Retained Products of Conception (RPOC)

When retained tissue happens

• after miscarriage: an incomplete miscarriage is the most common setting
• after medical abortion or medical management of miscarriage
• after surgical procedures, less commonly
• after childbirth: fragments of placenta or membranes; if the whole placenta does not deliver within 30 to 60 minutes it is called a retained placenta
• with placenta accreta spectrum, where the placenta grows too deeply into the uterine wall

Symptoms

• vaginal bleeding that is heavier or lasts longer than expected, or restarts after stopping
• passing clots or tissue
• cramping or pelvic pain
• foul-smelling discharge
• fever, chills and a tender uterus if infection develops
• a persistently positive pregnancy test

After birth, retained placental fragments are a common cause of secondary postpartum hemorrhage: heavy bleeding between 24 hours and 12 weeks after delivery.

Diagnosis

• pelvic exam: checking the cervix and the size and tenderness of the uterus
• transvaginal ultrasound: looks for thickened lining or a mass inside the uterus. Blood flow within the mass on Doppler ultrasound strongly suggests retained tissue rather than blood clot
• hCG blood test in early pregnancy loss, to see whether levels are falling
• blood count for anemia and signs of infection

A thick uterine lining alone after pregnancy can be normal, so ultrasound findings are interpreted along with symptoms.

Treatment

Choice depends on bleeding, infection, the amount of tissue, the time since the pregnancy ended and personal preference.

Expectant management

If bleeding is light, there is no infection and the amount of tissue is small, many people pass the tissue naturally over days to weeks.

Medication

Misoprostol helps the uterus contract and expel the tissue. It is commonly used after early pregnancy loss and is effective in many cases.

Procedures

• uterine aspiration (manual or electric vacuum): a quick procedure to remove tissue, under local anesthesia or sedation
• hysteroscopic resection: a thin camera inside the uterus lets the surgeon remove tissue precisely, which may reduce the risk of scarring
• dilation and curettage (D&C) in some situations
• emergency treatment for heavy bleeding: medicines to contract the uterus, blood transfusion and urgent removal of tissue

Infection

Antibiotics are given for infection. Infected retained tissue (septic abortion or postpartum endometritis) usually needs prompt removal.

Rh status

People who are Rh negative may need anti-D immunoglobulin if they have not already received it.

Complications

• heavy bleeding and anemia
• infection of the uterus, which can spread and cause sepsis
• Asherman's syndrome: scar tissue inside the uterus, more likely after repeated or vigorous curettage, which can cause light or absent periods and fertility problems

Recovery

After treatment, bleeding usually settles within days to a couple of weeks. Periods typically return within 4 to 8 weeks. Emotional support is important, especially after pregnancy loss. Seek help if bleeding persists, fever develops or periods do not return.

Frequently asked questions

What are the symptoms of retained products of conception?

Common symptoms are prolonged or heavy vaginal bleeding, passing clots, cramping, foul-smelling discharge and, if infected, fever and pelvic pain. A pregnancy test may stay positive longer than expected.

How is retained tissue diagnosed?

A transvaginal ultrasound is the main test. It can show tissue inside the uterus, and Doppler can show blood flow within it. Blood tests for hCG and blood count help assess the situation.

Will retained tissue pass on its own?

Often, yes. Small amounts of tissue after an early miscarriage frequently pass naturally within a few weeks if there is no infection or heavy bleeding. Misoprostol or a procedure can be used if it does not.

What happens if retained products of conception are not treated?

Untreated retained tissue can cause ongoing or heavy bleeding, anemia and infection of the uterus, which can become serious. Rarely, it leads to scarring inside the uterus. See a doctor if bleeding or other symptoms persist.