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OBJECTIVE:To evaluate the efficacy of pharmacologic interventions on the need for manual extraction of retained placenta or D&C. STUDY DESIGN: A systematic review of peer-reviewed English-language articles was conducted using PubMed, Cochrane Library, and Scopus. All randomized controlled trials that met our inclusion criteria were compiled and data was abstracted for the meta-analysis. Types of interventions included were oxytocin, prostaglandin, nitroglycerin, and ergometrine. The primary outcome evaluated were the need for manual extraction of placenta or D&C. Risk ratios were estimated based on random and fixed effects analyses. Interstudy heterogeneity was deemed present when I 2 3 50%. RESULTS: There were 15 RCTs that met our inclusion and exclusion criteria comparing interventions (oxytocin, prostaglandin and nitroglycerin; n¼1,083) to a control/placebo (n¼1,121; Figure 1). The use of any intervention was associated with a decreased need for manual extraction (RR 0.79, 95% confidence interval [CI] 0.69, 0.91). Oxytocin was the only intervention that showed a statistically significant improvement in the primary outcome (RR 0.68, 95% CI .52, .90). There were 10 included RCT's that compared oxytocin (n¼908) to other interventions including prostaglandin, carbetocin and ergometrine (n¼882, Figure 2). Overall, oxytocin was inferior to all three other interventions (RR 1.28, 95 CI 1.03, 1.60). In a planned sub-group analysis, carbetocin was associated with reduced risk of manual removal by 53% (RR 1.47, 95% CI 1.03, 2.10). CONCLUSION: Administration of any pharmacologic intervention is superior to control/placebo in reducing need for manual extraction of placenta or D&C. Carbetocin is superior to oxytocin in reducing need for manual extraction, although this drug remains commercially unavailable in the USA.

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