Evaluating Role of Hysteroscopy in Removal of Retained Products of Conception

INTRODUCTION

Retained products of conception (RPOC) is an intrauterine tissue that has developed during conception and is still persisting after miscarriage, medical or surgical termination of pregnancy, and vaginal or cesarean delivery.¹ Retained products of conception is one of the most common causes of postpartum bleeding. However, the clinical presentation can be that of abdominal pain, vaginal bleeding, fever, or late complications including intrauterine adhesions (IUAs) and infertility. The incidence is related to the gestational age of the pregnancy, most commonly after second-trimester delivery or termination of pregnancy. Retained products of conception is seen in about 1% of term pregnancies.² Long-term complications including the formation of IUAs result in adverse reproductive outcomes, such as subfertility, chronic pelvic pain, menstrual disturbances, and severe pregnancy complications such as abnormal placentation including the placenta accrete spectrum.³ Sometimes retained placenta or placental products can lead to severe hemorrhage, infection, or even death. A retained placenta is commonly seen after preterm vaginal delivery and in cases of placenta accreta.^1,4 Dilatation and evacuation (D&E) is a standard procedure for the removal of RPOC which is generally used worldwide. Steps included in this procedure are dilatation of the cervix and evacuation of tissues present in the uterine cavity such as RPOC.⁵ This procedure occurs under short general anesthesia as it can be painful. The complications of this procedure are a pain in the abdomen, bleeding per vagina, perforation of the uterus, cervical injury, and fever. As the patient can do day-to-day activity after 4 hours of operation, hence the patient can be discharged the same day if no complications present. Dilatation and evacuation procedure can also be used for medical termination of pregnancy of first-trimester pregnancy. Hysteroscope is an endoluminal endoscope that can be used as an aid to visualize inside the uterine cavity and perform a variety of intrauterine procedures under direct vision. It is a newer procedure which most commonly used in diagnostic as well as therapeutic procedure.⁶ To visualize the uterine cavity, a gas or liquid is introduced through the hysteroscopic sheath to create pressure and to visualize the uterine cavity better.⁴ Complications are rarely seen but can cause perforation of the uterus and it can very rarely cause embolism if the introduction of cavity is done by CO₂ gas, hence it not used nowadays as it can cause mortal complications.⁶

MATERIALS AND METHODS

It is a prospective comparative study conducted in the obstetrics and gynecology department at Mahatma Gandhi Mission’s Hospital, Kalamboli, over a span of 2 years in 60 pregnant women who were diagnosed by ultrasound to have RPOC >3 cm.

RESULTS

Interpretation: As p-value for the Chi-square is greater than that of 0.05 indicates that the proportion of primigravida and multigravida are almost the same in both the groups

COMPARISON

DISCUSSION

Retained product of conception is a postpartum complication which generally presents with post-aborted/postpartum hemorrhage and pain in the abdomen. The incidence of RPOC is 1% in the third-trimester deliveries.^2–6 In some studies, it has been shown that the incidence of RPOC after first-trimester abortion is 40%, second-trimester abortion is 17%, and third-trimester delivery is 2.7%.^7,8

Retained product of conception is associated with risk factors, such as placenta accrete, history of retained placenta in a previous pregnancy, advanced maternal age, assisted delivery, abortion in the second trimester of pregnancy, prolonged labor, prolonged use of oxytocin, post-C-section, placental abruption, succenturiate lobes, bilobed placenta, scarred uterus following gynecological uterine surgeries and in patients with mullerian uterine anomalies.⁹

In our study we have evaluated the safety and efficacy of hysteroscopic removal as compared with the standard procedure, that is, dilatation and curettage.

In our study, we have observed seven most common postoperative complications in group A patients which were patients that underwent D&E.

In our study, for group A complications are postoperative bleeding which is 0.6% as in other study it has shown around 0–2.4%¹⁰ In our study, injury to the cervix has shown in 0% of the patient, as in other study, it is 0–1.0%.¹⁰ In our study, uterine perforation is seen in one patient out of the 30 patients that underwent dilatation and evacuation (D&E), which comes to 3% of the population while in a study of 2,000 patients, it was reported to be around 0–0.4%.¹⁰

In this study, there were no patients with fever or infection postoperatively for both groups. However, studies conducted elsewhere have shown that infection/fever complication is 0.6–2.5%.¹⁰

In Forna F and Gülmezoglu’s study in 2001, and assessed in 2021, it was suggested that pain is more in D&E when curettage is done, and similar results were observed in our study that postoperative was slightly more in D&E patients when compared with hysteroscopic removal of RPOC.¹¹

In our study, USG was done on all patients on postoperative day 7. Out of 30 patients, four patients had persistent RPOC in group A postoperatively. One such study conducted on persistent RPOC post-evacuation showed the presenting complaint to be postoperative bleeding and was associated with preoperative diagnosis of adherent placenta, placenta accreta, and in some cases, missed abortion.¹²

In our study, group B patients have undergone hysteroscopy accompanied by evacuation with the help of grasper. In some studies, operative hysteroscopy to the uterine wall was associated with excessive bleeding, monopolar electrosurgery was used to provide hemostasis to allow for complete evacuation of the uterine cavity. However, in our study, electrocautery was not used.¹³

In group B patients, postoperative complications were that of mild pain in the abdomen and bleeding in a milder form. None of the patients had a fever, uterine perforation, cervical injury, or RPOC persistent after evacuation seen on USG. In some studies, overall complications was observed following hysteroscopic removal of RPOC.¹⁴

In another study, it has shown that in hysteroscopic evacuation followed by embolism, especially where CO₂ is used for insufflation but in our study, we used normal saline as insufflation media, and not a single case was reported to have embolic complication.¹⁵

When one compares postoperative complications, from the above study, hysteroscopy shows better results than D&E. Hence, hysteroscopy has better safety than D&E. Similarly efficacy of hysteroscopic procedure showed comparatively better results than D&E as postoperative USG was suggestive of RPOC more commonly in cases who underwent D&E.

CONCLUSION

This study shows that hysteroscopic removal of RPOC is a more effective and safer procedure compared with blind D&E. We recommend that it may be used as the first line of treatment for RPOC.

ORCID

Vaibhavi Birle https://orcid.org/0000-0003-3603-5865

Saumya Joshi https://orcid.org/0000-0002-2809-8113

Sanika Nagare https://orcid.org/0009-0000-3695-4373

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