Hysteroscopic Management of Retained Products of Conception

European Journal of Obstetrics & Gynecology and Reproductive Biology 173 (2014) 19–22

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology

jou rnal homepage: www.elsevier.com/locate/ejogrb

Hysteroscopic management of retained products of conception:

meta-analysis and literature review

Noam Smorgick *, Oshri Barel, Noga Fuchs, Ido Ben-Ami, Moty Pansky, Zvi Vaknin

Departments of Obstetrics and Gynecology, Assaf Harofe Medical Center, Afﬁliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

A R T I C L E I N F O A B S T R A C T

Article history: Objective: Hysteroscopic removal of retained products of conception (RPOC) may allow complete

Received 15 August 2013

removal of RPOC and decreased rates of intrauterine adhesions (IUA) when compared to the traditional

Received in revised form 1 November 2013

blind curettage. The aim of this meta-analysis is to examine the current evidence regarding the use of

Accepted 20 November 2013

hysteroscopy for treatment of RPOC.

Study design: A literature search was conducted in December 2012 using MEDLINE and ClinicalTrials.

Keywords:

The study selection criteria were use of the standard hysteroscopic technique for removal of RPOC in 5 or

Retained products of conception

more cases, in any study design. We reviewed 11 studies, of which 5 retrospective studies met the

Hysteroscopy

selection criteria (comprising 326 cases). The rates of incomplete RPOC removal, surgical complications,

post-operative IUA and subsequent pregnancies were abstracted and weighted events rates using a ﬁxed

meta-analysis model were calculated.

Results: 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%).

Conclusions: 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.

1. Introduction In 1997, Goldenberg et al. [4] reported on the use of

hysteroscopy for treatment of RPOC. Since that time, additional

Retained products of conception (RPOC) may occur after studies have reported increasing experience with this technique

medical and surgical pregnancy termination, miscarriage, and [5–8]. Using this approach, the uterine cavity is ﬁrst evaluated

vaginal or cesarean delivery [1]. Short-term complications of RPOC and areas with suspected RPOC are identiﬁed (Fig. 1). Subse-

include bleeding and infections, while long-term complications quently, using the loop of the resectoscope as a curette, the RPOC

include formation of intrauterine adhesions (IUA, also called are gently and selectively separated from the underlying

Asherman’s syndrome) which may signiﬁcantly affect future endometrium. During this procedure, the use of electrosurgery

reproductive outcomes due to infertility, miscarriages and is very limited and avoided if possible, with the goal of

pregnancy complications such as placenta accreta [2]. The minimizing thermal damage to the endometrium. This surgical

pathogenesis of IUA formation is complex and involves trauma approach has the theoretical advantage of reduced trauma to the

to the endometrium as well as the hypoestrogenic state common in endometrium, and possibly reduced rates of IUA and improved

the puerperal period. The traditional surgical treatment of RPOC future reproductive outcomes. Additional advantages may be

with dilatation and curettage may further contribute to the complete removal of RPOC without the need for a second

endometrial trauma [3]. procedure, and identiﬁcation and treatment of uterine cavity

anomalies, which are sometime the underlying cause of RPOC

[5].

The aim of this study is to examine the current evidence

* Corresponding author at: Gynecologic Endoscopy Unit, Departments of

regarding the use of hysteroscopy for treatment of RPOC in a meta-

Obstetrics and Gynecology, Assaf Harofe Medical Center, Zeriﬁn 70300, Israel.

analysis design. A secondary aim is to compare outcomes of

Tel.: +972 8 9779000; fax: +972 8 9778026.

E-mail address: [email protected] (N. Smorgick). traditional curettage with the hysteroscopic technique.

20 N. Smorgick et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 173 (2014) 19–22

2.3. Data analysis

The hysteroscopy treatment group consisted of patients who

underwent hysteroscopic removal of RPOC. We reviewed the

included studies and abstracted the number of cases in each study

with the main outcomes, deﬁned as intraoperative uterine

perforations, other intraoperative complications (deﬁned as

infections, signiﬁcant bleeding, and ﬂuid overload), postoperative

IUA in patients who underwent a second-look ofﬁce hysteroscopy,

subsequent pregnancies in those patients who planned to

conceive, and number of patients who required a second operative

procedure due to incomplete removal of RPOC. These numbers

were then analyzed to calculate overall weighted prevalence rates,

standard deviations and 95% conﬁdence interval (CI) using a ﬁxed

meta-analysis model for each of these outcomes. The rates of

subsequent pregnancies in women undergoing hysteroscopy

Fig. 1. Hysteroscopic image of retained products of conception in a patient versus curettage were compared with odds ratio and 95% CI.

presenting 2 months after delivery. There was only one study that assessed rates of IUA in patients

undergoing hysteroscopy versus suction and curettage, and we

were therefore unable to calculate the odds ratio for this

2. Methods complication based on this systematic review. Statistical analyses

were performed with the SPSS software version 20 (SPSS Inc.,

2.1. Search strategy Chicago, IL, USA) and Comprehensive meta-analysis software

version 2.2 (Biostat, NJ, USA).

A literature search was conducted in December 2012 using

MEDLINE and ClinicalTrials. The search terms used included 3. Results

‘‘retained products of conception’’, ‘‘residual trophoblastic tissue’’,

‘‘placental remnant’’ and ‘‘hysteroscopy*’’, which were combined Using our search criteria, 11 studies in the English language

using the Boolean operators ‘‘AND’’ or ‘‘OR’’. No time limits were reporting on the use of hysteroscopy for treatment of RPOC were

placed on the searches. Only studies in the English language were identiﬁed. Of those, ﬁve case reports describing four patients or

reviewed. References of selected studies were also examined for fewer were excluded. In addition, one study reporting on the use

additional relevant literature not found by the initial database of hysteroscopy in the ofﬁce setting without anesthesia was

searches. excluded [9]. That study described the use of the hysteroscopic

grasper introduced in the working channel of the hysteroscope to

2.2. Study selection remove RPOC, as opposed to the resectoscope loop used in all the

other included studies. The remaining ﬁve studies were included

We included studies describing the use of hysteroscopy for in the meta-analysis [4–8]. All included studies are of the

removal of RPOC in 5 or more cases, using the standard retrospective cohort design (Table 1). Three studies report the

hysteroscopic technique described above. Due to the paucity of outcomes of patients treated by hysteroscopy alone [4,6,8], and

available data, we included retrospective and prospective studies, two compare the outcomes of patients treated by hysteroscopy

cohort and case-control studies, as well as studies with a single and traditional suction and curettage in a retrospective non-

treatment group (hysteroscopy) and treatment–control groups randomized design [5,7]. In total, 326 patients underwent

(i.e., studies comparing hysteroscopy and traditional suction and hysteroscopic removal of RPOC and were included in this meta- curettage). analysis.

Table 1

Description of studies included in the meta-analysis describing hysteroscopic treatment of retained products of conception.

First author Study period Treatment groups Case number Type of pregnancy

Goldenberg [4] NA Hysteroscopy 18 88.9% – Surgical termination

11.1% – Delivery

Cohen [5] 1/1997–1/2000 Hysteroscopy 46 72.9% – Surgical termination

Curettage 24 27.1% – Delivery

Faivre [6] 10/1999–9/2006 Hysteroscopy 50 36.0% – Spontaneous abortion

26.0% – Surgical termination

22.0% – Medical termination

16.0% – Delivery

Rein [7] 2/2004–1/2007 Hysteroscopy 53 92.6% – Surgical termination

Curettage 42 7.4% – Delivery

Golan [8] 1/2001–8/2007 Hysteroscopy 159 55.3% – Surgical termination

27.0% – Medical termination

17.6% – Delivery

Total Hysteroscopy 326

Abbreviation: NA, not available.

Type of pregnancy – refers to the type of pregnancy after which the RPOC was diagnosed. Delivery refers to either vaginal or cesarean delivery at term. Surgical

termination refers to curettage performed for spontaneous abortion or termination of pregnancy. Medical termination refers to medical termination of pregnancy by RU486 and prostaglandin E1.

N. Smorgick et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 173 (2014) 19–22 21

A similar surgical technique was performed in all studies approaches [7]. Thus, we could not investigate further the

included. The procedures were performed under general or differences in IUA formation between the two techniques.

regional anesthesia. Misoprostol for preparation of the cervix

was not used in any of the studies. When required, cervical 4. Comment

dilatation with Hegar’s dilators up to 9 mm or 10 mm was

performed. The 26F Resectoscope (Karl Storz, Tuttlingen, While RPOC may complicate any type of pregnancy and

Germany) ﬁtted with a 4-mm cutting loop was used in four delivery, including surgical and medical abortions [1], their exact

studies [4–7], and the bipolar VersaPoint loop resectoscope incidence is unknown. Some prospective studies performed in

(Gynecare, Somerville, NJ, USA) in one study [8]. A 1.5% glycine women undergoing medical termination of early missed abortions

solution was used as a distension media in four studies [4–7], and suggested a high rate of RPOC of about 15% [10,11]. A prospective

the 0.9% NaCl solution was used in one study [8]. study by van den Bosch et al. [12] using ultrasound Doppler to

Complete removal of RPOC was reported in all cases, and no assess for RPOC after delivery or pregnancy termination described

patient undergoing hysteroscopy required a second operative suspicious ﬁndings in 6.3%. Since RPOC occur in reproductive-age

procedure. Uterine perforation occurred in 1/326 cases (weighted women who may desire future pregnancies, the most important

prevalence 1.2%, 95% CI 0.4–3.7%). Additional intraoperative long term complication of this condition is infertility, which is

complications included one case of systemic infection and one mostly related to the formation of IUA following treatment of

case with signiﬁcant vaginal bleeding (weighted prevalence of RPOC. One of the pathophysiologic mechanisms causing IUA is

0.9%, 95% CI 0.2–3.8% for both complications). There were no trauma to the endometrium, which could be exacerbated by the

reports of ﬂuid overload or hyponatremia complicating the traditional suction and curettage technique. Thus, the hystero-

procedure. scopic technique, in which the trauma to the endometrium is

Second-look hysteroscopy to assess for IUA was performed in possibly more limited, may yield better results regarding IUA. Our

four of the studies [4,6–8], in a total of 96 cases. Overall, IUAs were literature search and meta-analysis have identiﬁed case series and

reported in 4/96 cases (weighted prevalence of 5.7%, 95% CI 2.4– retrospective cohort studies using this technique, and their

13.0%) (Table 2). Pregnancy outcomes were reported in four studies combined descriptive results have shown that hysteroscopic

[5–8], for a total of 120 patients desiring a subsequent pregnancy. treatment of RPOC is safe and effective with complete removal

The pregnancy rate in those patients was 91/120 (weighted of the uterine content. However, the current available literature

prevalence of 75.4%, 95% CI 66.7–82.3%) (Table 2). Only two studies lacks enough evidence for us to state that the hysteroscopic

[5,7] compared the pregnancy rates between the hysteroscopic approach is superior to the traditional suction and curettage

group and the suction and curettage group. The calculated odds approach in terms of IUA rates and future pregnancies.

ratio for pregnancy in the hysteroscopy versus the curettage The incidence of IUA following traditional curettage has been

groups was 1.7, 95% CI 0.7–3.8, p = 0.1) (Fig. 2). assessed in several prospective studies. Jones [13] reported that 7

The hysteroscopic diagnosis of congenital Mullerian anomalies out of 78 (8.9%) women undergoing postpartum curettage

was reported in three studies (6–8), and found in 10 out of 262 developed IUA, while Adoni et al. [14] and Romer [15] reported

cases (weighted prevalence of 5.1%, 95% CI 2.3–11.0%). One IUA rates of 15% and 30%, respectively, in women undergoing

additional study reported a 21.4% (15/70) rate of anomalies in a curettage for missed abortions. In the current meta-analysis, the

combined group of patients undergoing hysteroscopy and suction rate of IUA was evaluated in subset of patients (less than 50%) who

and curettage [5]. underwent second-look hysteroscopy. In these patients, IUA were

Two studies retrospectively compared hysteroscopy with found to be uncommon, occurring in about 4% of women. We have

traditional curettage [4,7], but only one study compared the rates identiﬁed only one retrospective study, by Rein et al. [7], that

of IUA on second-look hysteroscopy between the two surgical compared the rates of IUA following hysteroscopy and curettage,

Table 2

Main outcomes and complications of hysteroscopic treatment of retained products of conception.

First author Patients desiring pregnancy Patients who conceived Second look hysteroscopy Intrauterine adhesions on second look hysteroscopy

Goldenberg [4] NA NA 5 0

Cohen [5] 17 14 NA NA

Faivre [6] 30 23 22 2

Rein [7] 45 31 48 2

Golan [8] 28 23 21 0

Weighted rate (%) 120 91 (75.4%, 66.7–82.3%) 96 4 (5.7%, 2.4–13.0%)

Abbreviation: NA, not available.

Presented as total number (weighted prevalence, 95% conﬁdence interval).

Fig. 2. Forest plot comparison of subsequent pregnancies in women undergoing hysteroscopy versus curettage.

22 N. Smorgick et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 173 (2014) 19–22

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