***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE To evaluate the efficacy and safety of misoprostol among patients with retained placenta in a low-re source setting . METHODS A prospect i ve , multicenter , r and omized , double-blind , placebo-controlled trial was carried out in Tanzania between April 2008 and November 2011 . It included patients who delivered at a gestational age of 28 weeks or more and had blood loss of 750 mL or less at 30 minutes after delivery .  Sublingual misoprostol ( 800 μg ) was compared with placebo as the primary treatment . Power analysis showed that 117 patients would be required to observe a reduction of 40 % in the incidence of manual removal of the placenta ( MRP ; P=0.05 , 80 % power ) , the primary outcome . The secondary outcomes were blood loss and number of blood transfusions . RESULTS Interim analysis after recruitment of 95 patients showed that incidence of MRP , total blood loss , and incidence of blood transfusions were similar in the misoprostol ( MRP , 40 % ; blood loss , 803 mL ; blood transfusion , 15 % ) and placebo ( MRP , 33 % , blood loss 787 mL , blood transfusion , 23 % ) groups . The trial was stopped because continuation would not alter the interim conclusion that misoprostol was ineffective . CONCLUSION Treatment with misoprostol was found to have no clinical ly significant beneficial effect among women with retained placenta . CLINICAL TRIAL REGISTRATION Current Controlled Trials IS RCT N16104753 OBJECTIVE To assess the effect of injecting an uterotonic agent in the umbilical vein during the third stage of labor in women with retained placentas . METHODS In this prospect i ve clinical study , 75 women with retained placentas received 20 mL of a 0.9 % saline solution with either 20 IU of oxytocin ( n=54 ) , 0.5 mg of carboprost tromethamine ( n=7 ) , or 0.2 mg of methylergometrine ( n=14 ) injected in the umbilical vein after clamping . The treatment success was determined by the clinical signs of placental ablation . RESULTS There were no statistically significant differences among the 3 therapeutic groups regarding age , parity , risk factors , pregnancy duration , type of delivery ( spontaneous , induced , or augmented ) , or possible early postpartum complications caused by the intraumbilical injection . The rates of therapeutic success were 76.9 % in the oxytocin group , 85.7 % in the synthetic prostagl and in group , and 64.2 % in the methylergometrine group . CONCLUSION The intraumbilical injection of uterotonics is a noninvasive , effective , and clinical ly safe method of shortening the third stage of labor in women with retained placentas OBJECTIVE The purpose of this study was to determine the extent that the administration of sulprostone reduces the need for manual removal of the placenta in patients with retained placenta . STUDY DESIGN A double-blinded sequential r and omized controlled trial of sulprostone versus placebo was conducted among 103 patients with retained placenta . RESULTS In the first phase of this sequential study , sulprostone was compared with placebo . The null hypothesis of equal effectiveness of both treatments was rejected after 50 patients . In patients with retained placenta , the placenta was expelled after sulprostone in 13 of 24 cases ( 51.8 % , bias adjusted ) , whereas expulsion after placebo was achieved in only 4 of 26 cases ( 17.6 % , bias adjusted ) . The difference was significant ( P = .034 ) . In the second phase of the study , in which the placebo arm was stopped , results were confirmed ; in 25 of 53 patients ( 47 % ) , the placenta was expelled . CONCLUSION Sulprostone reduces the need for the manual removal of the placenta by 49 % Background . Manual removal of placenta is performed in 1–3 % of cases , and whilst a well established and relatively safe procedure , it is not without complications , which include infection , hemorrhage , uterine rupture , and occasional maternal death . Methods . A three‐arm r and omized controlled trial of 50 IU Syntocinon ( in 30 ml N saline ) versus 800 mcg misoprostol ( in 30 ml N saline ) versus 30 ml N saline alone ( control ) , injected into the placental bed via the umbilical vein using the Pipingas method . A group sequential research model ( triangular test : PEST4 ) was adopted to minimize the sample size , as retained placenta is a relatively uncommon condition . Results . No significant difference in the rate of manual removal was observed between the control and  Syntocinon  groups . On triggering the automatic stopping rule for this arm of the trial all subsequent cases recruited were allocated to receive either Syntocinon or misoprostol . After a total of 54 cases a significant reduction in manual removal of placenta was observed in the  misoprostol  group , triggering the automatic stopping rule and terminating the trial . Conclusion . Misoprostol ( 800 mcg ) dissolved in 30 ml N saline and administered by intraumbilical injection using the Pipingas technique significantly reduces the need for manual removal for retained adherent placenta , whereas Syntocinon has similar effectiveness to injection of N saline alone The length of the third stage of labour is a potential modifiable risk factor for  postpartum haemorrhage at vaginal delivery , but there is no definitive evidence that early intervention to remove the placenta manually will prevent postpartum haemorrhage . We report a wide variation between countries in Europe in policies about the timing of manual removal of placenta .  Two groups of countries with clearly divergent policies were identified . A r and omised controlled trial is needed to provide definitive evidence on the risks and benefits of manual removal of placenta at different timings after vaginal delivery INTRODUCTION This study aim ed to determine the incidence of , and identify independent risk factors to retained placenta in Ile-Ife , southwestern Nigeria . METHODS This was a prospect i ve case-control study involving 120 women with retained placenta after vaginal birth at the Obafemi Awolowo University Teaching Hospital , Ile-Ife , southwestern Nigeria over a period of seven years . Two consecutive normal deliveries after each retained placenta served as controls . Following a bivariate analysis , a multivariate logistic regression model was constructed in order to define independent risk factors for retained placenta while controlling for confounding variables . RESULTS During the study period , there were 120 cases of retained placenta , and the total number of deliveries was 6,160 , making the incidence 1.9 percent . Independent risk factors associated with retained placenta include non-use of antenatal care  ( odds-ratio [ OR ] 22.71 , 95 percent confidence interval [ CI ] 10.5 - 49.12 , p-value is less than 0.000 ) , previous retained placenta ( OR 15.22 , 95 percent CI 3.30 - 70.19 , p-value is less than 0.000 ) , previous caesarean section ( OR 12.00 , 95 percent CI 2.05 - 70.19 , p-value is less than 0.006 ) , maternal age 35 years or more ( OR 7.10 , 95 percent CI 1.5 - 32.40 , p-values is less than 0.012 ) , gr and multiparity  ( OR 6.63 , 95 percent CI 1.88 - 23.40 , p-value is less than 0.003 ) , previous dilatation and curettage ( OR 4.44 , 95 percent CI 1.69 - 11.63 , p-value is less than 0.002 ) , preterm delivery ( OR 3.12 , 95 percent CI 1.12 - 8.68 , p-value is less than 0.029 ) and placenta weight less than 501 g ( OR 2.91 , 95 percent CI 1.34 - 6.32 , p-value is less than 0.007 ) . CONCLUSION Women with identifiable risk factors should be targeted for the prevention of retained placenta . There is a need for the training of birth attendants in the proper conduct of delivery and third stage of labour to prevent placenta retention and postpartum haemorrhage OBJECTIVE : To identify risk factors for immediate postpartum hemorrhage after vaginal delivery in a South American population . METHODS : This was a prospect i ve cohort study including all vaginal births ( N=11,323 ) between October and December 2003 and October and December 2005 from 24 maternity units in two South American countries ( Argentina and Uruguay ) .  Blood loss was measured in all births using a calibrated receptacle . Moderate postpartum hemorrhage and severe postpartum hemorrhage were defined as blood loss of at least 500 mL and at least 1,000 mL , respectively . RESULTS : Moderate and severe postpartum hemorrhage occurred in 10.8 % and 1.9 % of deliveries , respectively . The risk factors more strongly associated and the incidence of moderate postpartum hemorrhage in women with each of these factors were : retained placenta ( 33.3 % ) ( adjusted odds ratio [ OR ] 6.02 , 95 % confidence interval [ CI ] 3.50–10.36 ) , multiple pregnancy ( 20.9 % ) ( adjusted OR 4.67 , CI 2.41–9.05 ) , macrosomia ( 18.6 % ) ( adjusted OR 2.36 , CI 1.93–2.88 ) , episiotomy ( 16.2 % ) ( adjusted OR 1.70 , CI 1.15–2.50 ) , and need for perineal suture ( 15.0 % ) ( adjusted OR 1.66 , CI 1.11–2.49 ) . Active management of the third stage of labor , multiparity , and low birth weight were found to be protective factors . Severe postpartum hemorrhage was associated with retained placenta ( 17.1 % ) ( adjusted OR 16.04 , CI 7.15–35.99 ) , multiple pregnancy ( 4.7 % ) ( adjusted OR 4.34 , CI 1.46–12.87 ) , macrosomia ( 4.9 % ) ( adjusted OR 3.48 , CI 2.27–5.36 ) , induced labor ( 3.5 % ) ( adjusted OR 2.00 , CI 1.30–3.09 ) , and need for perineal suture ( 2.5 % ) ( adjusted OR 2.50 , CI 1.87–3.36 ) . CONCLUSION : Many of the risk factors for immediate postpartum hemorrhage in this South American population are related to complications of the second and third stage of labor . LEVEL OF EVIDENCE : OBJECTIVE To determine the frequency , causes and outcome of patients with retained placenta . METHODS Descriptive case series . This study was carried out at Liaquat University Hospital , Gynae Unit-I , from January 2005 to December 2007 . Two years retrospective and one year prospect i ve analysis of patients was done according to age , parity , causes , place of delivery , person who conducted the delivery , conservative and surgical procedures , maternal morbidity and mortality . Patients were examined and appropriate investigations were done . The patients who came with or developed retained placenta at Liaquat University Hospital were included in the study . The patients having retained placenta due to uterine abnormalities were excluded from the study . All the information was collected on a pre design ed proforma and analyzed on SPSS version 10.0 . RESULTS About 8782 patients were admitted during the specified period . Ninety patients had retained placenta . Frequency of retained placenta was 37.7 % in women of age group 26 to 30 years , 26.6 % upto age of 35 years , 22.2 % in age 20 - 25 years , it was low between 36 - 40 years of age , while the frequency was high in women of low parity ( 44.4 % ) . Causes included augmentation by oxytocics in 38.8 % , manipulation 38.8 % , inertia 14.4 % and tumour ( fibroid ) 7.7 % . Majority of patients ( 60 % ) had a home delivery . Delivery by Dai was done in 72.2 % . The commonest complication was anaemia 48.8 % , followed by puerperal pyrexia 24.4 % , hypovolaemic shock 22.2 % , acute renal failure 3.3 % and hepatic failure in 1.1 % respectively . CONCLUSION Retained placenta is a frequent cause of maternal morbidity in Pakistan Background Retained placenta is one of the common causes of maternal mortality in developing countries where access to appropriate obstetrical care is limited . Current treatment of retained placenta is manual removal of the placenta under anaesthesia , which can only take place in larger health care facilities . Medical treatment of retained placenta with prostagl and ins E1 ( misoprostol ) could be cost-effective and easy-to-use and could be a life-saving option in many low-re source setting s. The aim of this study is to assess the efficacy and safety of sublingually administered misoprostol in women with retained placent 
    Output:
    
Use of prostagl and ins result ed in less need for manual removal of placenta , severe postpartum haemorrhage and blood transfusion but none of the differences reached statistical significance .
Much larger , adequately powered studies are needed to confirm that these clinical ly important beneficial effects are not just chance findings .Similarly , no differences were detected between prostagl and ins and placebo in mean blood loss or the mean time from injection to placental removal ( minutes ) or side-effects ( vomiting , headache , pain and nausea between injection and discharge from the labour ward ) except for ' shivering ' which was more frequent in women who received prostagl and in .