REGISTRO DOI:10.69849/revistaft/th102501021457
Mayara de Cássia Benedito Andrade
Mari Hattori Ballantyne Wyper
Marina Quaglio Oinegue Fulfaro
Letícia Calazans Queiroz Cardone
Beatriz Oliveira dos Santos
Miguel Carvalho Mas Santacreu
Abstract: Bleeding is a normal feature of the healing process after childbirth or miscarriage. Under normal circumstances, this bleeding gradually decreases within the first week after delivery. However, if the bleeding is persistent and uterine atony is not the underlying cause, the most likely cause is retained products of conception (RPOC). The placenta is the primary component of RPOC, and its rich vascular connection to the uterus serves as a pathway for persistent bleeding. Late complications of RPOC include intrauterine adhesions (IUA) formation and infertility. Diagnosing RPOC accurately is crucial but often challenging, whether through clinical evaluation or imaging techniques. Traditionally, RPOC have been managed using blind dilation and suction curettage (D&C). However, hysteroscopic resection has emerged as a reliable and effective alternative. A precise diagnosis is essential for ensuring appropriate treatment and care. The aim of the present review is to access the current evidence regarding the use of hysteroscopy for the removal of RPOC. Evidence search was performed using the databases PubMed, Web of Sciences and SciELO.
Key words: hysteroscopy, retained products of conception, RPOC, retained products of conception.
Introduction
Retained products of conception (RPOC) are described as the retention of trophoblastic or placental tissue in the uterine cavity after a delivery or abortion (1). This complication affects about 1% of completed pregnancies (2) of either vaginal or cesarean section delivery. However, it is more commonly seen following a miscarriage or voluntary termination of pregnancy during the first or second trimester, with a reported prevalence of up to 6%, and reaching 15% after pharmacological abortions (3).
Symptoms associated with RPOC vary depending on the amount of retained tissue, the presence of infection and the individual’s response but include abnormal uterine bleeding, pelvic pain, fever, foul-smelling vaginal discharge, delayed or and absent menstrual return. Complications like endometritis and intrauterine adhesions (IUAs) may occur, potentially leading to secondary infertility (4). Since RPOC occurs in reproductive-age women who may desire future pregnancies, infertility is the most important long-term complication. Despite these associated risks, RPOC may sometimes be incidentally detected during an ultrasound examination.
Diagnosing RPOC can be challenging due to several factors that complicate the identification of retained tissue, overlap with other conditions, and variability in clinical presentation (3). Ultrasound findings may reveal a heterogeneous intracavitary hyperechoic focal mass, an irregular endometrium-myometrium interface, increased or irregular endometrial thickness, or a fluid layer. The use of Doppler ultrasound is particularly useful, as it identifies blood flow within the mass, aiding in distinguishing RPOC from hematomas and allowing classification based on vascularity (5,6). Color Doppler imaging is therefore highly recommended for improving diagnostic accuracy (6).
The Kamaya classification is a system for characterizing RPOC based on their vascularity as assessed by Doppler ultrasonography. It helps guide clinical decision making regarding the risk of complications like bleeding and the approach to management. The classification categorizes RPOC into four types based on the degree of vascularity observed, ranging from Type 0 (avascular) to Type 3 (marked vascularity) (6). Complementary to the Kamaya classification, the Gutenberg Classification incorporated vascularity and echogenicity on ultrasound to guide preoperative evaluations. This classification is useful especially for assessing bleeding risk during hysteroscopic RPOC removal and helps determine whether the procedure is safer in an office or operating room setting (7,8).
Management of RPOC has traditionally relied on dilation and curettage (D&C), historically considered the gold standard technique. However, this blind procedure carries risks, including incomplete tissue removal and uterine perforation (9). Additionally, D&C may cause non-selective endometrial damage, leading to IUAs in 15–40% of cases and potentially impacting fertility (10). Hysteroscopy is recognized as the gold standard technique for treating most intrauterine pathologies and serves as a minimally invasive alternative to D&C for managing RPOC (11). Because it allows direct visualization during the procedure, it is possible to perform a selective removal of retained tissue while preserving endometrial tissue, reducing the incidence of IUA to up to 7.5% (2,12).
Highly vascular RPOC can be confused with acquired uterine arteriovenous malformation (AVM), a rare but potentially life-threatening condition characterized by an abnormal connection between arteries and veins in the uterus without the usual intervening capillary network (13). Differentiating between these two conditions is crucial, as the treatment for RPOC, the D&C, can worsen bleeding, potentially leading to shock or death in patients with AVM. For this reason, D&C is contraindicated in AVM and accurate ultrasound diagnosis is vital (14).
The diagnosis of AVM relies heavily on imaging techniques. Transvaginal ultrasound is often the first step, revealing hypoechoic areas located within the myometrium and high-velocity, multidirectional blood flow. In contrast, vascularity in RPOC is typically confined to the endometrium, whereas the vascular component in AVM is predominantly situated in the myometrium (5). When AVM is suspected based on ultrasound findings, further diagnostic imaging is needed. Computed tomography angiography is the next step to provide more detailed visualization, with arteriography serving as the definitive diagnostic tool. Arteriography also allows for potential embolization to treat the condition, if necessary (15).
Hysteroscopy is a minimally invasive diagnostic and therapeutic procedure that offers significant advantages for the management of RPOC. Compared to traditional approaches like blind D&C, hysteroscopy provides superior precision, safety, and effectiveness. The direct visualization of the uterine cavity minimizes the risk of incomplete evacuation of retained tissue. Consequently, it also decreases the risk of damaging the adjacent endometrium, trauma and inflammation, thus lowering the likelihood of IUAs (8). The objective of this review is to provide a detailed examination of the use of hysteroscopy for the removal of RPOC in comparison to other methods. This includes highlighting its advantages, such as precision, safety, and minimal invasiveness, as well as discussing its potential drawbacks to offer a comprehensive understanding of its role in clinical practice.
RPOC Treatment
Management of RPOC is tailored to the patient’s clinical presentation, symptoms, and reproductive goals. Treatment options can generally be categorized as conservative, medical and surgical approaches. The conservative one that has been applied in asymptomatic and clinically stable cases who have more probabilities of adhering to follow up. In these cases, follow-up through simple observation is a potential approach, particularly for patients with minimal or no symptoms. Previous studies have demonstrated that conditions such as placental polyps and uterine AVM may resolve spontaneously without requiring medical or surgical intervention (15).
Medical management
Medical management is an approach for carefully selected cases. It consists in the administration of certain drugs. The anti-metabolite drug methotrexate has been utilized in the treatment of placental polyps. Additionally, hormonal therapies, including estrogen and progesterone preparations, danazol, and depot gonadotropin-releasing hormone (GnRH) preparations, have been employed in managing uterine AVM in asymptomatic and clinically stable patients. Accurate diagnosis of the underlying condition is crucial to ensure the selection of appropriate medical treatment. Studies show an overall success rate of 88% for medical management. After accounting for clustering effects, success rates were 82.5% for progestins, 89.3% for GnRH agonists, and 90.0% for methotrexate, all significantly exceeding the null hypothesis of 50% success (16). Progestins and GnRH agonists demonstrated the lowest complication rates. There were no identified predictors of success for medical management. Notably, 26 pregnancies were described following treatment, with no reported recurrences of AVM (17).
Surgical management
Surgical approaches are indicated when conservative or medical management fails or is not appropriate. These approaches are aimed at removing the retained tissue to prevent complications such as infection, bleeding and the formation of IUA, which can have long term effects on fertility. The main surgical techniques include D&C, suction and curettage, manual vacuum aspiration (MVA) and hysteroscopic resection (18). D&C is effective but has several drawbacks and is associated with a 30% chance of IUA formation (19). Despite this, D&C remains a widely used method for managing RPOC. Suction curettage offers a lower risk of uterine injury compared to D&C, but it is less effective in removing larger or more adherent retained tissue (20). MVA is a minimally invasive procedure that carries a lower risk of uterine perforation and other complications compared to D&C, but it is best suited for smaller or less complicated cases of RPOC (18).
Office hysteroscopy
Office hysteroscopy is usually recommended after suspected findings in ultrasound examination. Diagnostic followed by operative hysteroscopy allows a “see-and-treat” hysteroscopy, in other words, office hysteroscopy (21), resulting in savings of both cost and time for the patient and the physician. The initial studies demonstrating the effectiveness of hysteroscopic removal in an outpatient setting, performed without general anesthesia or cervical dilation, were published around 2009 (22, 23). These studies emphasize several advantages, including the elimination of hospitalization and the ability for patients to return to daily activities immediately –an especially significant benefit for breastfeeding mothers. Studies indicate that for RPOC with a diameter of up to 2 cm, operative hysteroscopy does not provide a significant advantage in success rates compared to see-and-treat hysteroscopy. However, when the RPOC diameter exceeds 2 cm, operative hysteroscopy demonstrates a higher success rate (24). It is important to note that when performed in-office only small-caliber instruments can be used, this could be a limitation when it comes to larger masses of tissue, or strongly adhered tissue to the myometrium. Research demonstrates that office hysteroscopy is highly effective, well-tolerated by patients, and associated with low complication rates. A study analyzing data from 101 patients with RPOC treated using office hysteroscopy between 2012 and 2015 concluded that this approach is the preferred method for managing RPOC in cases where the retained tissue is up to 30 mm thick, β-hCG levels are low or negative (up to 80 U/L), and Doppler ultrasonography shows absent or minimal vascularization (25). β-hCG levels were assessed because studies suggest that levels exceeding 100 U/L after first-trimester pregnancy termination can predict the presence of RPOC (26), potentially indicating greater tissue vitality, stronger vascularization, and increased adherence.
Hysteroscopic resection
One of the primary advantages of hysteroscopic resection, or resectoscopy, is its ability to allow direct visualization of the retained tissue, enduring complete removal. Specialized instruments, such as a resectoscope or hysteroscopic scissors, are used to remove the RPOC under direct visualization. If the tissue is vascularized, bipolar or monopolar energy is employed to control bleeding and ensure complete resection (27). By using a camera, the surgeon can accurately target the RPOC while minimizing trauma to the surrounding uterine tissue. This method has a much lower risk of IUA compared to D&C and is better suited for complex cases or when the RPOC is in difficult areas to access with other methods consequently, it demonstrates lower probability of the need for a second procedure (27). In addition, hysteroscopic resection is less invasive than D&C and has a quicker recovery time. However, the procedure requires specialized equipment and expertise and may not be available in all settings. A six-year observational study involving 50 patients evaluated the use of resectoscopy for treating late residual trophoblastic tissue. The findings demonstrated that the procedure is both safe and effective, offering favorable reproductive outcomes with complete evacuation of the uterus. Resectoscopy may serve as a viable alternative to traditional nonselective blind curettage (28). Research confirms that hysteroscopic resection is the preferred method for managing patients with RPOC, as it is associated with a lower risk of intrauterine adhesions (IUAs) and improved pregnancy outcomes (27, 29).
Hysteroscopic morcellation
Hysteroscopic morcellation is a minimally invasive surgical technique used for the removal of intrauterine pathology, such as RPOC, submucosal fibroids, or endometrial polyps. It involves the use of a specialized device called a hysteroscopic morcellator, which simultaneously cuts and removes tissue from the uterine cavity under direct visualization (30). In managing RPOC with hysteroscopic morcellators, the device is inserted into the uterine cavity via hysteroscope. A continuous flow of fluid helps keep the area clear and visible. The morcellator’s blade cuts and removes tissue through a small side opening while a vacuum suctions it out. This process clears blood clots and other tissue, ensuring good visibility and allowing for precise removal, even from deeper areas if needed (31).
Hysteroscopic morcellation has emerged as a safe and effective alternative for the removal of retained placental tissue, particularly in challenging cases such as angular pregnancies. This approach offers precision and efficiency, as demonstrated by two cases described by Yu et al. (2021). In these instances, persistent placental remnants were successfully removed using the MyoSure® device, leading to subsequent successful intrauterine pregnancies – a testament to the procedure’s potential in preserving fertility even after complex presentations (32). Another study shows the effectiveness of Bigatti shaver (IBS®), a device that was able to remove RPOC in a short operation time and with high success and low complication rate (33).
Van Wessel et al. (2019) provided further insights by comparing reproductive outcomes between hysteroscopic morcellation and loop resection for the treatment of RPOC. Their findings revealed no significant differences in live birth rates between the morcellation group (88.9%) and the loop resection group (68.2%). Additionally, there were no notable differences in the incidence of placental complications or pregnancy rates between the two techniques. These observations suggest that hysteroscopic removal of RPOC, independently of the method, does not appear to negatively impact reproductive outcomes, reinforcing its role as a reliable option in gynecological practice (34).
The broader effectiveness and safety of hysteroscopy for RPOC management were highlighted in a review by Vitale et al. (2020). This comprehensive analysis, evaluated 20 studies and over 2,000 women, demonstrated a high rate of complete tissue removal (91%) with minimal complications (2%) and low rates of adhesion formation (0.8%). Importantly, the review noted promising post-treatment reproductive outcomes, with a clinical pregnancy rate of 87% and 71% live births, underscoring hysteroscopy’s value in preserving fertility and preventing long-term complications (35).
Material and Methods
Evidence Search and Data Sources
A literature search was conducted using the databases PubMed, Web of Science, and SciELO to identify relevant studies. The search terms used were: “Hysteroscopy AND Retained Products of Conception”, “Office Hysteroscopy AND Retained Products of Conception” and “Operative Hysteroscopy AND Retained Products of Conception”. No restrictions were applied regarding publication year, but the search was limited to articles published in English.
Inclusion and Exclusion Criteria
Studies were included if they evaluated the use of hysteroscopy for the removal of RPOC; if they compared hysteroscopy with other methods, such as D&C or conservative management; reported on outcomes such as complication rates, subsequent pregnancies, adhesion formation, or procedural safety. As exclusions criteria: studies focusing on non-human subjects and articles lacking full text or sufficient data for analysis.
Study Selection
After the initial search, all identified articles were screened by title and abstract. Relevant full-text articles were retrieved and assessed for eligibility based on the inclusion and exclusion criteria. Quantitative data were summarized descriptively, while qualitative findings were analyzed to provide context.
Results
The findings from the literature review reveal that hysteroscopy, as a diagnostic and therapeutic tool for the management of RPOC, offers significant clinical advantages over traditional methods such D&C. Multiple studies have demonstrated that hysteroscopy ensures higher precision and lower complication rates, providing safer and more effective treatment options for women affected by RPOC.
Diagnostic capability of hysteroscopy
Hysteroscopy allows direct visualization of the uterine cavity, making it highly effective for identifying retained tissue. This capability minimizes the risk of misdiagnosis, which is common when relying solely on ultrasound. For instance, Doppler ultrasound findings, including heterogeneity and vascularity, are crucial for identifying RPOC, but these imaging methods have limitations, particularly in differentiating RPOC from conditions such as AVM (6). Gutenberg Classification helps in the preoperative evaluations. This classification is particularly valuable for evaluating the risk of bleeding during hysteroscopic RPOC removal and aids in determining whether the procedure is better suited for an office or operating room setting (7) (Table 1).
Hysteroscopy complements these imaging techniques by enabling the surgeon to confirm the presence and extent of retained tissue before proceeding with removal.
| Type | Lesion description |
| Type 0 | Hyperechogenic avascular mass |
| Type 1 | Different echoes with minimal or no vascularity |
| Type 2 | Highly vascularized mass confined to the cavity |
| Type 3 | Highly vascularized mass with highly vascularizes myometrium |
Table 1: Gutenberg’s classification according to ultrasonographic pattern findings.
Success Rates of Hysteroscopy in RPOC Removal
Studies report a high success rate of hysteroscopic RPOC removal. Vitale et al. (2020) reviewed 20 studies encompassing over 2,000 women and found a 91% rate of complete tissue removal, with a minimal complication rate of 2% and a low adhesion formation rate of 0.8%. Similarly, a six-year observational study involving 50 patients demonstrated that hysteroscopic resection effectively removed late residual trophoblastic tissue, ensuring complete evacuation and improving reproductive outcomes (33).
Office hysteroscopy, particularly for smaller masses (≤2 cm), has been highlighted as an efficient and cost-effective approach. Studies indicate that for retained tissue with low vascularity and minimal adherence, office hysteroscopy achieves comparable success rates to operative hysteroscopy while eliminating the need for hospitalization or general anesthesia (24).
Hysteroscopic Morcellation Versus Loop Resection
Hysteroscopic morcellation has emerged as a minimally invasive alternative to traditional resection techniques. Devices such as the MyoSure® and Bigatti Shaver® offer precision and efficiency in removing retained placental tissue. Yu et al. (2021) documented successful outcomes using hysteroscopic morcellators for angular pregnancies, demonstrating complete tissue removal with preservation of fertility.
In a comparative study by Van Wessel et al. (2019), reproductive outcomes between hysteroscopic morcellation and loop resection were similar, with live birth rates of 88.9% for morcellation and 68.2% for loop resection. Both techniques showed comparable rates of placental complications and overall pregnancy rates, emphasizing that hysteroscopic methods – independently of the device used – do not negatively impact reproductive outcomes.
Reproductive Outcomes
One of the primary advantages of hysteroscopic management of RPOC is the preservation of fertility. Vitale et al. (2020) reported promising reproductive outcomes, with clinical pregnancy and live birth rates of 87% and 71%, respectively, following hysteroscopic treatment. By minimizing trauma to the endometrium and reducing the risk of intrauterine adhesions (IUAs), hysteroscopy ensures better long-term reproductive health compared to D&C, which carries a 30% risk of IUA formation (3).
Discussion
Hysteroscopy’s ability to provide direct visualization ensures precise targeting and removal of retained tissue, reducing the likelihood of incomplete evacuation. Unlike blind D&C, which relies on tactile feedback and carries risks such as uterine perforation and excessive endometrial damage, hysteroscopy offers a more controlled and selective approach. This precision is particularly valuable in cases of highly vascular RPOC or when the retained tissue is deeply embedded in the myometrium. Studies have consistently shown that hysteroscopic resection significantly reduces the incidence of IUAs, with rates as low as 7.5%, compared to 15–40% with D&C (3, 35).
Hysteroscopic morcellation offers a significant advantage by combining tissue cutting and removal in a single step. This technique not only shortens operative times but also ensures thorough evacuation, even in cases of larger or more vascularized RPOC. The use of mechanical energy rather than thermal energy further reduces the risk of thermal damage to the endometrium, preserving uterine integrity and fertility (32, 33). In addition, the development of advanced hysteroscopic devices has further enhanced the efficacy and safety of the procedure. Instruments like the MyoSure® and Bigatti Shaver® offer superior precision and efficiency, making hysteroscopy a viable option even in resource-limited settings. The integration of continuous flow systems ensures clear visibility during the procedure, enabling the surgeon to navigate complex uterine anatomies and achieve complete tissue removal (32, 33).
Hysteroscopy is especially beneficial in complex cases, such as angular pregnancies or when distinguishing RPOC from AVM. The ability to visualize the uterine cavity directly allows for accurate diagnosis and safe intervention. AVM, characterized by abnormal vascular connections in the myometrium, poses a significant risk if treated with D&C due to the potential for massive hemorrhage. Hysteroscopy, combined with advanced imaging techniques such as Doppler ultrasound and computed tomography angiography, ensures accurate differentiation between these conditions, enabling appropriate treatment planning (6, 35).
Despite its advantages, hysteroscopy has certain limitations. The procedure requires specialized equipment and expertise, which may not be readily available in all healthcare settings. Additionally, office hysteroscopy, while convenient, is limited to smaller or less adherent RPOC due to the constraints of small-caliber instruments. For larger or more vascularized masses, operative hysteroscopy in an operating room setting may be necessary. Another challenge is the cost associated with hysteroscopic equipment and training. While the long-term benefits of hysteroscopy, including reduced complications and improved fertility outcomes, justify the investment, the initial setup costs may be prohibitive for some facilities.
Continued advancements in hysteroscopic technology and techniques are likely to further enhance its role in RPOC management. The development of smaller, more versatile instruments could expand the scope of office hysteroscopy, making it accessible to a broader patient population. Additionally, further research into the long-term reproductive outcomes of hysteroscopic RPOC management will provide valuable insights into its efficacy and safety.
The integration of AI in hysteroscopy is another promising avenue. AI algorithms could assist in real-time analysis of hysteroscopic images, improving diagnostic accuracy and guiding surgical interventions. Such innovations have the potential to further elevate the standard of care for women with RPOC (36, 37).
Conclusion
Hysteroscopy represents a significant advancement in the management of RPOC, offering superior precision, safety, and reproductive outcomes compared to traditional methods like D&C. Its ability to minimize complications, preserve fertility, and provide tailored treatment makes it the gold standard for RPOC management. While challenges remain in terms of accessibility and cost, ongoing technological advancements and research promise to make hysteroscopy an even more effective and widely available tool in gynecological practice.
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ORCID: https://orcid.org/0009-0004-4968-9643
Instituição: Hospital Israelita Albert Einstein
ORCID: https://orcid.org/0009-0006-2922-5723
Instituição: Hospital Israelita Albert Einstein
ORCID: https://orcid.org/0000-0001-9190-6622
Instituião: Hospital Israelita Albert Einstein
ORCID: https://orcid.org/0000-0001-9753-2190
Instituição: Hospital Israelita Albert Einstein
ORCID: https://orcid.org/0009-0009-9496-8461
Instituição: Faculdade Israelita Albert Einstein
ORCID: https://orcid.org/0009-0008-4158-8409