Retained Products of Conception (RPCs) are tissue remaining inside the uterus after a pregnancy ends, whether through miscarriage, delivery, or abortion. This residual tissue, often placental or fetal matter, can lead to serious medical complications such as heavy bleeding or infection. If RPCs are confirmed, prompt medical attention is necessary. This article reviews how RPCs are diagnosed and the methods available for their removal.
Identifying Symptoms of Retained Tissue
The presence of Retained Products of Conception manifests through distinct symptoms requiring immediate medical review. The most common sign is vaginal bleeding that is heavier or more prolonged than expected after the procedure. Bleeding is considered abnormal if it is significantly heavier than a normal menstrual period, includes large blood clots, or continues for more than three weeks.
The retained tissue can become infected, presenting as a fever, chills, or a foul-smelling vaginal discharge. Severe cramping or abdominal pain that does not subside should also raise concern, as should the failure of a normal menstrual period to return within six weeks.
Medical Confirmation and Assessment
Once symptoms suggesting RPCs are reported, clinicians use specific diagnostic tools to confirm the presence of tissue inside the uterus. Transvaginal ultrasound is the primary diagnostic method, providing high-resolution images of the uterine cavity. A common finding suggesting RPCs is an endometrial thickness of 15 millimeters or more, measured two weeks after the procedure.
Clinicians may also use a Color Doppler ultrasound, which assesses blood flow within the tissue. Increased vascularity in the area can indicate that the retained tissue is still metabolically active, often suggesting residual placental material. Blood tests monitor human chorionic gonadotropin (hCG) levels. If these levels remain elevated or do not drop as expected, it suggests viable tissue is still present. Hysteroscopy, which involves inserting a thin, lighted tube into the uterus, allows for a direct visual examination, and is used for both diagnosis and removal.
Non-Surgical Treatment Options
For patients who are clinically stable, have minimal symptoms, and where the retained tissue is small, non-surgical approaches are often the preferred first line of management. These conservative methods avoid the risks associated with surgical intervention and involve close follow-up.
Expectant Management
Expectant management, or “watchful waiting,” allows the body time to pass the tissue naturally. This approach is chosen when the retained tissue is small (often less than 30 millimeters in diameter) and the patient has stable vital signs. Expectant management has a variable success rate, but requires the patient to be available for close monitoring.
Medical Management
If watchful waiting is not preferred, medical management uses medication, most commonly misoprostol, to induce uterine contractions. Misoprostol works by causing the uterus to contract and expel the remaining contents. The medication is usually administered as a single dose of 800 mcg. Success rates are estimated between 60% and 70%, with common side effects including cramping and bleeding. Following either non-surgical method, a persistently positive home pregnancy test signals the need for further assessment.
Procedures for Surgical Removal
Surgical removal becomes necessary if non-surgical methods fail, the patient is experiencing heavy or uncontrolled bleeding, or if there is evidence of an infection. Surgical management provides a rapid and highly effective resolution. The procedure chosen depends on the size of the retained tissue and the patient’s clinical status.
Manual Vacuum Aspiration (MVA)
MVA is a minimally invasive procedure often performed in an office or clinic setting under local anesthesia. A thin tube is inserted through the cervix, and suction is created using a hand-held syringe or electric pump to gently remove the tissue. MVA is generally considered safer and less traumatic than other surgical options.
Dilation and Curettage (D&C)
D&C is typically reserved for cases where the patient is unstable or MVA is unsuitable. This procedure involves dilating the cervix and then using both suction and a sharp instrument called a curette to scrape the tissue from the uterine walls. D&C is often performed in an operating room under general or regional anesthesia.
Surgical procedures carry potential risks, including uterine perforation. Another complication is the formation of intrauterine adhesions, known as Asherman’s syndrome, which occurs when the delicate lining of the uterus is damaged. The risk of adhesion formation is higher with D&C compared to hysteroscopic resection, where the tissue is removed under direct visualization.
Post-Removal Care and Monitoring
Following successful RPC removal, patients require a period of recovery and monitoring. Mild abdominal cramps are common for up to 48 hours. Expected vaginal bleeding may continue intermittently for up to two weeks, gradually becoming lighter.
Patients should use sanitary pads instead of tampons to avoid infection. Sexual intercourse and bathing should be avoided until bleeding has completely stopped. Normal menstruation typically resumes within eight weeks. A follow-up appointment is advised, often two weeks later, to check for complications and confirm the uterus is clear, potentially including a repeat pregnancy test or ultrasound. Persistent fever, heavy bleeding that soaks multiple pads in an hour, or passing large blood clots are signs that warrant immediate medical attention.