From the Guidelines
Retained products of conception (RPOC) should be referred to as incomplete evacuation of the placenta (EPL) with terms like RPOC being alternate descriptions, as per the latest consensus conference recommendations 1. When managing RPOC, the approach depends on the clinical presentation, with options including expectant management, medical management, or surgical intervention.
- Key considerations in management include:
- Clinical presentation and symptoms
- Presence of bleeding or infection
- Patient's overall health and preferences For medical management, medications like misoprostol are used to stimulate uterine contractions and expel the retained tissue, with dosing typically in the range of 600-800 mcg vaginally or 400-600 mcg sublingually.
- Surgical management, such as dilation and curettage (D&C), is often necessary for patients with heavy bleeding, signs of infection, or when medical management fails, and should be performed under appropriate anesthesia. It's crucial to monitor patients for potential complications, including hemorrhage, infection, or the development of Asherman's syndrome (intrauterine adhesions), and to prescribe antibiotics if infection is suspected, with regimens such as ampicillin and gentamicin followed by oral amoxicillin-clavulanate being considered based on clinical guidelines and patient-specific factors.
- Follow-up ultrasound is essential to confirm the complete evacuation of the retained products, ensuring that no tissue remains that could lead to further complications, as emphasized in the context of incomplete EPL 1.
From the Research
Definition and Presentation of Retained Products of Conception
- Retained products of conception (RPOC) generally result after the first half of pregnancy termination and may also occur after vaginal or cesarean delivery 2.
- RPOC frequently presents with irregular or continuous vaginal bleeding, lower abdominal and pelvic pain, and discharge per vaginum due to infection 2.
- It can also cause late complications like formation of intrauterine adhesions and subfertility 2.
Diagnosis of Retained Products of Conception
- The diagnosis of RPOC, along with symptoms, is generally supported by ultrasonography with or without color Doppler 2.
- Patients also undergo uterine vasculature assessment to diagnose arteriovenous malformation (AVM) 2.
Management of Retained Products of Conception
- The management of RPOC has been conventionally done with blind dilation and suction curettage (D and C) 2, 3.
- However, expectant management, uterine artery embolization, and hysteroscopic resection of RPOC are safe and efficient alternatives 2, 3.
- Hysteroscopic resection of retained POC is reported to have favorable outcomes compared to blind dilation and curettage, including higher success rates and a lower risk of intrauterine adhesion formation 3.
- Medical management with misoprostol is also a treatment strategy to avoid D&C, with a success rate of 65% in avoiding D&C 4.
- The use of misoprostol for up to 48 hours can further improve evacuation of retained products of conception in spontaneous abortion 5.
Complications and Repeat Evacuation
- Evacuation of retained products of conception with suction curettage carries a risk of incomplete evacuation, which may lead to a further repeat evacuation 6.
- The incidence of repeat evacuation for suspected retained products is around 3.1% 6.
- Minimally invasive surgery may have a role in unique cases of placenta accreta spectrum (PAS) 3.