Diagnostic Accuracy of Sonographic and Clinical Parameters in the Prediction of Retained Products of Conception

Abstract

Objective. The purpose of this study was to assess the diagnostic accuracy of different parameters (clinical and sonographic) in the prediction and management of retained products of conception (RPOC) in the late postpartum period. Methods. This was a prospective cohort 3-year audit. Predefined data were collected and compared with histopathologic (HP) reports after uterine evacuation. The primary outcome measure was the diagnostic accuracy of different clinical and sonographic parameters, including color Doppler imaging in diagnosis of RPOC confirmed on HP reports. Secondary outcome measures were complication rates influencing maternal morbidity. Results. In total, 93 patients (0.92% of all deliveries) were selected. The presence of gestational tissue was confirmed on HP reports in 58% of cases. The likelihood ratio of sonography alone was 1.47 (95% confidence interval, 1.25-1.84), whereas that of sonography combined with color Doppler imaging was 2.16 (1.3-3.59), providing statistically significant accuracy regarding the prediction of RPOC. Conclusions. Sonography alone or combined with color Doppler imaging has better diagnostic accuracy than the usual clinical parameters used for the prediction of RPOC. Key words: cervical dilatation; color Doppler sonography; placenta; residua; sonography; vaginal bleeding. econdary postpartum hemorrhage (PPH), either alone or associated with pain, fever, or both, is a common clinical symptom of retained products of conception (RPOC). 1 The reported incidence in the literature is around 1% of all deliveries, and it represents one of the most common reasons for hospital referral and readmission in the postpartum period.1 The diagnosis of RPOC relies on different clinical symptoms and signs as well as sonographic assessment. 2-11After making a diagnosis, evacuation of the RPOC is indicated, and it is performed in approximately 70% of patients referred with secondary PPH.4 This is a relatively simple procedure that is generally thought to be safe. However, histopathologic (HP) samples obtained on uterine evacuation in cases of suspected RPOC after primary evacuation of the uterus were found to show positive findings for gestational remnants in approximately 60% of cases, whereas in the postpartum group, this incidence is 48.5%. 2,3,6,9 The false-positive rates are 28.9% if the diagnosis is based on sonography and 51.5% if it is based on clinical examination.

Comparison of Reproductive Outcomes following Retained Products of Conception after Vaginal Delivery versus First-Trimester Abortion

“…A presenting sign of vaginal bleeding was more prevalent in women with pathologically confirmed RPOC after spontaneous term vaginal delivery compared to those after pregnancy termination (table 2). These findings corroborate with a previously reported study, which explored the diagnostic accuracy of several clinical parameters in the prediction of RPOC and found that postpartum hemorrhage had the highest sensitivity, positive predictive value and positive likelihood ratio rates as compared with the other clinical symptoms [14]. …”

Correlation of ultrasound with histopathology for retained products of conception in medically managed abortions

“…Using histopathology as confirmatory test, the overall sensitivity of TVS for diagnosis of RPOC in present study is 92% which is comparable to study conducted by De Vries et al, Matijevic et al and Esmaeillou et al [11][12][13] The overall specificity of TVS is 60%, which is comparable to that in study conducted by Esmaeillou et al, higher than in study conducted by Matijevic et but lower than other studies. 12,13 This is because of relatively high number of false positive results which might be due to false interpretation of blood clot for RPOC which also looks like echogenic mass on ultrasound or presence of thickened endometrium giving impression of RPOC but proved to be thickened decidua with absence of chorionic villi on histopathology.…”

“…12,13 This is because of relatively high number of false positive results which might be due to false interpretation of blood clot for RPOC which also looks like echogenic mass on ultrasound or presence of thickened endometrium giving impression of RPOC but proved to be thickened decidua with absence of chorionic villi on histopathology.…”

Physiologic, Histologic, and Imaging Features of Retained Products of Conception

“…The sensitivity and specificity of US for the diagnosis of RPOC varies widely based on the diagnostic criteria and the clinical setting. However, more recent studies have defined more robust gray-scale and color Doppler US criteria with a high sensitivity and specificity for RPOC (7,8,(16)(17)(18)(19)(20)(21) (Table). …”