Full length article
Retained products of conception: What is the risk for recurrence on subsequent pregnancies?

https://doi.org/10.1016/j.ejogrb.2018.03.006Get rights and content

Abstract

Objective

To investigate whether women who were surgically treated for retained products of conception (RPOC) by either suction curettage or hysteroscopy are at risk for recurrent RPOC on their subsequent pregnancies.

Study design

Retrospective analysis of 442 women surgically treated for RPOC following delivery or abortion by suction curettage (N = 63, 14.3%) or hysteroscopy (N = 379, 85.7%). Information on subsequent pregnancies and their outcomes was available for 161 (36.4%) women.

Results

One or more live births were reported for 150 (93.2%) of the women for whom information on subsequent pregnancies was available. The overall rate of spontaneous abortions was 31/161 (19.3%). Recurrent RPOC were diagnosed in 25 (15.5%) cases, while third stage of labor placental problems (including retained placenta or cotyledons and placenta accreta) were found in 44 (27.3%) cases. Recurrent RPOC was associated with treatment by suction curettage compared with hysteroscopy for the initial RPOC on multivariate logistic regression analysis (Odds Ratio [OR] = 3.6, 95% Confidence Interval [CI]1.3–10.5, p = 0.01) and with the initial RPOC occurring after delivery compared with after abortion (OR = 8.4, 95%CI 1.8–39.5, p = 0.006).

Conclusion

Women treated for RPOC are at risk for recurrent RPOC and for third stage of labor placental problems on their subsequent pregnancies, especially those who had been managed by suction curettage in comparison with operative hysteroscopy. Clinical and ultrasound follow-up in the early and late postpartum period should be considered in women with a history of RPOC.

Introduction

Retained products of conception (RPOC) occur in up to 3% of all deliveries and abortions [1]. The treatment of RPOC includes uterine cavity evacuation by suction curettage or, increasingly, by operative hysteroscopy or hysteroscopic morcellation [[2], [3], [4]]. Both surgical techniques are associated with the long-term complications of intrauterine adhesions, which may cause traumatic amenorrhea, infertility, recurrent abortions and abnormal placentation [5]. However, the rates of post-surgical intrauterine adhesions differ between women treated by suction curettage compared with those managed by operative hysteroscopy. While intrauterine adhesions have been reported in up to 40–60% of women following curettage for RPOC, the rate of intrauterine adhesions following hysteroscopy is much lower, i.e., around 7–10% [[2], [6], [7], [8]]. The difference in the rates of intrauterine adhesions may be explained by the targeted and limited hysteroscopic removal as opposed to the global and “blind” uterine cavity curettage.

In view of the possible injury to the endometrium by the RPOC and by the surgical procedure used to remove them, the reproductive outcomes of these patients’ subsequent pregnancies could be compromised. In particular, there may be increased risk for placental problems due to abnormal placentation, such as placenta accreta, retained placenta and recurrent RPOC. To date, several studies have investigated the reproductive outcomes of patients treated for RPOC. Ikhena et al. [9] followed 111 patients treated hysteroscopically for RPOC and reported that abnormal placentation (including placenta previa, placenta accreta and retained placenta) was present in 18.1% of those patients’ subsequent pregnancies. Sonnier et al. [10] reported a conception rate of 71.1% at 6 months and 83.5% at 12 months among 53 patients treated hysteroscopically for RPOC. Ben Ami et al. [11] compared the reproductive outcomes of women with RPOC treated by dilatation and curettage (D&C) and hysteroscopy. They found that hysteroscopy was associated with a shorter mean time to further conception. None of those studies investigated the rates of recurrent RPOC, which could be increased in these women due to their potential endometrial injury. This information is of clinical importance since appropriate ultrasound postpartum follow-up may be offered to women who are at increased risk for RPOC.

The aim of this study is to determine the risk for recurrent RPOC and placental problems on subsequent pregnancies of women surgically treated for RPOC, and to compare this risk between women who underwent hysteroscopic removal versus removal by suction curettage.

Section snippets

Materials and methods

For this retrospective cohort study, we conducted a computerized search for all cases treated for RPOC in our institution between January 2008 and December 2015, using the ICD-9 codes 667.10–667.14 (retained portion of placenta or membranes). This study period was chosen because hysteroscopy became the main surgical approach for treatment of RPOC at that time. The medical records of all identified cases were retrospectively reviewed. We retrieved the information on demographics, medical

Results

A total of 442 women were operated for RPOC removal in our department during the study period. Their demographic, obstetric and surgical characteristics are presented in Table 1. Information on subsequent pregnancies was available in the medical records for 161 (36.4%) of those women. Comparisons of the baseline characteristics for women with and without information on subsequent pregnancies are shown in Table 1. No statistically significant differences were detected between those two groups in

Comment

RPOC may occur following delivery or abortion and necessitate surgical procedures for uterine cavity evacuation, often causing intrauterine adhesions, which could lead to infertility, recurrent abortions and abnormal placentation in subsequent pregnancies [5]. In the current study, the overall rate of deliveries among women treated for RPOC with available information on their subsequent pregnancies was high, reaching >90%. Nevertheless, those women are at risk for placental problems, including

Conflicts of interest

The authors have no conflict of interest to disclose.

References (11)

There are more references available in the full text version of this article.

Cited by (0)

Part of this publication was performed to fulfill the MD thesis requirements of the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

View full text