Hysteroscopic management of retained products of conception post Cesarean section, Two Case Reports and Review of the Literature — YRD
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Hysteroscopic management of retained products of conception post Cesarean section, Two Case Reports and Review of the Literature (1574)

Oshri Barel 1 2 , Noam Smorgick 2 , Ido Ben-Ami 2 , Zvi Vaknin 2
  1. Monash Health, Bentleigh East, VIC, Australia
  2. obstetrics and gynaecology, Asaf Harofe Medical Center, Zerifin, Israel

AIM      

To present two cases of hysteroscopy for treatment of Retained Products of Conception following Cesarean Section and current evidence in the literature.

INTRODUCTION  

Retained products of conception (RPOC) may occur after medical and surgical pregnancy termination, miscarriage, and vaginal or cesarean delivery. Short-term complications of RPOC include bleeding and infection, while long-term complications include formation of intrauterine adhesions (IUA, also called Asherman’s syndrome). The pathogenesis of IUA formation is complex, involving trauma to the endometrium compounded by the hypoestrogenic state common in the puerperal period. The traditional surgical treatment of RPOC with dilatation and curettage may further contribute to endometrial trauma. In 1997, Goldenberg et al.  reported on the use of hysteroscopy for treatment of RPOC. Since that time, additional studies have reported increasing experience with this technique. Using this approach, the uterine cavity is first evaluated and areas with suspected RPOC are identified. Subsequently, using the loop of the resectoscope as a curette, the RPOC are gently and selectively separated from the underlying endometrium. During this procedure, the use of electrosurgery is used sparingly and avoided if possible, with the goal of minimizing thermal damage to the endometrium.

Case 1

Adherent placenta was noted during Cesarean Section and was only partially removed. A follow-up hysteroscopy demonstrated retained products of conception and hysteroscopic resection was performed. Another procedure was required due to incomplete excision of the retained products in  the first procedure.

Case 2

Patient Presented with persistant vaginal bleeding following delivery by cesarean section. Hysteroscopy demonstrated a caesarean section niche and retained products of conception in the uterine cavity. The patient underwent hysteroscopic resection.

REVIEW OF THE LITERATURE                                                                                                                      

Only one study compared the rates of IUA following hysteroscopy and curettage, precluding a meta-analysis comparison of the two techniques. There were no cases of incomplete RPOC removal. Three perioperative complications occurred (uterine perforation, infection, and vaginal bleeding). IUA on follow-up hysteroscopy were found in 4/96 women (weighted rate of 5.7%, 95% CI 2.4%, 13.0%). Of the 120 women desiring a subsequent pregnancy 91 conceived (weighted rate of 75.3%, 95% CI 66.7%, 82.3%).

 CONCLUSION

The lack of traditional curettage comparison groups in most studies precludes the conclusion that hysteroscopy is superior to traditional   curettage, but this procedure does appear to have low complication rates, low rates of IUA, and high rates of subsequent pregnancies.