Retained products of conception

Background

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

Presentation

• Uterine 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
    • p/w ↑↑ WBC
    • Almost always fatal
• Amenorrhea
  • Menses should resume within 6 weeks of miscarriage/termination
  • Amenorrhea may be sign of remaining trophoblastic tissue

Differential Diagnosis

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

Physical Exam

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

Work-up

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

Treatment

• 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 abx
    • If patient does not respond to above:
      • Laparotomy +/- hysterectomy to evaluate for bowel injury, pelvic abscess, clostridial myometritis
• RPOC + endometritis
  • Cefotetan 2 g IV + doxycycline 100 mg IV or PO q12h
  • Outpatient: Ceftriaxone 250 mg IM + soxycycline 100 mg BID x 14 days +/- metronidazole 500 mg BID x 14 days
  • If patient does not respond to above:
    • Prompt uterine evacuation
• 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 f/u
    • 90% resolution at 6 weeks f/u
    • Use of prophylactic antibiotics not studied in RPOC patients

References

• Tintinalli
• UTD