Retained products of conception

Background

  • Abbreviation: RPOC
  • Fetal tissue or placenta that remains following abortion or delivery
  • Incidence of 0.5-1% of induced abortions

Clinical Features

  • Vaginal bleeding
    • Typical following abortions; should consider abnormal if heavy or last >3 weeks
  • Fever/Pain
    • Necrotic RPOC are prone to infection → uterine tenderness
    • Fever abnormal following evacuation of uterus
    • Consider possibility of uterine perforation/visceral injury if instrumentation used during abortion
    • Clostridial toxic shock syndrome possible after 1st trimester miscarriages/termination
      • ↑↑ WBC on presentation
      • Almost always fatal
  • Amenorrhea
    • Menses should resume within 6 weeks of miscarriage/termination
    • Amenorrhea may be sign of remaining trophoblastic tissue

Physical Exam

  • Uterine tenderness
  • Heavy vaginal bleeding
  • Uterine enlargement
  • Cervical OS typically open

Differential Diagnosis

  • Hematometra
  • Ectopic pregnancy
  • Traumatic termination
  • Gestational trophoblastic disease
  • Endometritis
  • Infected RPOC
  • PID

Postpartum Emergencies

Evaluation

  • Type and screen
  • bHCG (may be negative if tissue necrotic and not secreting hormone)
  • GC/C
  • CBC
  • PT/PTT
  • Transvaginal U/S

Management

  • RPOC + hemodynamic instability
    • IVF and pRBC as needed
    • Misoprostol 800 mcg PR (theoretic benefit; not studied)
    • Uterine evacuation
      • If patient does not respond to above:
        • Uterine tamponade
        • Uterine artery embolization
        • Hysterectomy
  • 'RPOC + sepsis
    • Emergent uterine evacuation
    • Broad spectrum antibiotics
      • If patient does not respond to above:
        • Laparotomy +/- hysterectomy to evaluate for bowel injury, pelvic abscess, clostridial myometritis
  • RPOC + endometritis
  • RPOC + prolonged bleeding (hemodynamically stable)
    • Uterine evacuation (preferred)
      • Indirect evidence supports use of prophylactic antibiotics
    • Medical management
      • Misoprostol
      • Not studied in RPOC but reasonable in patient who refuses surgical management
    • Expectant management
      • RPOC likely to resorb without intervention → resolution of bleeding
      • 50-85% resolution at 1-2 week follow up
      • 90% resolution at 6 weeks follow up
      • Use of prophylactic antibiotics not studied in RPOC patients

Disposition

See Also

References