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Retained products of conception
From WikEM
Contents
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
- Amniotic fluid embolus
- Chorioamnionitis
- Eclampsia
- Postpartum endometritis
- Postpartum headache
- HELLP syndrome
- Postpartum hemorrhage
- Mastitis
- Peripartum cardiomyopathy
- Preeclampsia
- Retained products of conception
- Uterine rupture
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
- If patient does not respond to above:
- '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
- If patient does not respond to above:
- RPOC + endometritis
- Cefotetan 2 g IV + doxycycline 100mg IV or PO q12h
- Outpatient: Ceftriaxone 250mg IM + doxycycline 100mg BID x 14 days +/- metronidazole 500mg 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 follow up
- 90% resolution at 6 weeks follow up
- Use of prophylactic antibiotics not studied in RPOC patients
- Uterine evacuation (preferred)
