Can retained tissue be present 3 months after a dilation and curettage (D&C)?

Retained Tissue 3 Months After D&C

Yes, retained products of conception can absolutely persist 3 months after dilation and curettage, though this represents a delayed complication that requires active management rather than expectant observation. 1, 2

Evidence for Long-Term Retained Tissue

Retained products of conception (RPOC) following D&C can persist for extended periods, with documented cases lasting months to years:

• A case report documented retained tissue persisting for 10 years after D&C, presenting as secondary infertility, demonstrating that RPOC can remain asymptomatic for prolonged periods 3
• RPOC related to pregnancy termination are most likely to be asymptomatic compared to those following delivery, which typically cause hemorrhage or infection 3
• At 3 months post-procedure, retained tissue represents a pathologic finding requiring intervention rather than normal postpartum vascularity 2

Diagnostic Approach at 3 Months

Transvaginal ultrasound with color Doppler is the primary diagnostic tool to confirm retained tissue and distinguish it from other conditions 2:

• Look for an echogenic or mixed-echo endometrial mass with vascularity extending to the endometrium - this indicates true RPOC rather than simple enhanced myometrial vascularity (EMV) 2
• EMV alone (vascularity restricted to myometrium without endometrial extension) is a normal finding after pregnancy loss and does not require intervention 2
• Marked vascularity extending to the endometrium at 3 months is pathologic and suggests hypervascular RPOC requiring specialized management 4

Critical Management Considerations

For Hypervascular RPOC (High Vascularity on Doppler)

Do not proceed directly to repeat D&C if marked vascularity is present, as this can cause life-threatening hemorrhage 4:

• Consider uterine artery embolization first, followed by D&C 4-7 days later once vascularity has decreased 4
• Alternatively, expectant management may allow spontaneous reduction in vascularity over 60+ days, after which D&C can be safely performed 4
• Confirm reduction of vascularity on repeat Doppler ultrasound before attempting surgical evacuation 4

Optimal Surgical Technique

Hysteroscopic resection is superior to ultrasound-guided D&C for retained tissue at this timepoint 5, 6:

• Hysteroscopic resection results in only 4.2% intrauterine adhesion rate versus 30.8% with repeat D&C 6
• Incomplete evacuation occurs in only 1% with hysteroscopic resection versus 29% with D&C 5
• Pregnancy rates are significantly higher after hysteroscopic resection (68.8% vs 59.9%) with shorter time to conception (11.5 vs 14.5 months) 6
• Use a resectoscope with 4-mm cutting loop without electrical current to minimize endometrial damage 6

Common Pitfalls to Avoid

• Performing blind repeat D&C without confirming vascularity pattern - this risks catastrophic hemorrhage with hypervascular RPOC 4
• Confusing normal EMV with pathologic RPOC - EMV is restricted to myometrium and requires no intervention 2
• Multiple aggressive curettage procedures - this dramatically increases Asherman syndrome risk (22.4% overall, 30% with D&C) 5
• Assuming ultrasound showing "retained tissue" always requires intervention - correlation with clinical symptoms is essential 7

Clinical Symptoms Requiring Urgent Evaluation

• Persistent or recurrent vaginal bleeding 1, 4
• Fever, uterine tenderness, or foul-smelling discharge indicating endometritis 2
• Secondary infertility - RPOC can prevent conception even when asymptomatic 3

When Intervention Is NOT Needed

If ultrasound shows only enhanced myometrial vascularity (restricted to myometrium, not extending to endometrium) without clinical symptoms, expectant management with reassurance is appropriate 2. This represents normal physiologic healing, not pathologic retained tissue.