Tocolysis for management of retained placenta.
BACKGROUND
Retained placenta affects 0.5% to 3% of women following delivery, with considerable morbidity if left untreated. Use of tocolytics, either alone or in combination with uterotonics, may be of value to minimise the need for manual removal of the placenta in theatre under anaesthesia.


OBJECTIVE
Evaluate the benefits and harms of tocolytics alone or in addition to uterotonics in the management of retained placenta in order to reduce the need for manual removal of placenta.


METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2010) and contacted experts in the field.


METHODS
Any adequately randomised controlled trial (RCT) comparing the use of tocolytics, either alone or in combination with uterotonics, with no intervention or with other interventions in the management of retained placenta. All women having a vaginal delivery with a retained placenta, regardless of the management of the third stage of labour (expectant or active). We included all trials with haemodynamically stable women in whom the placenta was not delivered at least within 15 minutes after delivery of the baby.


METHODS
Two review authors independently assessed trial quality and extracted data. Consultation of the third author was done if needed.


RESULTS
We included one RCT (involving 24 women). It compared the use of nitroglycerin tablets versus placebo after the treatment with oxytocin failed. There was a statistically significant reduction in the need for manual removal of placenta (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.66). There was also a statistically significant reduction in mean blood loss during the third stage of labour (mean difference (MD) -262.50 ml, 95% CI -364.95 to -160.05). Sublingual nitroglycerin caused some haemodynamic changes as it lowers the systolic blood pressure and diastolic blood pressure by a means of 6 and 5 mmHg respectively. Pulse rate increased by a mean of two beats per minute.


CONCLUSIONS
Sublingual nitroglycerin, given when oxytocin fails, seems to reduce both the need for manual removal of placenta and blood loss during the third stage of labour when compared to placebo. Further trials are needed to confirm its clinical role and safety. Its routine use cannot be recommended based on a single small study. There is no evidence available for other types of tocolytics.
Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University Hospital, Assiut, Egypt, 71511.
Hany
H
Abdel-Aleem
Mahmoud A
MA
Abdel-Aleem
Omar M
OM
Shaaban
D000286:Administration, Sublingual; D005260:Female; D006801:Humans; D005996:Nitroglycerin / Q000008:administration & dosage / Q000627:therapeutic use*; D010120:Oxytocics / Q000627:therapeutic use; D010121:Oxytocin / Q000627:therapeutic use; D018457:Placenta, Retained / Q000188:drug therapy*; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D015145:Tocolysis / Q000379:methods*; D015149:Tocolytic Agents / Q000008:administration & dosage / Q000627:therapeutic use*
D010120:Oxytocics; D015149:Tocolytic Agents; D010121:Oxytocin; D005996:Nitroglycerin