The standard treatment for retained placenta is manual extraction, in which a hand is introduced inside the uterus to cleave a plane between the placenta and the uterine wall. For women without an epidural, the procedure is extremely uncomfortable and may require additional measures such as intravenous narcotics or regional anesthesia. Although ultrasound-guided instrumental removal of the placenta is standard practice as part of second-trimester abortion by dilation and evacuation and may be done at many institutions, especially after failed manual extraction, it has not yet been described in the literature as a technique following vaginal birth. Our experience with this technique is that it causes less discomfort to the patient than a traditional manual extraction, because the instrument entering the uterus is much narrower than a hand. With the patient in dorsal lithotomy, we locate the cervix and stabilize it either with fingers or a ring forceps on the anterior lip. We introduce Bierer ovum forceps into the uterus under direct ultrasound guidance. The Bierer forceps are preferred because of their long length, large head, and serrated teeth that allow for a firm, secure grip on the placenta. We grasp the placental tissue with the forceps and apply slow, gentle traction in short strokes, regrasping increasingly more distal areas of placenta as necessary to tease out the placenta. After 1-2 minutes, the placenta separates and can be pulled out of the uterus, usually intact. Our experience suggests that this technique is a well-tolerated option for women without an epidural who have a retained placenta. Further study is needed to quantify the amount of discomfort and anesthesia that can be avoided with this technique, as well as whether there is any change in the frequency of infectious complications or the necessity of postremoval curettage.

In the Americas, women with Indigenous American ancestry are at increased risk of intrahepatic cholestasis of pregnancy (ICP), relative to women of other ethnicities. We hypothesized that ancestry-related genetic factors contribute to this increased risk. We collected clinical and laboratory data, and performed biochemical assays on samples from U.S. Latinas and Chilean women, with and without ICP. The study sample included 198 women with ICP (90 from California, U.S., and 108 from Chile) and 174 pregnant control women (69 from California, U.S., and 105 from Chile). SNP genotyping was performed using Affymetrix arrays. We compared overall genetic ancestry between cases and controls, and used a genome-wide admixture mapping approach to screen for ICP susceptibility loci. We identified commonalities and differences in features of ICP between the 2 countries and determined that cases had a greater proportion of Indigenous American ancestry than did controls (p = 0.034). We performed admixture mapping, taking country of origin into account, and identified one locus for which Native American ancestry was associated with increased risk of ICP at a genome-wide level of significance (P = 3.1 x 10(-5), Pcorrected = 0.035). This locus has an odds ratio of 4.48 (95% CI: 2.21-9.06) for 2 versus zero Indigenous American chromosomes. This locus lies on chromosome 2, with a 10 Mb 95% confidence interval which does not contain any previously identified hereditary 'cholestasis genes.' Our results indicate that genetic factors contribute to the risk of developing ICP in the Americas, and support the utility of clinical and genetic studies of ethnically mixed populations for increasing our understanding of ICP.