Retained Products of Conception

Retention of placental or fetal tissue within the uterine cavity following delivery or pregnancy loss, predisposing to secondary postpartum hemorrhage (see that entry) and puerperal sepsis (see that entry) given the tissue serving as a nidus for infection and preventing full uterine involution.

Persistent or heavy vaginal bleeding beyond the expected postpartum or post-miscarriage course, often with passage of clots or tissue, lower abdominal pain, and, if infection supervenes, fever, offensive lochia, and uterine tenderness.

• Clinical suspicion based on the history and examination (a uterus larger than expected for the time since delivery, or an open cervical os with bleeding)
• Pelvic ultrasound, though interpretation postpartum can be challenging given normal variability in endometrial appearance during involution, an endometrial thickness that is thin and echogenically normal makes significant retained tissue less likely, while a thickened or heterogeneous endometrial collection supports the diagnosis
• FBC and inflammatory markers if infection is suspected; blood cultures if systemically unwell

• Surgical evacuation (ultrasound-guided suction curettage) is the definitive treatment for significant retained tissue, particularly with ongoing bleeding
• Expectant management may be appropriate for small amounts of retained tissue without significant bleeding, with resolution and repeat ultrasound to confirm
• Antibiotics if infection is present or suspected (see Puerperal Sepsis entry for regimen)
• Uterotonics (oxytocin, or misoprostol 600 to 800 mcg PO/PV) may reduce bleeding while awaiting definitive management or as an adjunct to expectant management
• Anti-D prophylaxis for Rh negative women undergoing surgical evacuation

Referral: gynecology or obstetrics for surgical evacuation.