What is the management of retained products of conception?

Management of Retained Products of Conception

The management of retained products of conception (RPOC) should follow a stepwise approach, with initial diagnosis by ultrasound followed by appropriate intervention based on clinical presentation, with surgical evacuation being the most definitive treatment for symptomatic cases.

Diagnosis

• Transvaginal ultrasound combined with transabdominal approach provides the most comprehensive evaluation for RPOC, with color and spectral Doppler to assess internal vascularity patterns 1
• Diagnostic findings include intracavitary tissue with internal vascularity or persistent gestational sac following early pregnancy loss 2
• An endometrial thickness less than 10 mm has a high negative predictive value for incomplete early pregnancy loss, while vascular flow in the endometrial cavity increases the likelihood that tissue is present 2
• Bedside ultrasound in the emergency department can provide rapid diagnosis in symptomatic patients 3

Management Options

Medical Management

• Prostaglandin analogues can be effective for medical management of RPOC, potentially avoiding surgical intervention in some cases 4
• Oxytocin may be used for treatment of incomplete abortion via intravenous infusion: 10 units added to 500 mL of physiologic saline solution, infused at 20-40 drops/minute 5

Surgical Management

• Surgical evacuation remains the standard treatment for symptomatic RPOC to prevent complications 4, 6
• Options include:
  1. Dilation and Curettage (D&C): Traditional approach but carries risk of incomplete evacuation (3.1% requiring repeat procedure) 7
  2. Hysteroscopic Removal: Associated with increased surgical success and decreased postoperative intrauterine adhesions compared to blind D&C 8

Approach Based on Clinical Presentation

• For hemodynamically unstable patients with heavy bleeding: Immediate surgical evacuation is indicated 2
• For stable patients with minimal symptoms: Medical management may be attempted first, with surgical intervention if unsuccessful 4
• For patients with confirmed RPOC on imaging with moderate symptoms: Hysteroscopic removal is preferred over traditional D&C when available 8

Special Considerations

• Patients with history of cesarean delivery or other risk factors for abnormal placentation require careful evaluation, as RPOC may represent undiagnosed placenta accreta spectrum disorder 2, 6
• Enhanced myometrial vascularity on ultrasound is a common finding after pregnancy and should not be confused with arteriovenous fistula (rare complication of sharp curettage) or arteriovenous malformation 2
• In cases of suspected placenta accreta spectrum with RPOC, conservative management may be considered in select cases to preserve fertility, though this approach should be considered investigational 2

Follow-up

• After any intervention for RPOC, follow-up ultrasound is recommended to ensure complete evacuation 6
• Persistent bleeding or rising hCG levels after treatment warrant re-evaluation for persistent RPOC 2
• Patients with history of RPOC, especially with pathologic evidence of basal plate myometrial fibers (BPMF), should be monitored closely in subsequent pregnancies due to increased risk of placenta accreta 2

Complications to Monitor

• Incomplete evacuation requiring repeat procedure 7
• Intrauterine adhesions (Asherman syndrome), particularly after multiple curettage procedures 8
• Infection and hemorrhage 3, 6
• Long-term fertility implications, especially with aggressive curettage 6