ABSTRACT
Introducción. El objetivo de este artículo fue dar a conocer el protocolo institucional del manejo de la placenta percreta como un procedimiento varias horas después de la cesárea, con embolización de arterias placentarias de forma selectivas, previo a la práctica de la histerectomía, y presentar los resultados. Métodos. Estudio de serie de casos, donde se evaluaron las pacientes con placenta percreta, manejadas durante un año en un hospital de cuarto nivel de complejidad en la ciudad de Bogotá, D.C., Colombia. Se efectuó cesárea fúndica y se dejó la placenta in situ, 48 a 72 horas después se realizó embolización ultra selectiva y luego de 2 a 3 días se procedió a practicar la histerectomía vía abdominal. Resultados. Se evaluaron 5 pacientes, con paridad de 3,8 embarazos promedio, con diagnóstico de placenta percreta. El tiempo promedio de espera entre la embolización y la histerectomía fue de 1,6 días. No se presentaron complicaciones asociadas a la embolización, ni morbimortalidad materno fetal. Los volúmenes de sangrado en promedio durante la histerectomía de cada paciente fueron de 1160 ml. Conclusión. Existen datos limitados sobre el tratamiento óptimo del acretismo placentario. La sospecha diagnóstica permite planificar de forma favorable el manejo intraparto y, es por ello, que el surgimiento de nuevas técnicas, como la embolización de arterias placentarias, constituyen alternativas para un manejo más seguro de las pacientes.
Introduction. The objective of this article was to present the institutional protocol for the management of percrete placenta as a procedure several hours after cesarean section, with selective embolization of placental arteries, prior to the practice of hysterectomy, and to present the results. Methods. Case series study, where patients with percrete placenta were evaluated, managed for 1 year in a hospital of fourth level of complexity in the city of Bogotá, Colombia. A fundic cesarean section was performed and the placenta was left in situ, 48 to 72 hours later an ultra-selective embolization was performed, followed by an abdominal hysterectomy after 2 to 3 days.Results. Five patients with a diagnosis of placenta percreta were evaluated; mean wait time between embolization and hysterectomy was 1.6 days. There were no complications associated with embolization, or maternal-fetal morbidity and mortality. Average bleeding volumes during hysterectomy for each patient were 1160 ml. Conclusion. There are limited data on the optimal treatment of percrete placenta. Diagnostic suspicion allows for a favorable planning of intrapartum management and, for this reason, the emergence of new techniques, such as placental artery embolization, constitute alternatives for a safer management of patients.
Subject(s)
Humans , Placenta Accreta , Placenta, Retained , Placenta Previa , Cesarean Section , Embolization, Therapeutic , HysterectomyABSTRACT
Aproximadamente 75% das doenças em vacas leiteiras acontecem no primeiro mês após o parto e esses problemas têm sua origem associada ao sistema imune e ao consumo de alimentos duas a três semanas antes do parto. Doenças relacionadas ao trato reprodutivo como, por exemplo, retenção de placenta pode afetar a eficiência reprodutiva assim como a produção de leite. Os efeitos das doenças nos processos fisiológicos dos animais se transformam em impactos econômicos passíveis de serem mensurados. Objetivou-se avaliar o impacto econômico da retenção de placenta em um rebanho composto de 900 vacas em lactação. O diagnóstico de retenção de placenta foi definido como presença da placenta 24 horas após o parto. Foi utilizado um banco de dados no estudo, do qual foram extraídas as seguintes informações: ano de parição, época de parição, ordem de lactação, presença da placenta 24 horas após o parto, e número de doses de sêmen por gestação. Para cálculo do impacto econômico foram considerados os custos diretos (tratamento, mão de obra, redução da produção de leite e descarte de leite durante o período de tratamento) e indiretos (aumento do período de serviço, aumento do número de doses de sêmen e aumento do risco de descarte). Os valores médios relacionados aos custos foram obtidos junto ao veterinário responsável pela propriedade com referência ao ano de 2009 para que os cálculos fossem realizados. O custo total por ocorrência de retenção de placenta em vacas primíparas no período de chuva e seca foi de US$51,8 e em vacas multíparas foi de US$70,6 e US$87,9 nas épocas de seca e de chuvas, respectivamente. A retenção de placenta apresentou custo para a propriedade no período avaliado de US$8.878,0 ou 19.666 litros de leite. A retenção de placenta apresentou impacto econômico importante na propriedade leiteira nas condições avaliadas.(AU)
Approximately 75% of diseases in dairy cows occur in the first month after parturition and these problems have their origin associated with the immune system and food consumption two to three weeks before parturition. Diseases related to the reproductive tract, such as retained placenta, can affect reproductive efficiency as well as milk production. The effects of diseases on the physiological processes of animals become economic impacts that can be measured. The objective of this study was to evaluate the economic impact of retained placenta on a herd of 900 lactating cows. The diagnosis of placental retention was defined as presence of the placenta 24 hours postpartum. A database was used in the study, from which the following information was extracted: placenta presence 24 hours after calving, year of calving, calving season, and number of semen doses per gestation. In order to calculate the economic impact, the direct costs (treatment, labor, reduction of milk production and milk discharge during the treatment period) and indirect costs (increase in the service period, increase in the number of semen doses and increase of the risk of disposal). The average values related to the costs were obtained from the veterinarian responsible for the property with reference to the year 2009 for the calculations to be carried out. The total cost per occurrence of placenta retention in primiparous cows in the rainy and dry season was US$51.8 and in multiparous cows was US$70.6 and US$87.9 in times of drought and rain, respectively. Retention of placenta presented a cost for the property in the evaluated period of US$8,878.0 or 19,666 liters of milk. Retention of placenta presented a significant economic impact on milk production under the conditions evaluated.(AU)
Subject(s)
Animals , Female , Pregnancy , Infant , Economic Indexes , Cattle/physiology , Placenta, Retained/economicsABSTRACT
Objetivou-se identificar alguns indicadores bioquímicos e hormonais durante o final da gestação e início da lactação de vacas leiteiras sadias, quando comparadas com as que apresentaram algum tipo de transtorno clínico ao longo do experimento. Para tanto, utilizou-se 39 vacas mestiças (holandês x Gir), distribuídas em dois grupos, o primeiro (G1) com 22 animais hígidos e o segundo (G2) com 17 vacas que apresentaram algumas enfermidades (retenção de placenta, endometrite, mastite, pododermatite e distocia materna). O delineamento experimental ocorreu a partir das coletas realizadas nos períodos -60, -40, -20, -10 dias antes do parto, 0 (dia do parto), e +10, +20, +40, +60 dias pós-parto. Analisou-se os metabólitos energéticos (glicose, frutosamina, AGNEs e β-hidroxibutirato), hormonais (insulina e cortisol), proteicos (proteína total, albumina, globulina e ureia) e minerais (CaT, P, Mg, K, Na e Cl). As variáveis estudadas foram interpretadas por meio de análise de variância ao nível de 5% de probabilidade. Analisando o perfil energético, verificou-se uma maior mobilização no G2 durante o periparto, por meio dos menores valores de frutosamina e glicose, além das concentrações superiores de AGNEs e β-hidroxibutirato. O comportamento dos hormônios insulina e cortisol foi similar, observando apenas efeito de momento, cujos maiores concentrações ocorreram no dia do parto. O perfil proteico revelou, pela proteína total apenas efeito de momento, em que seus menores valores foram verificados no dia do parto, contudo, a albumina do G2 foi inferior ao G1 em todos os momentos, já as globulinas do G2 foram superiores ao grupo das vacas hígidas e a ureia apresentou concentrações maiores no G1. Com relação aos minerais o cálcio total, magnésio e cloro apontaram níveis inferiores desde o período inicial das coletas no grupo G2. Conclui-se, que esses metabólitos estudados sinalizaram precocemente a deficiência nutricional durante o final da gestação, repercutindo no período de transição, e comprometendo o mecanismo de adaptação das vacas, com isso aumentando os riscos para maior ocorrência de enfermidades.(AU)
This study aimed to identify some biochemical and hormonal indicators during late pregnancy and early lactation from healthy dairy cows crossbred compared with those who had some type of clinical disorder throughout the experiment. Therefore, we used 39 Crossbred dairy cows (Holstein x Gyr), divided into two groups, the first (G1) with 22 healthy animals and the second (G2) with 17 cows showed some disease (retained placenta, endometritis, mastitis, foot rot and maternal dystocia). The experiment took place from collections made in the period -60, -40, -20, -10 days before delivery, 0 (parturition day), and +10, +20, +40, +60 days postpartum. We analyzed energy metabolites (glucose, fructosamine, NEFA and β-hydroxybutyrate), hormone (insulin and cortisol), protein (total protein, albumin, globulin and urea) and minerals (CaT, P, Mg, K, Na and Cl). The variables studied were interpreted by analysis of variance at 5% probability. Analyzing the energetic profile, there was a greater mobilization in G2 during childbirth, through the lower fructosamine and glucose values, besides higher concentrations of Agnes and β-hydroxybutyrate. The behavior of the hormones insulin and cortisol was similar, noting only effect of time, whose higher levels occurred on the day of delivery. The protein profile revealed by total protein only time effect in their lowest values were recorded on the day of delivery, however, albumin G2 was lower than the G1 at all times, since the G2 globulin were higher than the group of otherwise healthy cows and urea showed higher concentrations in G1. With respect to the total mineral calcium, magnesium and chlorine showed lower levels from the initial period of the collections in G2. It follows that these metabolites studied early signal nutritional deficiency during late pregnancy, reflecting the transition period, and compromising the adjustment mechanism for cows, thereby increasing the risks to higher incidence of disease.(AU)
Subject(s)
Animals , Female , Pregnancy , Cattle , Biomarkers/blood , Cattle/blood , Lactation/blood , Pregnancy Complications/veterinary , Cattle/physiologyABSTRACT
O cruzamento com a raça Jersey vem sendo utilizado principalmente como alternativa para o aumento da concentração de sólidos do leite em rebanhos puros Holandês, sendo a capacidade de produção desses animais conhecida em diversos estudos. Entretanto, ainda existem limitadas informações sobre diversos fatores relevantes para a tomada de decisão e para o manejo de rebanhos cruzados, tais como resistência a doenças e facilidade de parto, sendo esta a motivação do presente trabalho, o qual objetivou avaliar a sanidade, a imunidade e a facilidade de parto de vacas mestiças Holandês x Jersey em relação a vacas puras Holandês. Foram analisados dados de dificuldade de parto, duração da gestação, retenção de placenta, indicadores sanguíneos para doenças metabólicas pós-parto (cetose e paresia puerperal hipocalcêmica) e de imunidade obtidos em vacas mestiças Holandês x Jersey e puras Holandês durante o período de um ano. O grupamento genético não afetou a facilidade de parto (P=0,4376), a retenção de placenta (P=0,7074) e a duração da gestação (P=0,2812). Vacas mestiças apresentaram maiores concentrações de gamaglobulinas (1,776 contra 1,456g/dL) e de proteína total (7,019 contra 6,525g/dL). Quanto à concentração de ß-hidroxibutirato (BHBA), ocorreu diferença somente no dia do parto, com valores mais altos para as vacas mestiças (0,580 contra 0,427mmol/L). Observou-se diferença entre grupamentos genéticos para concentração de cálcio iônico (P=0,082), com vacas mestiças apresentando concentração mais baixa (3,92 contra 4,3 mg/dL). Conclui-se que vacas mestiças apresentam melhor performance em indicadores de imunidade e pior nos indicadores de cetose e paresia puerperal hipocalcêmica no pós-parto em relação às puras Holandês. O cruzamento não aumenta o risco de distocia em vacas inseminadas com touros Holandês.(AU)
The crossbreed with the Jersey breed has been used mainly as an alternative to increasing the concentration of milk solids in Holstein herds, the production capacity of these animals having become the focus of several studies. However, there is still limited information on many relevant factors for decision-making and management of crossbreed herds, such as disease resistance and ease of calving, and this is the motivation for this work, which aimed to evaluate the health, immunity and calving difficulty in Holstein x Jersey crossbred cows compared to pure Holstein cows. Data from calving difficulty, retained placenta, gestation length, blood indicators for postpartum metabolic diseases (ketosis and hypocalcemic puerperal paresis) and immunity in a herd composed by crossbreeds and Holstein cows during one year was analyzed. The genetic groups did not affect ease of calving (P = 0.4376), retained placenta (P = 0.7074) and gestation length (P=0.2812). Crossbred cows had higher concentrations of gammaglobulins (1.776 versus 1.456g/dL) and total protein (7.019 versus 6.525g/dL). For the concentration of BHBA, differences occurred only at calving, with higher values for crossbred cows (0.580 versus 0.427mmol/L). Difference was observed between genetic groups for concentration of ionized calcium (P = 0.082), with crossbred cows presenting lower concentrations (3.92 versus 4.3mg/dL). In conclusion, crossbred cows have superior performance compared to Holstein cows for immunity indicators and lower for hypocalcemic puerperal paresis and ketosis indicators on the day of calving. Crossbred cows do not have an increased risk of dystocia in relation to pure Holstein cows when mated with Holstein bulls.(AU)
Subject(s)
Animals , Female , Cattle , Immunity/genetics , Immunoglobulins , Ketosis/veterinary , Parturient Paresis/genetics , Placenta, Retained/veterinary , Postpartum Period/genetics , Crosses, GeneticABSTRACT
Objective To investigate the diagnostic value and imaging characteristics of MRI in the placenta accreta of patients with retained placenta.Methods Archieves of patients with retained placenta confirmed by clinical pathology were reviewed,with focus on imaging findings of MRI,including location of and signal intensity of placenta attach,hematometra,presence and absence of placenta accreta,signal intensity of retained placenta,shape,margin and border of retained placenta.The imaging characteristics were analysized with blindness and compared between patients with and without placenta accreta.Diagnostic value of MRI and ultrasound for the placenta accreta of patients with retained products of conception was assessed.Results There was no significant difference between the two groups of MRI characteristics except that the edge of the placenta was not clear.The sensitivity,specificity,accuracy,positive predictive value and negative predictive value for the evaluation of placenta accreta by MRI and ultrasound were 93.8% vs 56.3%,90.9% vs 90.9%,92.6%vs 70.4%,0.94 vs 0.9,0.91 vs 0.59,respectively;there were significant differences between MRI and ultrasound for sensitivity, specificity and negative predictive value.Conclusion M RI is substantially better than ultrasound for the diagnosis of placenta accreta. The unclear placenta edge and signs of placental infiltration of the myometrium are the basis for MRI diagnosis of placenta accreta.
ABSTRACT
We present a case of retained placenta accreta treated by high-intensity focused ultrasound (HIFU) ablation followed by hysteroscopic resection. The patient was diagnosed as submucosal myoma based on ultrasonography in local clinic. Pathologic examination of several pieces of tumor mass from the hysteroscopic procedure revealed necrotic chorionic villi with calcification. HIFU was performed using an ultrasound-guided HIFU tumor therapeutic system. The ultrasound machine had been used for real-time monitoring of the HIFU procedure. After HIFU treatment, no additional vaginal bleeding or complications were observed. A hysteroscopic resection was performed to remove ablated placental tissue 7 days later. No abnormal vaginal bleeding or discharge was seen after the procedure. The patient was stable postoperatively. We proposed HIFU and applied additional hysteroscopic resection for a safe and effective method for treating retained placenta accreta to prevent complications from the remaining placental tissue and to improve fertility options.
Subject(s)
Humans , Chorionic Villi , Fertility , High-Intensity Focused Ultrasound Ablation , Methods , Myoma , Placenta, Retained , Ultrasonography , Uterine HemorrhageABSTRACT
We present a case of retained placenta accreta treated by high-intensity focused ultrasound (HIFU) ablation followed by hysteroscopic resection. The patient was diagnosed as submucosal myoma based on ultrasonography in local clinic. Pathologic examination of several pieces of tumor mass from the hysteroscopic procedure revealed necrotic chorionic villi with calcification. HIFU was performed using an ultrasound-guided HIFU tumor therapeutic system. The ultrasound machine had been used for real-time monitoring of the HIFU procedure. After HIFU treatment, no additional vaginal bleeding or complications were observed. A hysteroscopic resection was performed to remove ablated placental tissue 7 days later. No abnormal vaginal bleeding or discharge was seen after the procedure. The patient was stable postoperatively. We proposed HIFU and applied additional hysteroscopic resection for a safe and effective method for treating retained placenta accreta to prevent complications from the remaining placental tissue and to improve fertility options.
Subject(s)
Humans , Chorionic Villi , Fertility , High-Intensity Focused Ultrasound Ablation , Methods , Myoma , Placenta, Retained , Ultrasonography , Uterine HemorrhageABSTRACT
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.
ABSTRACT
Calving records of Holstein dairy cows from 2005 to 2010 comprising Goyang and Paju cities herd with 2,362 calving events representing 240 twin births were used to evaluate the effect of abomasal displacement and retained placenta after single or twin births on fertility. In retained placenta cows, the period of twin pregnancy (mean 270.5 days) was shorter than that of single pregnancy (mean 274.8 days), however first artificial insemination period (twin: mean 107.4 days, single: mean 92.0 days), non-pregnant period (twin: 154.8 days, single: 132.2 days), and number of insemination (twin: mean 2.00 times, single: mean 1.87 times) of twin pregnancy were increased as compared with single pregnancy. In abomasal displacement cows, first artificial insemination period (twin: mean 122.9 days, single: mean 106.0 days), non-pregnant period (twin: 172.4 days, single: 152.0 days), and number of insemination (twin: mean 2.16 times, single: mean 1.89 times) of twin pregnancy were increased as compared with single pregnancy. The prevalence of complication such as retained placenta, abomasal displacement with single or twin births increased first artificial insemination period, non-pregnant period, and number of insemination period.
Subject(s)
Humans , Pregnancy , Displacement, Psychological , Fertility , Insemination , Insemination, Artificial , Korea , Parturition , Placenta, Retained , Pregnancy, Twin , Prevalence , TwinsABSTRACT
The objective of this study was to evaluate the duration of retained placenta (RP) on postpartum diseases and culling in dairy cows. Data were collected from 456 Holstein cows between 2008 and 2010. RP (> or = 24 h after parturition) and postpartum diseases were diagnosed by farm managers and a veterinarian according to standardized definitions. The overall incidence rate of RP was 14.0%, and the incidence rate of RP with fourth and higher parity was two times that of cows having offspring for the first time. The duration of RP was 2 to 15 days with a mean of 6.8 days, except for cases of fourth and higher parity which had a mean of 10.5 days. A total of 63% of cows with RP had postpartum diseases. Among the cows diagnosed with RP, 23.4% developed metritis, and of those, 35.3% developed endometritis or pyometra. A total of 25% (n = 16) cows with RP were culled within 60 days in milk (DIM) and of those culled, 75% (n = 12) had postpartum diseases. These results suggest that RP increases the risk of postpartum diseases such as metritis and mastitis and is a culling hazard up to 60 DIM.
Subject(s)
Female , Humans , Endometritis , Incidence , Mastitis , Milk , Parity , Placenta, Retained , Postpartum Period , Pyometra , VeterinariansABSTRACT
Uterine sacculation is a very rare complication associated with pregnancy in which a part of the uterine wall balloons, and it is difficult to diagnose because it is usually asymptomatic. It frequently contains the placenta and sometimes may be involved with the trapped placenta after delivery due to its structural characteristic. It is impossible to remove the retained placenta in the sac by using usual methods such as manual delivery or curettage so most of patients with it end up with having a laparotomy. Especially, if the placenta in it is accompanied by abnormal adherence of the placenta or serious hemorrhage, hysterectomy should be considered. Currently several conservative methods for the retained placenta including selective uterine artery embolization and administration of methotrexate have been introduced and these may be tried to treat the retained placenta in the uterine sacculation for avoiding operation and preserving future reproductive potential in selective cases. We experienced a case of placenta increta in the uterine sacculation that was diagnosed first during cesarian section and was treated with selective uterine artery embolization followed by methotrexate administration. This case is reported with a brief review of the literatures.
Subject(s)
Humans , Pregnancy , Curettage , Hemorrhage , Hysterectomy , Laparotomy , Methotrexate , Placenta Accreta , Placenta , Placenta, Retained , Uterine Artery EmbolizationABSTRACT
Uterine sacculation is a very rare complication associated with pregnancy in which a part of the uterine wall balloons, and it is difficult to diagnose because it is usually asymptomatic. It frequently contains the placenta and sometimes may be involved with the trapped placenta after delivery due to its structural characteristic. It is impossible to remove the retained placenta in the sac by using usual methods such as manual delivery or curettage so most of patients with it end up with having a laparotomy. Especially, if the placenta in it is accompanied by abnormal adherence of the placenta or serious hemorrhage, hysterectomy should be considered. Currently several conservative methods for the retained placenta including selective uterine artery embolization and administration of methotrexate have been introduced and these may be tried to treat the retained placenta in the uterine sacculation for avoiding operation and preserving future reproductive potential in selective cases. We experienced a case of placenta increta in the uterine sacculation that was diagnosed first during cesarian section and was treated with selective uterine artery embolization followed by methotrexate administration. This case is reported with a brief review of the literatures.
Subject(s)
Humans , Pregnancy , Curettage , Hemorrhage , Hysterectomy , Laparotomy , Methotrexate , Placenta Accreta , Placenta , Placenta, Retained , Uterine Artery EmbolizationABSTRACT
The objectives of this study were to determine the risk factors for retained placenta by evaluating several reproductive factors in individual cows, and to determine the effects of retained placenta on the occurrence of postpartum diseases and subsequent reproductive performance in dairy herds. The health status, cow parity, calving, and breeding dates were recorded from 805 calvings in nine dairy herds from October 2000 to March 2004. We used logistic regression to evaluate the effects of these factors on the incidence of retained placenta. A stepwise procedure, used to obtain the appropriate model with alpha = 0.05, revealed that abnormal partus and gestation length were important risk factors for retained placenta. The occurrence of endometritis and metabolic disorders was greater (p<0.01) in the group with retained placentas than in the control group. The mean intervals from calving to first service and conception were prolonged (p<0.05) by 7 and 18 days, respectively, in the group with retained placentas compared to the control group. These results suggest that abnormal partus and gestation length are strongly correlated with the development of retained placenta, which increases the occurrence of postpartum diseases and subsequently decreases reproductive performance in dairy herds.
Subject(s)
Animals , Cattle , Female , Pregnancy , Cattle Diseases/epidemiology , Dairying , Korea/epidemiology , Logistic Models , Obstetric Labor Complications/veterinary , Parity , Parturition , Placenta, Retained/physiopathology , Postpartum Period , Puerperal Disorders/epidemiology , Reproduction , Risk FactorsABSTRACT
Retained placenta around which the uterus firmly contracted occurs in about 1% of all vaginal deliveries and may require uterine muscle relaxation to facilitate manual extraction. It is associated with profuse hemorrhage and life threatening shock. Therefore anesthesiologist may face the difficulty to provide analgesia and rapid uterine relaxation. A 32-yr-old multigravida was transferred to the emergency room in hypovolemic shock state at 1 hour after vaginal delivery. Ketamine 30 mg, fentanyl 50 mcg were given intravenously for analgesia and sedation. Oxygen 6 L/min was supplied via face mask. With ongoing fluid resuscitation, nitroglycerin 500 mcg was injected as an intravenous bolus. Within 80 seconds, the uterus relaxed enough to extract the retained placenta. The recovery of uterine muscle tone occurred approximately 1 minute after manual removal with administration of intravenous methylergonovine. In summary, the use of intravenous nitroglycerin may be a useful and safe alternative to general anesthesia in cases of manual removal of retained placenta.