Effect of Oxytocin Injection into Umbilical Vein for Management of Retained Placenta

Background: Retained placenta is one of the causes of post-partum hemorrhage in Bangladesh as it is worldwide. If a retained placenta is left untreated, there is a high risk of maternal morbidity and mortality and it has inherent risks of infection and hemorrhage. Manual removal of placenta which is the recommended treatment of retained placenta usually requires regional or general anesthesia. Intraumbilical injection of saline solution with oxytocin might represent an important option for management of retained placenta. Objectives: The aim of this study was to assess the effect of intraumbilical vein oxytocin in the management of retained placenta and to compare it to the risk of manual removal of placenta. Materials and Methods: This experimental study was conducted in the department of Obstetrics and Gynecology in Dhaka Medical College & Hospital during July to December 2004. Total 50 patients with retained placenta were included in this study. The patients were divided purposively randomly into two groups ---Groups A and B. Twenty patients in Group A were managed by intraumbilical vein injection of 10 units of oxytocin in 20 mL of normal saline slowly and 30 patients in Group B were managed by manual removal of placenta. Results: Among the patients of Group A, 16 (80%) delivered placenta spontaneously with expulsion time of 7--12 minutes. Remaining 4 patients (20%) required manual removal of placenta even after intraumbilical vein injection of oxytocin. Group A patients had less complications, required less blood transfusion, less antibiotics and less hospital stay compared to Group B patients. Conclusion: Intraumbilical vein administration of oxytocin is superior to manual removal in the management of retained placenta.


Effect of Oxytocin Injection into Umbilical Vein for Management of Retained Placenta
evidences that manual removal of placenta may be a risk factor for infection 3 , post-partum endometritis and risk of increased bleeding by interfering with normal mechanism of placental separation. 2 Routine administration of oxytocin during the third stage hastens placental separation, reduces blood loss of delivery and decreases the chance of PPH by 40%. 2 Oxytocin is the first line agent because of the paucity of side effects compared with all other available agents. 5 Umbilical vein injection of saline solution with oxytocin might represent an important option for management of retained placenta.This relatively simple and affordable technique could be used either for first response before proceeding to manual removal if necessary or as the only response where manual removal is not feasible. 6This procedure facilitates high concentration of oxytocin to the placental bed and uterine wall, resulting in uterine contraction and placental separation. 7traumbilical vein injection (IUV) is inexpensive, non-surgical, non-aggressive, cheap and pharmacological method which may be included in the treatment of retained placenta before going to manual lysis of placenta. 8garding retained placenta, findings from international studies and clinical researches showed that appropriate and adequate management during emergency can reduce the mortality and long term complications.As there are very few numbers of studies done on retained placenta in Bangladesh, we designed this experimental study to assess the effect of intraumbilical vein oxytocin in the management of retained placenta and to compare it to the risk of manual removal of placenta.

Materials and Methods
This experimental study was conducted in labor ward in the department of Obstetrics and Gynecology in Dhaka Medical College Hospital (DMCH), Dhaka during the period July to December, 2004.Patients who had undergone vaginal delivery and failed to deliver placenta within 30 minutes of delivery of the baby and admitted with retained placenta irrespective of whether active management policy was followed or not were included.Patients having comorbidities along with retained placenta, having partial separation, morbid adhesion and retention of placenta for more than 24 hours, who presented with chorioamnionitis, complicated 1 st and 2 nd stage of labor and with abruption placenta were excluded.Study subjects were purposively randomly divided into two groups.Group A included 20 patients who were given intraumbilical vein oxytocin and Group B included 30 patients who were managed with planned manual removal of placenta.
A solution of 10 mL oxytocin diluted in 20 mL normal saline (0.9% sodium chloride) was injected into the umbilical vein in all patients of Group A after the umbilical cord was clamped distally.The umbilical vein injection was given over a period of 30 minutes and traction was avoided until there was evidence of placental separation. 9Suprapubic pressure was applied while observing for evidence of placental separation.No other intervention was performed to cause placental separation until at least 15 minutes after administration of oxytocin.After expulsion of the placenta oxytocin was administered as indicated.
Comparison between the groups was done by chisquare test using the SPSS version 16.0.p values <0.05 were considered significant.

Results
Total 8501 obstetric patients were admitted during the study period.Among them, number of patients having retained placenta was 175 (2.05%

Discussion
This study showed that during the period from January to December 2004 the incidence of retained placenta was 2.05% of total obstetric admission in DMCH.In a study by Chhabra et al 10 in Kasturba Hospital, Delhi, it was found that incidence of retained placenta was 0.23% of all births over 15 years.In their study, out of four deaths two women delivered at nearby district hospital and were referred moribund and died.The policy option was that the properly conducted delivery can reduce the incidence of retained placenta and if removal occurs timely, appropriate care can save life.
Regarding management of retained placenta the present study can be compared with a number of studies.In this study, 16 (80%) patients of Group A, who were managed by intraumbilical vein injection of 10 units oxytocin in 20 mL normal saline, delivered placenta spontaneously with an expulsion time of 7 to 12 minutes after injection and 4 (20%) patients required manual removal.Study done by Golan et al 3 using the same methodology showed that expulsion of placenta occurred in all of their 10 cases a few minutes after intraumbilical injection.The average injection-expulsion time was 2--5 minutes.Using the proposed method of oxytocin injection into the umbilical cord of retained placenta they were able to spare 80% of the patients.A study done in department of Obstetrics and Gynecology, Liverpool Women's Hospital, United Kingdom revealed that women given an intraumbilical oxytocin injection had a significant increase in spontaneous expulsion of placenta within 45 minutes of delivery and fewer manual removal of placenta was needed.The result of their study suggested clinically important beneficial effect of intraumbilical oxytocin injection in the management of retained placenta. 11These findings are consistent with the present study.In this study, requirement of blood transfusion was less in oxytocin group.This finding correlates with study done by Gajvani et al. 11 A study done by Das SR 12 shows that 23.31% cases needed general anesthesia while removing the placenta manually.In the present study, only 2 (10%) patients in Group A required general anesthesia whereas in Group B, 20 (66.66%) patients required general anesthesia.Patients of Group B required exploration of uterus and had to stay longer in hospital than patients of Group A. In this study complications at or after management of retained placenta with intraumbilical vein injection of oxytocin was less than the non-oxytocin group.Among oxytocin group 18 (90%) cases had no complications and 2 (10%) cases developed PPH.In non-oxytocin group eight patients developed fever and sepsis after manual removal of placenta.The complications were very less in oxytocin group which correlates with the findings of study done by Golan et al. 3 The present study reveals that intraumbilical oxytocin solution is superior to manual removal of placenta.As this study was done in a small number of patients, we recommend that community based study having adequate sample size should be carried out to find out further evidence of efficacy and feasibility of the method in low resource setting.

Table I :
Units of blood transfusion per patient

Table V :
Frequency of use of antibiotics