Retained products of conception (RPOC) are tissue from a pregnancy that remains in the uterus after a termination, miscarriage, or delivery. This retained tissue, which can include placental or fetal remnants, prevents the uterus from contracting fully and healing properly. RPOC significantly raises the risk of two major complications: heavy, prolonged bleeding, which can lead to hemorrhage, and uterine infection. Promptly addressing this condition is important to ensure the patient’s health and prevent long-term complications.
Identifying Retained Products of Conception
Persistent or unusual symptoms following the procedure often indicate retained products of conception (RPOC). While some bleeding and cramping are expected during recovery, signs like prolonged heavy vaginal bleeding, especially with large clots, suggest the uterus has not completely emptied. Other concerning symptoms include fever or chills, which signal a developing infection, and severe, worsening pelvic pain or tenderness. A foul-smelling vaginal discharge is also a common sign of infection associated with retained tissue.
If RPOC is suspected based on symptoms, a physician will use diagnostic imaging to confirm the presence of tissue. Transvaginal ultrasound is the primary tool for this diagnosis, as it provides a clear image of the uterine cavity. The presence of an irregular mass or an endometrial thickness of 15 millimeters or greater can suggest RPOC. However, a precise cutoff measurement alone is not always definitive, and the clinical picture must also be considered.
Blood tests also play a supporting role in the diagnosis by measuring the level of human chorionic gonadotropin (hCG), the pregnancy hormone. Since the placenta produces this hormone, persistently high or slowly declining hCG levels after a procedure indicate that placental tissue remains in the uterus. The combination of patient symptoms, ultrasound findings, and hormone levels guides the final diagnosis before a management plan is chosen.
Non-Surgical Management Options
The choice to pursue non-surgical management depends on the patient’s stability and the size of the retained tissue seen on ultrasound. Non-surgical options are considered when the patient is clinically stable, without signs of active infection or excessive hemorrhage. These approaches aim to allow the body to expel the tissue naturally or with the aid of medication, thereby avoiding the risks associated with surgical instrumentation.
Expectant management, or “watchful waiting,” is an option for patients with a small amount of retained tissue and minimal symptoms. This involves closely monitoring the patient to allow the tissue to pass on its own, a process successful in roughly 50% to 67% of cases. The risks include prolonged bleeding and a chance of developing a serious infection or a hemorrhage that would necessitate emergency surgery.
Medical management uses medication to stimulate the uterus to contract and expel the remaining contents. Misoprostol, a synthetic prostaglandin, is the drug most commonly prescribed for this purpose, working by softening the cervix and causing uterine contractions. This approach offers a greater chance of complete expulsion than expectant management, with success rates often reported between 60% and 85%. Side effects of misoprostol can include cramping, nausea, diarrhea, and chills. However, failure to pass the tissue completely or the onset of heavy bleeding may still lead to the need for a surgical procedure.
Surgical Removal Procedures
When non-surgical options are unsuitable or have failed, or if the patient is experiencing heavy bleeding, surgical intervention becomes the standard for removing RPOC. These procedures are performed in a clinical setting under anesthesia to ensure patient comfort and safety. Surgical removal allows for immediate evacuation of the tissue, resolving symptoms quickly and reducing the risk of ongoing complications.
Manual Vacuum Aspiration (MVA) is a minimally invasive technique used for smaller amounts of retained tissue. A thin tube is inserted through the cervix into the uterus, and a syringe-like device or machine creates gentle suction to remove the contents. MVA can be performed with local anesthesia, is quick, and carries a lower risk of trauma to the uterine lining compared to other surgical methods.
Dilation and Curettage (D&C) involves gently widening the cervix and then using a curette or suction device to scrape or aspirate the tissue from the uterine walls. D&C may be necessary for larger or more complex cases of RPOC. Because it is a “blind” procedure, it carries a higher risk of damaging the basal layer of the endometrium. Damage to this layer can lead to the formation of intrauterine adhesions, known as Asherman’s syndrome, which can affect future fertility.
Hysteroscopy offers a more targeted approach, especially when fertility preservation is a concern or the RPOC is chronic. A thin, lighted tube with a camera is inserted into the uterus, allowing the surgeon to directly visualize and precisely remove the retained tissue using specialized instruments. This visual guidance significantly lowers the risk of damaging the surrounding healthy uterine lining. Hysteroscopy is a safer option for reducing the incidence of intrauterine adhesions compared to blind D&C.
Post-Procedure Care and Monitoring
Following the successful removal of RPOC, patients can expect a recovery period involving some discomfort and bleeding. Mild abdominal cramping and light vaginal bleeding are common for up to two weeks after the procedure. Simple over-the-counter pain relievers can manage any discomfort experienced during this time.
Patients are advised to use sanitary pads instead of tampons to reduce the risk of introducing bacteria into the healing uterus. To minimize the risk of infection, sexual intercourse is discouraged until the bleeding has completely stopped. A patient should seek immediate medical attention if they develop a high fever, experience severe pain not relieved by medication, or notice a foul-smelling vaginal discharge, as these are signs of a persistent infection.
Follow-up monitoring confirms that the tissue has been completely removed and the uterus is healing. A urine pregnancy test is recommended two to three weeks after the procedure to ensure pregnancy hormones have returned to a negative level. A persistently positive test suggests residual tissue may still be present, necessitating further evaluation. In some cases, a follow-up ultrasound may also be performed to visually confirm that the uterine cavity is clear.