DSOG Guideline Bulletin: Retained Products of Conception in Postpartum Women
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Abstract
The aim of this guideline was to update an existing guideline from 2014. Retained products of conception (RPOC) is a recognized cause of secondary postpartum hemorrhage (PPH), affecting 1-6% of postpartum women. Despite its clinical significance, evidence on the diagnosis and management of RPOC remains limited. This guideline provides recommendations for both hemodynamically stable and unstable patients. Seven research questions were formulated to evaluate diagnostic methods of RPOC and compare different treatment modalities. The level of evidence was graded according to the Oxford Centre for Evidence-based Medicine Levels of Evidence depending on the study quality. According to the literature diagnosis of RPOC remains challenging, as RPOC can mimic normal postpartum uterine changes on ultrasound. Ultrasound, particularly with Doppler flow, plays a valuable role in diagnosis of RPOC, and findings such as a midline echo ≥10 mm or an intracavitary hyperechogenic mass should be correlated with clinical symptoms to guide management. Management options include watchful waiting and surgical intervention. Medical management has shown limited success, often necessitating secondary surgical treatment. Watchful waiting may be considered in hemodynamically stable patients regardless of ultrasonographic findings, although comparative data with active treatment is inconclusive. Surgical treatments include dilation and curettage (D&C) or hysteroscopic resection. Though widely used, D&C is a blind procedure with risks such as uterine perforation and intrauterine adhesions, potentially affecting future fertility. Hysteroscopy, offering direct visualization and targeted removal, minimizes endometrial damage and adhesions and is increasingly preferred where expertise and resources are available. Hemodynamically unstable patients with ongoing severe bleeding may undergo D&C, preferably guided by ultrasound. Hysteroscopy within the first postpartum weeks, especially in the presence of ongoing heavy bleeding, can be technically difficult to conduct, but is the preferred choice when possible. The level of evidence across studies ranged from 2b to 4, emphasizing the need for further research in this field.
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