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Miscarriage and Postpartum Hemorrhage with Retained Products of Conception (RPOCS)

The recently pregnant uterus is especially vulnerable to injury--both perforation and adhesion (scar) formation.

 

The risk for developing adhesions following a post partum D&C is from 14 - 48% with an increased risk for a repeat D&C for persistent bleeding. The risk is also increased if the time between birth and curettage or the length between fetal demise and curettage is lengthened (1-5). 

Performing a post partum D&C in the presence of severe hemorrhage is often a life saving procedure. Clearly, it has risks but most often the procedure is appropriately performed. You should ask about your risks of the procedure but be very clear on the benefits as well. One of the risks of a post partum D&C is a complication known as Asherman’s Syndrome, also known as intrauterine adhesions (scarring inside the uterus). This risk has been reported to be between 14 % and 48 % (1,2,3).

The complication rate increases when repeat D&Cs are necessary. For single

D&Cs for miscarriage, the rate is between 16-20%. When multiple D&Cs are needed to remove retained products of conception (RPOCs) from miscarriage, the rate is from 14 – 48% (1-3). For post partum RPOCs, the rate is 25% (4). Many physicians, including very competent gynecologists, believe that the risk of complications from a D&C is between 1 - 5%. When looking at all purposes for D&Cs performed, that’s close to being true, but during this delicate time, the risk is much higher. Some women who develop intrauterine scar tissue will lose their fertility or go on to suffer multiple miscarriages. 

In summary, during the immediate post partum period  (a recently pregnant uterus), about 1 in 6 to 1 in 2 women will acquire intrauterine adhesions (IUA) from D&Cs (especially if repeat D&Cs were needed). It should be noted that there are some camps of thought who do not equate Asherman’s Syndrome with mild intrauterine adhesions, because they believe that Asherman’s Syndrome implies decreased or no bleeding (hypomenorrhea or amenorrhea). Thus, some believe that if someone has Asherman’s Syndrome, she has IUA, but having IUA, does not necessarily mean that she has Asherman’s Syndrome.

ASHERMAN’S SYNDROME (AS) = INTRAUTERINE ADHESIONS (IUA) =SCARRING INSIDE THE UTERUS

For women who had D&Cs using sharp curettage, (this is rarely used anymore for treatment of incomplete miscarriage, instead a blunt curette and/or suction is used) for first trimester miscarriages), Friedler et al (1993), found (by follow-up diagnostic hysteroscopy) that 19% had IUA (1). Following one D&C for miscarriage the rate of scarring was 16.3%. It remained unchanged (14 %) after two D&Cs, but rose significantly to 32% after three D&Cs.  Another finding was that following repeat D&Cs for miscarriage, the severity of IUA increased. This study demonstrates the need for preventative treatment and close follow-up of patients after D&C for miscarriage. Namely, if menstrual flow diminishes or stops following a D&C, testing should begin promptly in order to determine if IUA are present (1).     

A study by Romer (1994) found a 47.6% rate of IUA with recurrent D&Cs for miscarriages and an 18.8% rate in women with one D&C for miscarriage (2).   

Wesendorp et al (1998) detected IUA in 40% of the women who presented with menstrual disorders following a D&C for retained placental pieces or repeat curettage for miscarriage or retained placenta (3).  These doctors used hysteroscopy for diagnosis. 

Intrauterine scar formation has been estimated to occur in about 25% of

D&Cs performed between one and four weeks after delivery. Also, it is estimated to occur in up to 30% of miscarriages as the interval between fetal demise and D&C increases (4,5).     

For more information on Intrauterine Adhesions/Asherman’s Syndrome, visit www.ashermans.org

Discuss with your doctor the possibility of expectant management (let’s wait and see) and/or medical management [medicine such as methylergonovine (Methergine) and misoprostol (Cytotec) to expel retained products of conception (RPOCs)].  Note that these medications are also prescribed for elective termination of pregnancy and thus some pharmacists will not dispense them. Please ask your doctor which pharmacies do carry these medications in your area to help treat your miscarriage or retained placenta.

In this study by Fontanarosa et al (2007), expectant management or medical management for cases of miscarriage (as deemed appropriate by their doctors’ decisions) demonstrated success in 97% of the patients. Surgical intervention was necessary in 2% of the miscarriages and the subsequent pregnancy rate after a year was 81% (6).  

Recently, Gomez Ponce de Leon et al (2007), found that only about 1% of pregnancies result in intrauterine fetal death with retained fetus (meaning that the fetus died in the uterus, but did not spontaneously miscarry). This study discussed some valuable strategies to be employed during misoprostol therapy (7). 

These surgical alternatives (to D&C) have some advantages. If expectant or medical management does not work for a patient suffering a miscarriage, gestational sac aspiration or removal under hysteroscopic or ultrasound visualization could be considered. 

Mitwally et al (2006) investigated gestational sac aspiration as an alternative to