What is the recommended management for retained products of conception?

Management of Retained Products of Conception

Hysteroscopic removal is the recommended first-line management for retained products of conception (RPOC) to reduce risks of hemorrhage, infection, and future fertility complications. 1

Diagnosis

Clinical Presentation

• Persistent vaginal bleeding
• Abdominal/pelvic pain
• Dilated cervix
• Fever or signs of infection

Diagnostic Criteria

• Ultrasound findings:
  • Endometrial mass or focal endometrial thickening
  • Endometrial thickness >10mm (high positive predictive value)
  • Presence of vascularity on Doppler imaging within the endometrial abnormality
  • Enhanced myometrial vascularity (EMV) - focal vascularity deep to prior implantation site

Management Algorithm

First-line Treatment

1. Hysteroscopic removal under direct visualization
   • Preferred over blind procedures (D&C) to minimize:
     • Acute complications: bleeding, infection, uterine perforation
     • Long-term complications: intrauterine adhesions (IUAs)

Alternative Approaches

1. Office aspiration with Karman cannula

   • For suitable cases with confirmed RPOC on Doppler ultrasound
   • 90% success rate in avoiding need for hysteroscopy 2
   • Average pain score of 4.9/10 during procedure

2. Medical management

   • Consider in hemodynamically stable patients without signs of infection
   • May be attempted before surgical intervention
   • Success rates lower than surgical management

3. Traditional suction curettage

   • Higher risk of incomplete evacuation (3.1% requiring repeat procedure) 3
   • Higher risk of intrauterine adhesion formation
   • Should be avoided in favor of hysteroscopic approach when possible

Special Considerations

Risk Assessment

• Higher risk of complications:
  • History of cesarean delivery or uterine surgery (risk of placenta accreta spectrum) 4
  • History of sharp curettage (risk of arteriovenous fistula) 1
  • Presence of adenomyosis (may complicate removal) 5

Timing

• Optimal timing is within 5 weeks postpartum/post-abortion 1
• Delayed intervention increases risk of adhesion formation

Follow-up

• Post-procedure ultrasound to confirm complete removal
• Clinical follow-up to ensure resolution of symptoms
• Consider hysteroscopy 2-3 months after treatment if fertility is desired to assess for intrauterine adhesions 1

Potential Complications

Immediate Complications

• Persistent vaginal bleeding
• Infection and endometritis
• Pelvic pain

Long-term Complications

• Intrauterine adhesion formation (Asherman syndrome)
• Subfertility/infertility
• Menstrual disturbances
• Increased risk of abnormal placentation in future pregnancies (including placenta accreta spectrum) 5

Important Cautions

• Blind procedures like dilation and curettage should be avoided due to higher risk of complications 5
• Reliance solely on ultrasound for diagnosis has a high false-positive rate (34% overall, 51.5% postpartum) 6
• Enhanced myometrial vascularity should not be confused with arteriovenous malformation/fistula, which is a rare complication 1

Hysteroscopic management has been shown to be highly effective with lower complication rates compared to traditional methods, making it the preferred approach for treating RPOC 7.