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Chapter 9 - Management of Post-Partum Retained Placental Remnants

Published online by Cambridge University Press:  14 July 2023

By
Mary Connor  and
Priya Madhuvrata
Edited by
Swati Jha  and
Priya Madhuvrata
Swati Jha
Affiliation:
Sheffield Teaching Hospital NHS Foundation Trust
Priya Madhuvrata
Affiliation:
Sheffield Teaching Hospital NHS Foundation Trust
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Summary

Placental remnants following birth are often heralded by secondary post-partum haemorrhage. Diagnosis is assisted by an ultrasound scan, with MRI indicated when the scan is inconclusive. Emergency measures are required for excessive bleeding. A conservative approach is appropriate when bleeding is not heavy. Confirmation of intra-uterine placental tissue by repeated scans ensures surgery is confined to women with a high chance of retained tissue. Traditional curettage is often replaced by hysteroscopic resection allowing direct and precise removal of placental remnants with less trauma to adjacent normal endometrium. Hysteroscopic treatment, under general anaesthetic or as an outpatient, is preferably deferred for 2–3 months after delivery to minimise complications, without compromising longer-term outcomes like fertility or subsequent pregnancy rates. Intra-uterine adhesions may occur especially following repeated blind curettage, which can compromise future fertility. Clear communication with the patient and partner is important. Further research into the management options for postdelivery placental remnants is required to ascertain best practice.

Keywords

post-partum retained products of conceptionplacental remnantssecondary post-partum haemorrhageendometrial thicknessvascularityhysteroscopic resectionintra-uterine adhesions
Type
Chapter
Information
Gynaecology for the Obstetrician , pp. 83 - 94
Publisher: Cambridge University Press
Print publication year: 2023

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References

Alexander, J., Thomas, P. and Sanghera, J.. Treatments for secondary postpartum haemorrhage. Cochrane Database of Systematic Reviews (Online), (2002), Cd002867.CrossRefGoogle Scholar
Van den Bosch, T., Daeman, A., Van Schoubroeck, D., et al. Occurrence and outcome of residual trophoblastic tissue. A prospective study. Journal of Ultrasound in Medicine, 27 (2008), 357–61.Google Scholar
Hoveyda, F. and MacKenzie, I. Z.. Secondary postpartum haemorrhage: Incidence, morbidity and current management. BJOG: An International Journal of Obstetrics and Gynaecology, 108 (2001), 927–30.Google Scholar
Kamaya, A., Petrovitch, I., Chen, B., et al. Retained products of conception: Spectrum of color Doppler findings. Journal of Ultrasound in Medicine, 28 (2009), 1031–41.Google Scholar
Westendorp, I. C. D., Ankum, W. M., Mol, B. W. J. and Vonk, J.. Prevalence of Asherman’s syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion. Human Reproduction, 13 (1998), 3347–50.CrossRefGoogle ScholarPubMed
Mavrides, E., Allard, S., Chandraharan, E., et al. (on behalf of the Royal College of Obstetricians and Gynaecologists). Prevention and management of postpartum haemorrhage. GTG 52. BJOG: An International Journal of Obstetrics and Gynaecology, 124 (2016), e106–e149.Google Scholar
Vitale, S., Parry, J. P., Carugno, J., et al. Surgical and reproductive outcomes after hysteroscopic removal of retained products of conception: A systematic review and meta-analysis. Journal of Minimally Invasive Gynecology, 28 (2021), 204−17.Google Scholar
Iraha, Y., Okada, M., Toguchi, M., et al. Multimodality imaging in secondary postpartum or postabortion hemorrhage: Retained products of conception and related conditions. Japanese Journal of Radiology, 36 (2018), 12–22.CrossRefGoogle ScholarPubMed
Mulic-Lutvica, A. and Axelsson, O.. Ultrasound finding of an echogenic mass in women with secondary postpartum hemorrhage is associated with retained placental tissue. Ultrasound in Obstetrics & Gynecology, 28 (2006), 312–19.CrossRefGoogle ScholarPubMed
Lee, N. K., Kim, S., Lee, J. W., et al. Postpartum hemorrhage: Clinical and radiologic aspects. European Journal of Radiology, 74 (2010), 50–9.Google Scholar
Smorgick, N., Segal, H., Eisenberg, N., et al. Serum b-HCG level in women diagnosed as having retained products of conception: A prospective cohort study. Journal of Minimally Invasive Gynecology, 29 (2022), 424−28.CrossRefGoogle Scholar
Combs, C. A., Murphy, E. L. and Laros, R. K.. Factors associated with postpartum hemorrhage with vaginal birth. Obstetrics & Gynecology, 77 (1991), 69–76.Google ScholarPubMed
Urner, F., Zimmermann, R. and Krafft, A.. Manual removal of the placenta after vaginal delivery: An unsolved problem in obstetrics. Journal of Pregnancy, (2014), 2746515.CrossRefGoogle Scholar
Greenbaum, S., Wainstock, T., Dukler, D., Leron, E. and Erez, O.. Underlying mechanisms of retained placenta: Evidence from a population based cohort study. European Journal of Obstetrics & Gynecology and Reproductive Biology, 216 (2017), 12–17.Google Scholar
Babarinsa, I. A., Hayman, R. G. and Draycott, T. J.. Secondary post-partum haemorrhage: Challenges in evidence-based causes and management. European Journal of Obstetrics & Gynecology and Reproductive Biology, 159 (2011), 255–60.Google Scholar
NICE CG190. Intrapartum Care for Healthy Women and Babies. (2019). www.nice.org.uk/guidance/cg190/resources/intrapartum-care-for-healthy-women-and-babies-pdf-35109866447557Google Scholar
Cohen, S. B., Kalter-Ferber, A., Weisz, B. S., et al. Hysteroscopy may be the method of choice for management of residual trophoblastic tissue. Journal of the American Association of Gynecologic Laparoscopists, 8 (2001), 199–202.Google Scholar
Faivre, E., Deffieux, X., Mrazguia, C., et al. Hysteroscopic management of residual trophoblastic tissue and reproductive outcome: A pilot study. Journal of Minimally Invasive Gynecology, 16 (2009), 487–90.Google Scholar
Golan, A., Dishi, M., Shalev, A., et al. Operative hysteroscopy to remove retained products of conception: Novel treatment of an old problem. Journal of Minimally Invasive Gynecology, 18 (2011), 100–3.Google Scholar
Wada, Y., Hakahashi, H., Suzuki, H., et al. Expectant management of retained products of conception following abortion: A retrospective cohort study. European Journal of Obstetrics & Gynecology and Reproductive Biology, 260 (2021), 1–5.CrossRefGoogle ScholarPubMed
Neilson, J. P., Gyte, G. M., Hickey, M., Vazquez, J. C. and Dou, L.. Medical treatments for incomplete miscarriage. Cochrane Database of Systematic Reviews, (2013), CD007223. https://doi.org/10.1002/14651858.CD007223.pub3Google Scholar
Hooker, A. B., Aydin, H., Brölmann, H. A. and Huirne, J. A.. Long-term complications and reproductive outcome after the management of retained products of conception: A systematic review. Fertility and Sterility, 105 (2016), 156–64.Google Scholar
Hamerlynck, T. W. O., van Vliet, H. A. A. M., Beerens, A-S., Weyers, S. and Schoot, B. C.. Hysteroscopic morcellation versus loop resection for removal of placental remnants: A randomized trial. Journal of Minimally Invasive Gynecology, 23 (2016), 1172–80.CrossRefGoogle ScholarPubMed
Goldenberg, M., Schiff, E., Achiron, R., Lipitz, S. and Mashiah, S.. Managing residual trophoblastic tissue: Hysteroscope for directing curettage. Journal of Reproductive Medicine, 42 (1997), 26–8.Google Scholar
Georgiou, D., Tranoulis, A. and Jackson, T. L.. Hysteroscopic tissue removal system (MyoSure) for the resection of polyps, submucosal leiomyomas and retained products of conception in an out-patient setting: A single UK institution experience. European Journal of Obstetrics & Gynecology and Reproductive Biology, 231 (2018), 147–51.Google Scholar
Jakopic Macek, K., Blaganje, M., Kenda Suster, N., Drusany Staric, K. and Kobal, B.. Office hysteroscopy in removing retained products of conception – a highly successful approach with minimal complications. Journal of Obstetrics and Gynaecology, 40 (2020), 1122–6.Google Scholar
Hooker, A. B., Muller, L. T., Paternotte, E. and Thurkow, A. L.. Immediate and long-term complications of delayed surgical management in the postpartum period: A retrospective analysis. Journal of Maternal-Fetal and Neonatal Medicine, 28 (2015), 1884–9.Google Scholar
Tarasov, M., Burke, Y. Z., Stockheim, D., Orvieto, R. and Cohen, S. B.. Does the time interval between the diagnosis to hysteroscopic evacuation of retained products of conception affect reproductive outcome. Archives of Gynecology and Obstetrics, 302 (2020),1523–8.CrossRefGoogle ScholarPubMed
Ben-Ami, I., Melcer, Y., Smorgick, N., et al. A comparison of reproductive outcomes following hysteroscopic management versus dilatation and curettage of retained products of conception. International Journal of Gynecology & Obstetrics, 127 (2014), 86–9.CrossRefGoogle ScholarPubMed

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