Retained products of conception: risk factors and complications following pregnancy

Posted: 21/10/2020

Retained products of conception (RPOC) are the placental and/or fetal tissue that remain in the womb following childbirth, a medical termination of pregnancy or a miscarriage.

After childbirth it is vital for the attending midwife to examine the placenta carefully to check that it is complete, as any tissue left behind can cause serious problems. After a caesarean delivery, in addition to inspecting the placenta, the inside of the womb should be examined by the obstetrician before suturing to ensure that none of the placenta is left behind.

The risk of RPOC is much higher after a termination or miscarriage, as it can be more difficult to determine if all of the placental and fetal tissue has been expelled from the womb. RPOC are reported in 17% of first trimester miscarriages and 40% of late (second trimester) miscarriages, compared to less than 3% of full term deliveries.

One of the most serious risk factors for RPOC is the condition placenta accreta, where the placenta becomes attached to the muscle of the womb and/or to nearby structures such as the bladder. This condition is more common if:

• the placenta is lying low and covers the neck of the cervix (placenta previa);
• a woman has previously had a caesarean delivery;
• uterine scarring from previous surgery is present; and/or
• a woman has had multiple previous pregnancies.

Other risk factors are failure to progress during delivery and instrument delivery.

What are the symptoms?

Women with RPOC may experience a number of symptoms, including:

• heavy vaginal bleeding — after childbirth, a termination or miscarriage, some bleeding is normal, but if the bleeding is very heavy (for example significantly heavier than period bleeding, or with large blood clots), prolonged (lasts more than three weeks) and/or doesn’t reduce over time, it may be due to RPOC. This bleeding can be life threatening;
• fever, abdominal or pelvic pain and tenderness — these symptoms can be signs of an infection in the retained products; and
• late period — ie if a woman’s period doesn't return within six weeks after the event.

If an individual has some or all of these symptoms, they should report them to a doctor.

Diagnosis

If RPOC are suspected, a patient may have to undergo tests such as a physical examination, laboratory testing, ultrasound, or hysteroscopy (a procedure that lets the doctor look inside the womb using a thin, lighted tube).

Treatment

Treatment of RPOC will be dependent on the clinical situation. For example, some women may be given misoprostol, a synthetic hormone, which encourages the womb to expel the remaining tissue. However, where there is heavy bleeding, surgery may be required. The procedure, evacuation of retained products of conception (ERPC), is performed under a general anaesthetic. A speculum is inserted into the vagina and the cervix (neck of the womb) is stretched open in order to insert an instrument to remove the remaining tissue from the womb. Some women may be able to go home and return to hospital for the operation in a couple of days, but where the bleeding is particularly heavy, an emergency operation may be necessary.

Other treatments, like fluids and antibiotics, might also be needed.

If you need help

The clinical negligence team at Penningtons Manches Cooper has experience of acting for clients who have suffered problems arising from failure to diagnose and/or treat RPOC.

For example:

• In this case study, the team represented a client where a large piece of retained placenta was negligently missed after her daughter’s birth by caesarean section. The failure to detect and remove it resulted in continued bleeding, a very distressing emergency operation, a delayed discharge home from hospital, and psychological symptoms (an adjustment disorder and continuing post-traumatic symptoms). The hospital admitted failings in the care provided and the client was awarded damages.
• In another case, a client complained of heavy blood loss and clots after delivery of her baby. As this is not unusual post-delivery, she was advised to observe the bleeding and return to hospital if it carried on. The heavy blood loss continued and four weeks later the client was rushed to hospital by ambulance. She was diagnosed with an infection and discharged that day, still suffering from bleeding. Two days later she was again taken to hospital by ambulance. By this time a blood transfusion was required due to the extent of blood loss. A scan was arranged, confirming RPOC, and the client subsequently underwent a procedure to remove these. The hospital eventually acknowledged failings in the care provided and a settlement was negotiated.

Specialist members of the team are happy to provide initial advice and an informal, no obligation conversation with anyone who has concerns about the care they have received.

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