Expectant management of retained products of conception following abortion: A retrospective cohort study

Risk factors for procedural interventions for retained products, after failed treatment with misoprostol or mifepristone and misoprostol for first trimester pregnancy loss - A retrospective cohort study

OBJECTIVE

To evaluate the risk factors for procedural extraction of retained products of conception after pharmacological treatment for early pregnancy loss.

METHODS

A retrospective cohort study of patients with early pregnancy loss treated with vaginal misoprostol between November 1, 2012, and March 31, 2018, compared to patients treated with Mifepristone and misoprostol co-treatment between May 1, 2018, and February 28, 2023, who subsequently underwent a procedural intervention due to retained products of conception.

RESULTS

We identified 429 patients treated with misoprostol monotherapy and 418 treated with mifepristone-misoprostol co-treatment. Mifepristone-misoprostol co-treatment was associated with a lower averaged misoprostol dosing (1.21 vs. 1.5; P < 0.001) and a reduced rate for any procedural intervention (17.7 % vs. 23.4 %; P = 0.03). Treatment with more than one course of misoprostol was associated with an increased risk for procedural intervention (OR = 4.21 with misoprostol monotherapy, 95 % CI: 2.53-6.99, and OR = 3.75 with mifepristone-misoprostol co-treatment, 95 % CI: 2.08-6.79) CONCLUSION: Administering mifepristone prior to misoprostol for first-trimester pregnancy loss decreases the likelihood of repeated misoprostol dosing and subsequently reduces the rate for procedural intervention for retained products of conception.

Effectiveness of office hysteroscopy for retained products of conception: insights from 468 cases

PURPOSE

Retained products of conception (RPOC) are a common complication following pregnancy. Office hysteroscopy (OH) is increasingly used for diagnostics and management due to its minimally invasive nature. However, incidence of incomplete OH removal and procedures in which no RPOC are identified despite prior suspicion remains a concern. This study aimed to identify factors associated with these outcomes to improve patient selection and procedural success.

METHODS

A retrospective study was conducted on patients referred for OH for presumed RPOC between August 2015 and April 2023 at the Department of Gynecology and Obstetrics, University Medical Centre Ljubljana, Slovenia. Inclusion criteria included hemodynamically stable patients with prolonged bleeding and/or suspicious ultrasound (US) findings post-pregnancy. Patients with RPOC thickness of more than 30 mm or strong tissue vascularization on US were excluded. Data on patient demographics, US features, and procedural outcomes were analyzed.

RESULTS

Out of the 468 patients, RPOC removal was performed in 333 cases (71.2%), of which 225 (67.6%) were successfully completed, while in 135 cases (28.8%), the procedure was only diagnostic due to the absence of RPOC. Regarding procedural success, neither the pregnancy outcome, i.e., termination of pregnancy (TOP) vs delivery, nor gestational age significantly correlated with it. Longer time from pregnancy end to OH significantly improved procedural success in both groups, after TOP (p = 0.025) and in cases of large RPOC after delivery (p < 0.001). Parity significantly altered procedural success only in the delivery group (p < 0.007). The success rate of the procedure was significantly higher in cases when only small RPOC were observed (p < 0.001). Absence of RPOC occurred more frequently following TOP than after delivery (p < 0.001). Procedures in which no RPOC were confirmed were significantly associated with a longer interval between pregnancy end and OH in both TOP (p = 0.013) and delivery group (p = 0.003). Gestational age significantly correlated with the absence of RPOC only in the delivery group (p = 0.003). The likelihood of not confirming RPOC was higher where US thickness and length were lower (p = 0.007 and p = 0.011, respectively).

CONCLUSION

OH is effective for managing RPOC with a high success rate, but the absence of RPOC in a considerable number of OH-treated patients stresses the need for better diagnostic criteria and patient selection to minimize overtreatments. Further prospective studies are needed to optimize the timing and indications for OH.

Imaging in Acute Obstetric Conditions: A Pictorial Essay

Acute abdominopelvic pain during pregnancy and the postpartum period is a diagnostic challenge owing to the overlapping symptoms of obstetric, gastrointestinal, and urinary conditions coupled with pregnancy-induced physiological changes. This pictorial essay reviews critical obstetric emergencies and categorizes cases into two phases: the first covers the preconception-to-pregnancy period, while the second focuses on the postpartum period. This essay covers key obstetric emergencies, such as ovarian hyperstimulation syndrome, hyperreactio luteinalis, ectopic pregnancy, red degeneration of fibroids, placenta accreta spectrum disorders, placental abruption, uterine rupture, retained products of conception, and uterine arteriovenous malformations, with an emphasis on their clinical and imaging characteristics. While ultrasound remains the first-line modality, MRI offers superior soft tissue contrast for more complex cases, and CT is reserved for critical scenarios in which the radiation risk is outweighed by diagnostic necessity. Timely and accurate imaging is essential for differentiating these conditions, guiding interventions, such as uterine arterial embolization and surgery, and minimizing maternal and fetal morbidity. This work aims to enhance the diagnostic precision and multidisciplinary management of obstetric emergencies, ensuring optimal clinical outcomes.

Emergent Hysteroscopic Removal of Retained Products of Conception Following Laparoscopic Temporary Uterine Artery Ligation

Here, we describe two cases of retained products of conception (RPOC) that were successfully managed with hysteroscopic resection after laparoscopic temporary uterine artery ligation. Both patients were diagnosed with RPOC after early miscarriages. Case 1 was urgently admitted due to massive bleeding and underwent surgery following a blood transfusion. After laparoscopic temporary bilateral uterine artery ligation, the mass was hysteroscopically removed, and the ligation was subsequently released. The patient subsequently achieved an ongoing pregnancy. Case 2 underwent semi-emergency surgery due to intermittent bleeding. Initially, hysteroscopic surgery was planned. However, bleeding resulted in poor visualization of the operative field, and laparoscopic surgery was performed. In many previous reports of RPOC with heavy bleeding, uterine artery embolization was performed. However, there are concerns regarding the effect of a long-term reduction in uterine blood flow on fertility. Our method is not expected to decrease fertility because the ischemic effect is very short.

Outcomes and complications of second-trimester induction of labor using laminaria and gemeprost: A single-center experience in Japan

AIM

To document the outcomes of second-trimester induction of labor with laminaria cervical dilation followed by gemeprost vaginal tablets, with a particular emphasis on its complications.

METHODS

This was a single-center retrospective cohort study of women who experienced medical abortions between 12 and 21 weeks of gestation from January 2016 to July 2021. Procedures were performed with three laminaria cervical dilation for 2 days followed by the administration of gemeprost (1 mg, vaginal tablet) every 3 h with a maximum of five tablets per day. Epidural anesthesia was provided upon request. The primary outcome was successful labor induction, which was defined as fetal expulsion without assisted surgical procedures. Other maternal outcomes, complications and related interventions during and after the procedure were assessed.

RESULTS

Among 319 women, 313 (98.1%) experienced successful labor induction with a median of one gemeprost tablet. The median blood loss during the abortion was 145 mL, and three women (0.9%) required blood transfusion. Fever was observed in 19 women (6.0%) during hospitalization, although most cases were drug fever. Thirteen women (4.1%) had abnormal uterine bleeding ~24 days after the abortion. Eleven cases (3.4%) were associated with retained products of conception, of which three cases required uterine artery embolization and three needed surgical curettage.

CONCLUSIONS

Second-trimester induction of labor with laminaria cervical dilation and subsequent gemeprost vaginal tablets is a reliable method for completing medical abortions. Abnormal uterine bleeding several weeks after abortion is suspected to be a retained product of conception that could require invasive treatment.

Predictors of successful expectant and medical management of miscarriage: A systematic review

INTRODUCTION

15.3% of pregnancies result in miscarriage, management options include expectant, medical, or surgical. However, each patient has a range of variables, which makes navigating the available literature challenging when supporting individual patient decision-making. This systematic review aims to investigate whether there are any specific predictors for miscarriage management outcome.

MATERIAL AND METHODS

The following databases were searched, from the start of each database up to April 2023: PubMed, Medline, and Google Scholar. Inclusion criteria were studies interrogating defined predictors for expectant or medical management of miscarriage success. Exclusion criteria were poor quality, review articles, trial protocols, and congress abstracts. Data collection was carried as per PRISMA guidelines. Quality assessment for each study was assessed using the QUIPS proforma.

RESULTS

Relevant predictors include demographics, ultrasound features, presenting symptoms, and biochemical markers. Across the 24 studies there is heterogeneity in miscarriage definition, predictors reported, and management outcomes used. Associations with certain variables and miscarriage management outcomes are described. Ten studies assessed the impact of miscarriage type on expectant and/or medical management. The majority found that a diagnosis of incomplete miscarriage had a higher success rate following expectant or medical management compared to missed miscarriage or anembryonic pregnancy.

CONCLUSIONS

We conclude that there is evidence supporting the possibility to offer personalized miscarriage management advice with case specific predictors. Further larger studies with consistent definitions of predictors, management, and outcomes are needed in order to better support women through the decision-making of miscarriage management.

The efficacy of early office hysteroscopy in preventing intrauterine adhesions after abortion: a randomized controlled trial

BACKGROUND

Intrauterine adhesions (IUA) are a challenging clinical problem in reproductive infertility. The most common causes are intrauterine surgery and abortions. We aimed to investigate whether early second-look office hysteroscopy can prevent IUA.

METHODS

A single-center, prospective, two-armed, randomized controlled trial was designed to explore the efficacy of early office hysteroscopy after first-trimester induced abortion (suction dilatation and curettage [D&C]) and to further analyze fertility outcomes. Women aged 20-45 years undergoing suction D&C and desiring to conceive were recruited. Between October 2019 and September 2022, 66 women were enrolled, of whom 33 were allocated to group A (early hysteroscopy intervention). The women in intervention group A were planned to receive 2 times of hysteroscopies (early and late). In group B, women only underwent late (6 months post suction D&C) hysteroscopy.

RESULTS

The primary outcome was the IUA rate assessed using office hysteroscopy 6 months after artificial abortion. Secondary outcomes included menstrual amount/durations and fertility outcomes. In intervention group A, 31 women underwent the first hysteroscopy examination, and 15 completed the second. In group B (late hysteroscopy intervention, 33 patients), 16 completed the hysteroscopic exam 6 months after an artificial abortion. Twenty-one women did not receive late hysteroscopy due to pregnancy. The IUA rate was 16.1% (5/31) at the first hysteroscopy in group A, and no IUA was detected during late hysteroscopy. Neither group showed statistically significant differences in the follow-up pregnancy and live birth rates.

CONCLUSIONS

Early hysteroscopy following suction D&C can detect intrauterine lesions. IUA detected early by hysteroscopy can disappear on late examination and become insignificant for future pregnancies. Notably, the pregnancy outcomes showed a favorable trend in the early hysteroscopy group, but there were no statistically significant differences.

TRIAL REGISTRATION

ClinicalTrials.gov , ID: NCT04166500. Registered on 2019-11-10. https://clinicaltrials.gov/ct2/show/NCT04166500 .

Clinical and ultrasonographic characteristics of pregnancy-related enhanced myometrial vascularity: prospective cohort study

OBJECTIVE

To assess the ultrasonographic, epidemiological, clinical and evolutive characteristics of enhanced myometrial vascularity (EMV) following a first-trimester termination of pregnancy (TOP) or management of non-viable pregnancy.

METHODS

This prospective study included women who underwent follow-up ultrasound examination 5-6 weeks after a first-trimester TOP or after management of a first-trimester non-viable pregnancy at the University Hospital Polyclinic San Martino of Genoa between March 2021 and March 2022. EMV was characterized using two- and three-dimensional ultrasound and Virtual Organ Computer-aided Analysis. Ultrasonographic diagnosis of EMV was made when an unusual, tortuous myometrial vessel structure, with high-velocity blood flow, protruding towards the endometrium was observed, while an abnormal junctional zone, absent endometrial midline and heterogeneous endometrium supported the diagnosis. Patients with EMV underwent expectant management with planned ultrasonographic follow-up every 2 weeks until resolution.

RESULTS

During the study period, 305 women underwent TOP, of whom 132 attended the initial follow-up 5-6 weeks later, at which 52 were diagnosed with EMV. Ninety-six women were managed for a non-viable pregnancy, of whom 32 presented for follow-up, at which six had a diagnosis of EMV. Thus, overall, 164 of 401 women were included in the study and EMV was identified in 58 (35%) of these. The prevalence of EMV 5-6 weeks after a TOP was therefore between 52/305 (17%) and 52/132 (39%), and that after management of a non-viable pregnancy was between 6/96 (6%) and 6/32 (19%). Bleeding/pelvic pain was present in half (29/58) of the women with EMV, and serum human chorionic gonadotropin was detectable in 29% (17/58) at the first follow-up examination. At ultrasound assessment, all cases with EMV presented abundant tortuous myometrial vessels with high-velocity flow projecting from the myometrium towards the endometrium, along with non-uniform heterogeneous endometrium in 97% of cases, which often (67% of these) contained cystic areas, absence of the endometrial midline in 98% of cases and an abnormal junctional zone in 97% of cases (64% interrupted, 33% irregular). Most (67%) women with EMV were parous and 90% of them had undergone TOP rather than management for a non-viable pregnancy. Medical management of the TOP or non-viable pregnancy was more frequent in women with than those without EMV (93% vs 77%, P = 0.023). Multiple regression analysis showed the risk of EMV to be increased following TOP vs non-viable pregnancy (odds ratio (OR), 3.67 (95% CI, 1.16-11.56), P = 0.026) and in parous compared with nulliparous women (OR, 2.95 (95% CI, 1.45-6.01), P = 0.002). All women with EMV underwent expectant management. Eleven women did not return for subsequent follow-up examinations and did not present to our outpatient or emergency facilities, so were lost to further follow-up. Spontaneous resolution of the lesion was observed within 7-16 weeks after the procedure in 96% (45/47) of the remaining cases. Two women chose to undergo surgery for pelvic discomfort, and histology showed the presence of neovessels mixed with retained chorionic villi.

CONCLUSIONS

EMV is a transient and common finding 5-6 weeks following first-trimester TOP or management of non-viable pregnancy. TOP and being parous are risk factors for EMV. Expectant management of EMV is appropriate, because, in almost all cases, this resolves spontaneously, without complications, within 2-4 months. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

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.

Assisted reproductive technology-associated risk factors for retained products of conception

OBJECTIVE

To evaluate assisted reproductive technology-associated risk factors for retained products of conception among live births.

DESIGN

Registry-based retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

Cycle-specific data for a total of 369,608 singleton live births after fresh and frozen-thawed embryo transfers (FETs) between 2007 and 2017 were obtained from the Japanese assisted reproductive technology registry.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Retained products of conception after delivery. Odds ratios and 95% confidence intervals for risk factors associated with retained products of conception during fresh and frozen cycles.

RESULT(S)

In total, 132 deliveries (0.04% of eligible assisted reproductive technology registry deliveries) had retained products of conception; 122 (92.4%) of these deliveries occurred after FET transfer cycles. Cases with retained products of conception were significantly more likely to have undergone vaginal delivery than cases without retained products of conception (78.0% vs. 61.1%); they were also more likely to have been complicated with the placenta accreta spectrum (24.2% vs. 0.45%). Among patients undergoing FETs, factors associated with a significantly increased risk of retained products of conception were embryo stage at transfer, use of hormone replacement cycles, and assisted hatching. Use of hormone replacement cycles represented the largest risk factor (adjusted odds ratio, 4.9; 95% confidence interval, 2.0-12.4), such that retained products of conception occurred in 0.05% (51 of 97,958) of deliveries after hormone replacement cycles but only 0.01% (5 of 47,079) of deliveries after natural cycles. Subgroup analysis showed that hormone replacement cycles and assisted hatching remained significant risk factors for retained products of conception in cases without polycystic ovary syndrome and anovulation and cases with vaginal delivery, but not cases with cesarean section. Among fresh embryo transfers, an increased number of retrieved oocytes was the only significant risk factor for retained products of conception.

CONCLUSION(S)

Our analyses demonstrated that most of the cases involving retained products of conception were derived from FETs, and we identified the use of hormone replacement cycles as the largest risk factor for retained products of conception within this group.

Clinical Prediction of Retained Products of Conception: Combining Obstetric History and Ultrasound for Improved Accuracy in Severe Postpartum Hemorrhage

Background The current challenge is how to improve the management of postpartum hemorrhage (PPH) to reduce the maternal mortality rate further. This study aimed to investigate whether a combined specific obstetric history and ultrasonographic findings can improve the predictive accuracy of retained products of conception (RPOC) with severe PPH. Methods This retrospective study included 56 patients who were diagnosed with RPOC. We extracted the following clinical data: obstetric history of second-trimester miscarriage, the time at which there was clinical suspicion of RPOC after the previous pregnancy (TIME), grayscale ultrasonographic finding (RPOC long-axis length [SIZE]), and color Doppler ultrasonographic finding based on the Gutenberg classification (RPOC hypervascularity). In this study, we defined cases requiring blood transfusion therapy or transcatheter arterial embolization as severe PPH. The patients were divided into two groups according to the presence or absence of severe PPH. The predictors of severe PPH were evaluated using logistic regression models. Model A comprised a combination of second-trimester miscarriage and TIME, Model B comprised a combination of Model A and long-axis SIZE, and Model C comprised a combination of Model B and RPOC hypervascularity. Results The multivariable analysis showed that long-axis SIZE was the only significant predictor of severe PPH (odds ratio [OR], 10.38; 95% confidence interval [CI], 2.06-63.86) independent of second-trimester miscarriage, TIME, and RPOC hypervascularity. The c-statistic was higher in Model C (OR, 0.863; 95% CI, 0.731-0.936) than in Model A (OR, 0.723; 95% CI, 0.551-0.847) and Model B (OR, 0.834; 95% CI, 0.677-0.923). Conclusion Combining a specific obstetric history (second-trimester miscarriage and TIME) and ultrasonographic findings (long-axis SIZE and RPOC hypervascularity) improves the predictive accuracy of RPOC with severe PPH. This prediction model may be a useful clinical screening tool for RPOC with severe PPH.

Office intrauterine morcellation for retained products of conception

OBJECTIVE

Proposing hysteroscopic morcellation (HM) as a surgical-therapeutic approach in the treatment of retained products of conception (RPOC) to prevent intrauterine adhesions (IUAs).

DESIGN

Prospective analysis.

SETTING

A teaching and university hospital.

PATIENTS

Women with RPOC.

INTERVENTIONS

Office -HM with 'Truclear 5 C'.

MATERIAL AND METHODS

Twenty-two consecutive patients presenting with trophoblastic residue retention after miscarriage and interruption of pregnancy or placenta remnants after cesarean section or delivery were enrolled. These women underwent office-HM with 'Truclear 5 C'. Primary outcomes were median time and rate of hospitalization. The quality of the specimen was also analyzed. A hysteroscopic second look for IUAs was performed.

RESULTS

Mean procedure time was six minutes (SD ± 5). Tissue samples had a mean collection size 2.5 cm3+0.9. 38% of the samples had spotting or abnormal vaginal discharge. Dilatation of the cervical canal was not performed in any case. Second-look hysteroscopy did not show any de novo IUAs in any of the enrolled patients.

CONCLUSIONS

In the hysteroscopic treatment of RPOC, HM is a valid choice in an office setting without the use of cervical dilatation. Removal of RPOC was uneventful in all cases, simple and carried out faster without any adverse outcomes.

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part I: Obstetric (Non-Fetal) Complications

Acute abdominopelvic pain in pregnant and postpartum patients presents clinical and therapeutic challenges, often requiring quick and accurate imaging diagnosis. Ultrasound remains the primary imaging investigation. Magnetic resonance imaging (MRI) has been shown to be a powerful diagnostic tool in the setting of acute abdominal pain during pregnancy and puerperium. MRI overcomes some drawbacks of US, avoiding the ionizing radiation exposure of a computed tomography (CT) scan. Although CT is not usually appropriate in pregnant patients, it is crucial in the emergency evaluation of postpartum complications. The aim of this article is to provide radiologists with a thorough familiarity with the common and uncommon pregnancy and puerperium abdominal emergencies by illustrating their imaging appearances. The present first section will review and discuss the imaging findings for acute abdominopelvic pain of obstetric (non-fetal) etiology.

Management of Hypervascular Retained Products of Conception With Massive Bleeding

Retained products of conception (RPOC) could be a factor for massive postpartum hemorrhage; however, a management protocol is yet to be established. Performing a surgical intervention is controversial due to the potential for natural healing. Herein, we report the management of a hypervascular RPOC case with massive bleeding. Abortion was performed in a 40-year-old patient with gravida 2 and para 0, at 20 weeks and five days of gestation following the detection of Down's syndrome on prenatal screening. Post-delivery transvaginal ultrasonography identified an intrauterine mass measuring 4cm × 5cm × 5cm. The patient was then followed up in the outpatient department. One month after the abortion, the patient developed abnormal vaginal bleeding. Transvaginal ultrasonography revealed a hypervascular myometrial RPOC with turbulent flow. Although the bleeding stopped upon her admission to our hospital, the patient developed recurrent abnormal vaginal bleeding after nine days of hospitalization, which resulted in a hemoglobin level drop to 5.9 g/dL. CT and MRI scan findings raised the suspicion of hypervascular RPOC or uterine artery pseudoaneurysm. Uterine artery embolization was performed, leading to diminished vascularity in the RPOC, which was confirmed through color Doppler ultrasonography. The remnant placenta was successfully resected hysteroscopically, and a subsequent transvaginal ultrasonography showed a decrease in blood flow. In conclusion, hypervascular RPOC, previously reported as uterine artery pseudoaneurysms, should be considered when detecting hypervascular myometrial lesions in postpartum ultrasonography. Hypervascular RPOC with hemorrhage might benefit from hysteroscopic resection after achieving hemostasis with uterine artery embolization. This case report highlights the potential risks of awaiting spontaneous resolution in large RPOC and suggests that timely surgical intervention is both effective and essential.

Efficacy of estrogen-progestogen therapy for women with vascular retained products of conception following miscarriage or abortion

OBJECTIVE

To assess the clinical characteristics and endocrinological background of women with vascular retained products of conception (RPOC) after miscarriage or abortion and evaluate the effect of estrogen-progestogen therapy (EPT) as an initial treatment on this population based on their endocrinological background.

MATERIALS AND METHODS

Women with vascular RPOC after miscarriage or abortion at less than 20 weeks of pregnancy who were given EPT (conjugated estrogen and norethisterone) were retrospectively reviewed. Their clinical characteristics, hormonal parameters, ultrasonographic findings, and outcomes were evaluated.

RESULTS

Of 35 women with vascular RPOC, 30 (86%) presented with vaginal bleeding at a visit, and 6 (17%) required inpatient management due to heavy bleeding. Among women who presented with vaginal bleeding, serum progesterone levels were significantly lower (0.25 vs. 6.5 ng/mL, p = 0.004) than those in women who did not present with vaginal bleeding. There were no differences in serum hCG levels (10.5 vs. 3.1 mIU/mL) or serum estradiol levels (65.4 vs. 162.3 pg/mL). After withdrawal bleeding following the first course of EPT, vaginal bleeding was stopped in 27 of the 30 women (90%), and 23 (66%) of all women had a thin and linear endometrium. All women could be treated by up to two courses of EPT and did not require additional interventions. The median duration to hCG normalization after the initial EPT was 24.5 (9-88) days.

CONCLUSION

Women with vascular RPOC who have no bleeding had significantly higher levels of serum progesterone, indicating that administration of progestogen may have an effect on hemostasis. Endometrial bleeding can be prevented or stopped, and retained tissues can be conservatively expelled by oral administration of EPT, including norethisterone, in women with vascular RPOC.

The role of contrast-enhanced ultrasound in the diagnosis and guiding therapy of early cervical ectopic pregnancy

We described the ultrasonic imaging characteristics of four patients with cervical ectopic pregnancy (CEP) and inevitable miscarriage (IM) with the gestational sac (GS) located at the level of the cervical canal discussed and analyzed them in combination with relevant data, such as surgery and outcomes. It was found that contrast-enhanced ultrasound (CEUS) could provide a more accurate differential diagnosis of early CEP and IM than conventional ultrasound (US), thus providing more effective guidance for clinical therapy. In CEP, CEUS shows sustained annular hyperenhancement of the GS wall. However, CEUS shows nonenhancement or pedicle-like enhancement in IM with the GS located at the level of the cervical canal.

Hysteroscopic resection with temporary balloon catheter occlusion of bilateral internal iliac arteries for managing retained products of conception after spontaneous abortion: Two cases report

Retained products of conception (RPOC) is a condition in which trophoblastic tissue remains in the uterus after pregnancy, causing massive hemorrhage in some cases. Though RPOC is commonly treated by intrauterine curettage or hysteroscopic resection uterine artery embolization or hysterectomy may be performed in case of massive bleeding. We experienced two cases of RPOC after surgery for missed abortion that failed to respond to conservative treatment and required surgical treatment. They were treated by hysteroscopic resection with temporary balloon catheter occlusion of bilateral internal iliac arteries for fertility preservation. After the balloon catheters were inflated, the reduction of blood flow to RPOC was observed under transvaginal ultrasound. In both cases, good visualization was maintained throughout the surgery with minimal bleeding. They were discharged the next day and resumed menstruation 1 month after surgery. This paper demonstrates the usefulness of this procedure as a minimally invasive and fertility-preserving surgery.

Conservative Management for Retained Products of Conception in Late Pregnancy

This retrospective study aims to compare the early manual removal of placenta (MROP) and conservative management of retained products of conception (RPOC) after 34 weeks of gestation. Nineteen cases underwent MROP within 24 h of delivery, of which nine patients had no symptoms requiring emergent treatment. These 9 patients (group M) were compared with 22 patients who were treated conservatively (group C). Massive bleeding was observed in 5 (56%) patients in group M and 11 (50%) patients in group C, with no significant difference in frequency. However, the lowest hemoglobin level within 72 h after massive bleeding was lower in group M (median: 6.7 vs. 7.7 g/dL, p = 0.029), suggesting that massive bleeding occurred in a short period of time. On the other hand, a retained placenta was observed in four patients in group M after the MROP; however, the placenta disappeared more quickly than in group C (median; 1.0 vs. 99.0 days, p = 0.009). In group C, all bleeding and infection occurred within 60 days of delivery, including heavy bleeding in six cases during the placental-extraction trial. Human chorionic gonadotropin in group C fell below the measurable threshold at a median of 67 days postpartum. In conclusion, for RPOC without urgent symptoms, early MROP and conservative treatment have their advantages and disadvantages. Randomized controlled trials are needed to determine which of those treatments is superior.

Management of Symptomatic Vascularized Retained Products of Conception by Proximal Uterine Artery Embolization with Gelatin Sponge Torpedoes

PURPOSE

To evaluate the effectiveness and safety of temporary proximal uterine artery embolization (UAE) for the treatment of highly vascularized retained products of conception (RPOCs).

MATERIALS AND METHODS

This retrospective analysis included women who underwent treatment for vaginal bleeding after abortion, miscarriage, or delivery, with highly vascularized RPOCs detected by Doppler ultrasound (US) (ie, presence of an enhanced myometrial vascularity, a low resistance index of <0.5, and a peak systolic velocity of ≥0.7 m/s). A unilateral or bilateral embolization with torpedoes of gelatin foam was performed. From November 2017 to January 2021, 24 women with a median age of 30 years (interquartile range, 26.0-34.5 years) with symptomatic highly vascularized RPOCs were included. Clinical success was defined as bleeding arrest between the UAE and 1-month follow-up. Technical success was defined as the complete obstruction of at least 1 uterine artery supplying vascular abnormalities. The safety of the procedure according to the classification of the Society of Interventional Radiology and evolution of lesions on US were also reported.

RESULTS

Technical success was achieved in all 24 (100%) patients, with bilateral arterial embolization in 19 (79%) patients and unilateral embolization in 5 (21%) patients. Clinical success was achieved in all 24 (100%) patients. Five patients still had uterine retention at the 1-month follow-up, including 2 patients with highly vascularized RPOCs. Two patients benefited from hysteroscopy, and 3 had noninvasive management. Four minor adverse events were reported (1 patient had infectious endometritis and 3 patients had a postembolization syndrome).

CONCLUSIONS

Proximal UAE with torpedoes of gelatin foam is safe and effective for the management of symptomatic highly vascularized RPOCs.

Serum Β-HCG Level In Women Diagnosed With Retained Products Of Conception: A Prospective Cohort Study

STUDY OBJECTIVE

Retained products of conception (RPOC) may occur following delivery or abortion, often necessitating operative hysteroscopy for their removal. A preoperative diagnosis of RPOC by ultrasonography is not always accurate and may lead to unnecessary surgical procedures. We sought to evaluate whether serum level of β-human-chorionic-gonadotropin (β-HCG) may aid in the preoperative diagnosis of RPOC.

DESIGN

Prospective cohort study.

SETTING

Gynecology department in a university affiliated medical center.

PATIENTS

Women undergoing operative hysteroscopy for removal of RPOC between 12/2019 and 1/2021.

INTERVENTION

Operative hysteroscopy for RPOC removal. Serum β-HCG level were obtained on the day of surgery, and level ≥5.0 mIU/ml were considered positive. All operative specimens were evaluated by pathology for the presence of trophoblastic tissue.

MEASURMENTS AND MAIN RESULTS

Of the 105 women recruited to the study, the operative pathology showed trophoblastic tissue in 81 (77.1%) cases, and they were included in the data analysis. The β-HCG level was positive in 16 (19.8%) of those 81 cases. Positive β-HCG level was significantly associated with RPOC following an abortion (surgical or medical) compared to RPOC following delivery. In addition, the mean RPOC mass was larger in the β-HCG-positive group compared with the β-HCG-negative group (29.1 ± 9.5 mm versus 23.8 ± 8.9 mm, respectively, P=.004), and the interval from termination of pregnancy to surgery was shorter (4.8 ± 1.7 weeks versus 7.5 ± 2.1 weeks, respectively, P<.001). Relatively high β-HCG level (352 mIU/mL and 3561 mIU/mL) were found in two cases in which the RPOC mass was implanted on a previous cesarean section scar.

CONCLUSION

β-HCG level is non-contributory to the preoperative diagnosis of RPOC.