Retained products of conception

Products of conception, abbreviated POC, is a medical term used for the tissue derived from the union of an egg and a sperm. It encompasses anembryonic gestation (blighted ovum) which does not have a viable embryo.

In the context of tissue from a dilation and curettage, the presence of POC essentially excludes an ectopic pregnancy.

Retained products of conception is where products of conception remain in the uterus after childbirth, medical abortion or spontaneous abortion (colloquially known as miscarriage). Miscarriage with retained products of conception is termed delayed when no or very little products of conception have been passed, and incomplete when some products have been passed but some still remain in utero.

The diagnosis is based on clinical presentation, quantitative HCG, ultrasound, and pathologic evaluation. A solid, heterogeneous, echogenic mass has a positive predictive value of 80%, but is present in only a minority of cases. A thickened endometrium of > 10 mm is usually considered abnormal, though no consensus exists on the appropriate cutoff. A cut-off of 8 mm or more has 34% positive rate, while a cut off of 14 mm or more has 85% sensitivity, 64% specificity for the diagnosis. Color Doppler flow in the endometrial canal can increased confidence in the diagnosis, though its absence does not exclude it, as 40% of cases of retained products have little or no flow. The differential in suspected cases includes uterine atony, blood clot, gestational trophoblastic disease, and normal post partum appearance of the uterus. Post partum blood clot is more common, reported in up to 24% of postpartum patients, and tends to be more hypoechoic than retained products with absent color flow on Doppler, and resolving spontaneously on follow up scans. The presence of gas raises the possibility of post partum endometritis, though this can also be seen in up to 21% of normal post pregnancy states. The normal post partum uterus is usually less than 2 cm in thickness, and continues to involute on follow up scans to 7 mm or less over time. Retained products are not uncommon, occurring in approximately 1% of all pregnancies, though it more common following abortions, either elective or spontaneous. There is significant overlap between appearance of a normal post partum uterus and retained products. If there is no endometrial canal mass or fluid, and endometrial thickness is less than 10 mm and without increased flow, retained products are statistically unlikely.

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