I must say 100mls isn't much blood, but they stated you were in critical condition. Did you lose a lot of blood at home?

[Reha]

Originally Posted by NightWalker

I must say 100mls isn't much blood, but they stated you were in critical condition. Did you lose a lot of blood at home?

I think that the 100cc is just how much she lost in the OR, as that was in the OR report. Also, I am guessing that they took her into OR as it sounded like her condition was getting critical, and they wanted to be prepared to do anything if it came down to it. It says they transferred her to the OR for low blood pressure, anemia, and the retained placenta.

[rabbitmum]

Originally Posted by NightWalker

"This is what has me confused. When you 1st arrived at the hospital, it says they attempted to remove the placental fragement, but weren't able to. Then, they took you to the OR, inserted the speculum, and were able to see the placental pieces and, it says, they were easily removed 'without difficulty'. I am wondering...WHY? Why was it suddenly easier to remove it in the OR? Anyone have any ideas about this?"

I had a retained placenta twice. The first time the doctor removed it without anaesthesia, and it was torture from which it took me many years to recover psychologically. The second time I was taken into OR after the doctor first tried to remove it and I screamed. In addition to it being just too painful it must be difficult for a doctor to perform what is basically surgery on a patient who is screaming and not lying still. But it depends on how stuck the placenta or placenta residue is, I suppose.

[because]

Originally Posted by mendomidwife

Did you deliver the placenta spontaneously ?

No. I passed what we thought were pieces of it at home and bled ALOT. Three attempts by three different people in the ER but none could get it. I'm also confused as to why it says there was no difficulty once we were in the OR - can it just *release* like that on its own?

Originally Posted by medomidwife

Your placental tissue was friable (mushy), and there were calcifications - this is sometimes from being post dates or from smoking or from nothing. Some women with poor diets have friable placental tissue, but healthy women have it too.

Ds was definitely born at 38w6d and I eat well and don't smoke, etc. Weird, huh?

Originally Posted by mendomidwife

You don't want to put any traction on these types cords....they tear easily.

It did tear right at the delivery.

Originally Posted by NightWalker

Also, was this ER docs or L&D triage? I must say 100mls isn't much blood, but they stated you were in critical condition. Did you lose a lot of blood at home?

Yes. I lost alot at home and in the ambulance. I don't think it was measured (at least no one ever gave me a number), but I could feel gushes with every third stage contraction, filled some chux pads. When I squatted at one point to try to pass the placenta, there was a steady trickle of blood that the midwife said was not normal when I asked.

Originally Posted by Lennon

and they wanted to be prepared to do anything if it came down to it. It says they transferred her to the OR for low blood pressure, anemia, and the retained placenta.

Yes. There was alot of people talking to me about hysterectomies, etc.

Additional question #1: Before we saw these reports, my midwife guessed that it was accreta. Is anyone else thinking this based on the reports? Would accreta eventually come out "without difficulty" like that?

Additional question #2: During the 2WW, I had had a sinus infection followed by an allergic reaction to the antibiotic for the infection. Then at 37-38 weeks, I was quite ill with pneumonia and was on another antibiotic. Could either of these infections or drugs affected the placenta's formation or health? A few of the weird placenta details (the opacity, the meconium, the thickness, etc.) are mention in conjunction with infection in some reading I've done....

Thank you all so much for your insight! I would love to hear more thoughts on this.

[Defenestrator]

Originally Posted by because

No. I passed what we thought were pieces of it at home and bled ALOT. Three attempts by three different people in the ER but none could get it. I'm also confused as to why it says there was no difficulty once we were in the OR - can it just *release* like that on its own?
Additional question #1: Before we saw these reports, my midwife guessed that it was accreta. Is anyone else thinking this based on the reports? Would accreta eventually come out "without difficulty" like that?

I am guessing that the doctor felt like he/she could be a little more aggressive when you were anesthetized in the OR. I would not call this an accreta, because it did release on its own.

One other thought that just popped into my head was that it was possible that you were given some kind of drug either by your midwife or at the hospital which finally kicked in and produced contractions strong enough to shear it off.