Expectant versus medical management for retained products of conception after medical termination of pregnancy: A randomized controlled study

Vascular Retained Products of Conception Following Delivery: Efficacy of Estrogen-Progestogen Therapy

OBJECTIVE

To evaluate the clinical features of women with vascular retained products of conception (RPOC) following delivery and to assess the efficacy of estrogen-progestogen therapy (EPT) as an initial intervention for this group.

METHODS

A retrospective study was conducted of women with vascular RPOC after delivery at ≥ 20 weeks gestation who received EPT (combination of conjugated estrogen and norethisterone) between 2017 and 2023. Clinical characteristics, hormonal levels, ultrasonographic assessments, and treatment outcomes were analyzed.

RESULTS

A cohort of 21 women with vascular RPOC following delivery was identified. The median interval from delivery to initial hospital consultation was 48 days (IQR: 33-50), with five patients requiring inpatient care due to substantial bleeding. Among the 21 patients, 18 received EPT. Following the first course of EPT and subsequent withdrawal bleeding, 17 (94%) showed resolution of vascularity on color Doppler, and 11 (61%) exhibited a linear endometrial pattern. All patients completed treatment within two EPT courses, with no need for further intervention. The median time to human chorionic gonadotropin normalization from EPT initiation was 14 days (IQR: 3-25).

CONCLUSION

EPT incorporating norethisterone appears effective in attenuating and eliminating endometrial blood flow in women with vascular RPOC after delivery, facilitating intrauterine tissue expulsion without additional treatments.

Reproductive surgery remains an essential element of reproductive medicine

Background

Reproductive surgery has long been neglected and is perceived to be simple surgery that can be undertaken by all gynaecologists. However, given the ever-expanding knowledge in the field, reproductive surgery now comprises surgical interventions on female reproductive organs that need to be carefully planned and executed with consideration given to the individuals symptoms, function of the organ and fertility concerns.

Objectives

To discuss the different perspectives of reproductive surgeons and other gynaecological surgeons, e.g., gynaecological oncologists, and advanced minimally invasive surgeons, regarding diagnosis and management of pelvic pathology that affects reproductive potential. Furthermore, to highlight the gaps in knowledge and numerous controversies surrounding reproductive surgery, while summarising the current opinion on management.

Materials and Methods

Narrative review based on literature and the cumulative experience of the authors.

Main outcome measures

The paper does not address specific research questions.

Conclusions

Reproductive surgery encompasses all reproductive organs with the aim of alleviating symptoms whilst restoring and preserving function with careful consideration given to alternatives such as expectant management, medical treatments, and assisted reproductive techniques. It necessitates utmost technical expertise and sufficient knowledge of the female genital anatomy and physiology, together with a thorough understanding of and respect to of ovarian reserve, tubal function, and integrity of the uterine anatomy, as well as an up-to-date knowledge of alternatives, mainly assisted reproductive technology.

What is new?

A holistic approach to infertile women is only possible by focusing on the field of reproductive medicine and surgery, which is unattainable while practicing in multiple fields.

The accuracy of ultrasound scan in diagnosing retained products of conception: a systematic review and meta-analysis

OBJECTIVE

This study aimed to analyze and summarize the evidence on the accuracy of different ultrasound methods in the diagnosis of retained products of conception.

DATA SOURCES

We searched Ovid SP, the Cumulative Register to Nursing & Allied Health Literature, EBSCO, and grey literature including Core, Trip, Networked Digital Library of Theses and Dissertations Global ETD search, BMJ Best Practice, PubMed, GreyLit report website (http://www.greylit.org/), Cochrane Central Register of Controlled Trials, and Google scholar (https://scholar.google.com/).

STUDY ELIGIBILITY CRITERIA

We included prospective and retrospective cross-sectional or Cohort studies that evaluated both ultrasound findings (before management of retained products of conception) and histopathologic results of retained products of conception at all gestational ages.

METHODS

We used Covidence for data extraction from the studies and quality assessment. The meta-analysis was performed using RevMan 5.4 (forest plot), MetaDTA version 2.01, and Meta-DiSc 2.0 online software.

RESULTS

In total, 11 studies were eligible for data extraction and meta-analysis. The total number of study participants from these 11 studies were 1567. Of these, 9 studies were included to test the accuracy of an echogenic mass, 4 studies analyzed the accuracy of endometrial thickness, and 5 studies analyzed the accuracy of color Doppler flow to predict retained products of conception. We found that echogenic mass had the highest sensitivity, specificity, and diagnostic odds ratio for predicting retained products of conception. The sensitivity, specificity, and diagnostic odds ratio were 0.915 (95% confidence interval, 0.844-0.955), 0.843 (95% confidence interval, 0.615-0.947), and 57.787 (95% confidence interval, 15.171-220.112), respectively. The diagnostic threshold for endometrial thickness was set at 10 mm with a sensitivity, specificity, and diagnostic odds ratio of 0.667 (95% confidence interval, 0.072-0.981), 0.866 (95% confidence interval, 0.375-0.986), and 12.927 (95% confidence interval, 0.23-726.582). The sensitivity, specificity, and diagnostic odds ratio of color Doppler flow were 0.850 (95% confidence interval, 0.756-0.913), 0.406 (95% confidence interval, 0.198-0.655), and 3.893 (95% confidence interval, 1.005-15.081).

CONCLUSION

Our review concluded that an echogenic mass is the most sensitive and specific predictor of retained products of conception after any pregnancy event. The most important limitation of our review is that the design of the studies included led to significant statistical heterogeneity.

Sonographic Findings of Vascular Signals for Retained Products of Conception in Women Following First-Trimester Termination of Pregnancy

OBJECTIVES

To evaluate the occurrence of retained products of conception (RPOC) after termination of pregnancy in the first trimester and to assess the vascular signals with transvaginal ultrasonography (TVUS) examination in the detection of retained products.

METHODS

A retrospective cohort study was performed using TVUS examination in patients following termination of pregnancy. In cases of RPOC, 3 scales of vascular signal were identified: type 1, no or small amount, spot flow signals; type 2, medium amount, strip-like flow signals; type 3, rich amount, circumferential-like flow signals. The correlation between vascular signals and placenta accreta spectrum (PAS) staging was proposed by sonography and histopathology findings.

RESULTS

The 3 vascular patterns were differently distributed within non-RPOC as well as RPOC patients with and without PAS: type 1 vascular signal detection rates of non-RPOC and RPOC were 97.8% (262/268) and 28.1% (18/64), respectively. Of 64 cases of RPOC, 48.4% (31/64) of the patients had type 2 vascular signals. Vascular signals were enhanced in RPOC with PAS patients whose diagnosis was confirmed by histopathology.

CONCLUSIONS

The vascularity (amount of flow), vascular pattern (spot, strip- or circumferential-like flow), and the flow penetrating myometrium were significant findings for distinguishing concomitant RPOC with and without PAS. Additionally, RPOC may contribute to PAS progression, or PAS and RPOC in coordination strengthen the observed vascular signals.