A 38-year-old woman, gravida 2, para 1, at 35 weeks' gestation comes to the emergency department because of an episode of vaginal bleeding that morning. The bleeding has subsided. She has had no prenatal care. Her previous child was delivered with a caesarean section because of a breech presentation. Her temperature is 37.1°C (98.8°F), pulse is 88/min, respirations are 14/min, and blood pressure is 125/85 mm Hg. The abdomen is nontender and the size of the uterus is consistent with a 35-week gestation. No contractions are felt. The fetal heart rate is 145/min. Her hemoglobin concentration is 12 g/dL, leukocyte count is 13,000/mm3, and platelet count is 350,000/mm3. Transvaginal ultrasound shows that the placenta covers the internal os. Which of the following is the most appropriate next step in management?

Schedule elective cesarean delivery

Perform bimanual pelvic examination

Perform emergency cesarean delivery

Administer oxytocin to induce labor

A 29-year-old G2P2 female gives birth to a healthy baby boy at 39 weeks of gestation via vaginal delivery. Immediately after the delivery of the placenta, she experiences profuse vaginal hemorrhage. Her prior birthing history is notable for an emergency cesarean section during her first pregnancy. She did not receive any prenatal care during either pregnancy. Her past medical history is notable for obesity and diabetes mellitus, which is well controlled on metformin. Her temperature is 99.0°F (37.2°C), blood pressure is 95/50 mmHg, pulse is 125/min, and respirations are 22/min. On physical examination, the patient is in moderate distress. Her extremities are pale, cool, and clammy. Capillary refill is delayed. Which of the following is the most likely cause of this patient’s bleeding?

Chorionic villi attaching to the myometrium

Chorionic villi invading into the myometrium

Placental implantation over internal cervical os

Chorionic villi attaching to the decidua basalis

Chorionic villi invading into the serosa

A 24-year-old primigravida presents at 36 weeks gestation with vaginal bleeding, mild abdominal pain, and uterine contractions that appeared after bumping into a handrail. The vital signs are as follows: blood pressure 130/80 mm Hg, heart rate 79/min, respiratory rate 12/min, and temperature 36.5℃ (97.7℉). The fetal heart rate was 145/min. Uterine fundus is at the level of the xiphoid process. Slight uterine tenderness and contractions are noted on palpation. The perineum is bloody. The gynecologic examination shows no vaginal or cervical lesions. The cervix is long and closed. Streaks of bright red blood are passing through the cervix. A transabdominal ultrasound shows the placenta to be attached to the lateral uterine wall with a marginal retroplacental hematoma (an approximate volume of 150 ml). The maternal hematocrit is 36%. What is the next best step in the management of this patient?

Admit for maternal and fetal monitoring and observation

Manage as an outpatient with modified rest

Corticosteroid administration and schedule a cesarean section after

A 34-year-old G3P2 presents at 33 weeks gestation with vaginal bleeding that started last night while she was asleep. She denies uterine contractions or abdominal pain. She had a cesarean delivery in her previous pregnancy. She also reports a 10 pack-year smoking history. The vital signs are as follows: blood pressure, 130/80 mm Hg; heart rate, 84/min; respiratory rate, 12/min; and temperature, 36.8℃ (98.2℉). The physical examination is negative for abdominal tenderness or palpable uterine contractions. The perineum is mildly bloody. On speculum examination, no vaginal or cervical lesions are seen. A small amount of blood continues to pass through the cervix. Which of the following findings would you expect on ultrasound examination?

Partial covering of the internal cervical os by the placental edge

Retroplacental blood accumulation

Loss of the clear retroplacental space

A 30-year-old woman, gravida 2, para 1, abortus 1, comes to the physician because of failure to conceive for 12 months. She is sexually active with her husband 2–3 times per week. Her first child was born at term after vaginal delivery 2 years ago. At that time, the postpartum course was complicated by hemorrhage from retained placental products, and the patient underwent dilation and curettage. Menses occur at regular 28-day intervals and previously lasted for 5 days with normal flow, but now last for 2 days with significantly reduced flow. She stopped taking oral contraceptives 1 year after the birth of her son. Her vital signs are within normal limits. Speculum examination shows a normal vagina and cervix. The uterus is normal in size, and no adnexal masses are palpated. Which of the following is the most appropriate next step in management?

Hysteroscopy with potential adhesiolysis

Measurement of serum FSH and LH concentrations

Measurement of antisperm antibody concentration

Estrogen/progestin withdrawal test

A 34-year-old G5P5 woman gave birth to a healthy infant 30 minutes ago by vacuum-assisted vaginal delivery and is now experiencing vaginal bleeding. The placenta was delivered spontaneously and was intact upon examination. The infant weighed 5.2 kg and had Apgar scores of 8 and 9. No perineal tear or intentional episiotomy occurred. The patient has type 1 diabetes. She had good glycemic control throughout her pregnancy. She took a prenatal vitamin daily. Blood pressure is 135/72 mmHg, pulse is 102/min, and respirations are 18/min. Upon physical examination, the uterine fundus is soft and palpated 4 cm above the umbilicus. There are 3-cm blood clots on the patient’s bed pad. Which of the following is the next best step in management for the patient’s bleeding?

Perform uterine massage and administer oxytocin

Manually remove retained placental fragments

Perform uterine artery embolization

A 36-year-old G4P3 is admitted to the obstetrics floor at 35 weeks gestation with painless vaginal spotting for a week. She had 2 cesarean deliveries. An ultrasound examination at 22 weeks gestation showed a partial placenta previa, but she was told not to worry. Today, her vital signs are within normal limits, and a physical examination is unremarkable, except for some blood traces on the perineum. The fetal heart rate is 153/min. The uterine fundus is at the xiphoid process and uterine contractions are absent. Palpation identifies a longitudinal lie. Transvaginal ultrasound shows an anterior placement of the placenta with a placental edge-to-internal os distance of 1.5 cm and a loss of the retroplacental space. Which of the following statements best describes the principle of management for this patient?

With such placental position, she should be managed with a scheduled cesarean in the lower uterine segment at 37 weeks’ pregnancy

Cesarean hysterectomy should be considered for the management of this patient

She can be managed with an unscheduled vaginal delivery with a switch to cesarean delivery if needed

Any decision regarding the mode of delivery in this patient should be taken after an amniocentesis to determine the fetal lung maturity

This patient without a significant prepartum bleeding is unlikely to have an intra- or postpartum bleeding

A 22-year-old woman comes to the physician because of a 1-month history of a light greenish, milky discharge from both breasts. There is no mastalgia. She has hypothyroidism and migraine headaches. Her mother has breast cancer and is currently undergoing chemotherapy. Menses occur at regular 28-day intervals with moderate flow; her last menstrual period was 1 week ago. Current medications include levothyroxine and propranolol. She appears anxious. Her temperature is 37.1°C (98.78F), pulse is 82/min, and blood pressure is 116/72 mm Hg. The lungs are clear to auscultation. Breast examination is unremarkable. Pelvic examination shows a normal vagina and cervix. Serum studies show: Thyroid-stimulating hormone 3.5 μU/mL Progesterone 0.7 ng/mL (Follicular phase: N < 3) Prolactin 18 ng/mL Follicle-stimulating hormone 20 mIU/mL A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

Reassurance and recommend avoidance of nipple stimulation

Retained placenta management for USMLE Step 1: High-Yield OB/GYN Lessons

Definition & Diagnosis - The Stubborn Afterthought

Definition: Failure of the placenta to deliver within 30 minutes of birth with active management, or 60 minutes with physiological management.
Etiologies:
- Placenta Adherens: Weak myometrial contractions fail to detach a normally implanted placenta.
- Trapped Placenta: Detached placenta is trapped by a closing cervix.
- Placenta Accreta Spectrum: Abnormal placental invasion into the uterine wall.
Diagnosis:
- Primarily clinical, based on the time criteria.
- Signs: Umbilical cord does not lengthen, no gush of blood, fundus remains high.
- Ultrasound can confirm retained products of conception.

Empty vs. Retained Placenta in Uterus

⭐ Gentle cord traction during active management (Brandt-Andrews maneuver) is diagnostic and therapeutic, but excessive force can cause uterine inversion or cord avulsion.

Initial Management - Gentle Persuasion

First-line, non-invasive techniques employed immediately after the diagnosis of retained placenta, prioritizing maternal stability and avoiding uterine trauma.

Conservative Measures:
- Ensure bladder is empty (catheterize if needed).
- Initiate uterine massage to promote contraction.
- Encourage breastfeeding or nipple stimulation to release endogenous oxytocin.
Controlled Cord Traction (CCT):
- Brandt-Andrews Maneuver: Apply gentle, sustained downward traction on the umbilical cord while simultaneously providing suprapubic counter-pressure with the other hand to prevent uterine inversion.
- Only attempt if the uterus is well-contracted.

Brandt-Andrews maneuver for retained placenta

⭐ Before attempting any traction, always confirm the uterus is firm and contracted. Applying traction to an atonic uterus is a leading cause of uterine inversion.

Invasive Management - The Manual Override

Manual Placental Extraction
- Indication: Placenta not delivered within 30 minutes of fetus.
- Prerequisites: Adequate analgesia (IV sedation/regional anesthesia), empty bladder.
- Technique: Aseptically insert one hand into the uterus, following the umbilical cord. Identify the cleavage plane between the placenta and uterine wall. Use the side of the hand in a shearing motion to separate, then gently withdraw.

Retained Placenta Management: Manual & Instrumental

Uterine Curettage
- Indication: Failure of manual extraction or persistent bleeding from suspected retained fragments.
- Setting: Operating room with anesthesia.
- Tool: Large, blunt Bumm or "banjo" curette is preferred.
- 💡 Ultrasound guidance is critical to minimize the risk of uterine perforation and ensure complete removal.

⭐ Exam Favorite: Aggressive uterine instrumentation, particularly curettage for retained products, is the leading cause of Asherman syndrome (intrauterine adhesions), which can cause secondary amenorrhea and infertility.

High-Yield Points - ⚡ Biggest Takeaways

Retained placenta is the failure to deliver the placenta within 30 minutes of birth.

The placenta accreta spectrum is the most common underlying cause.

Initial management involves controlled cord traction and uterotonic agents like oxytocin.

If initial attempts fail, proceed to manual extraction under adequate anesthesia.

Manual removal increases the risk of both uterine atony and endometritis.

Suspect retained fragments in any patient with secondary PPH or uterine subinvolution.

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