“Retained Placenta: More common than you think” – with Dr. Stephanie Melka

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right, Melka, welcome back to the podcast.

Dr. Melka: Hello again.

Dr. Fox: We’re doing a back-to-back here, so this is great. And the topic for today is retained tissue, right. We’re talking the world of gynecology pregnancy. So we’re talking about retained placental fragments, sometimes called retained placenta, sometimes called retained products of conception, POCs. And this is a fairly common conundrum, I would say.

Dr. Melka: Yes.

Dr. Fox: Tell me, like, what are we talking about? What happens that this is discovered?

Dr. Melka: So this is basically tissue from the pregnancy that is left behind in the uterus, whether it’s term placental tissue after a delivery or after a miscarriage, just earlier pregnancy tissue.

Dr. Fox: Right. And so, this can happen after a miscarriage, it happens on its own. It can happen…

Dr. Melka: Yes. It can happen after a procedure for a miscarriage.

Dr. Fox: D&C.

Dr. Melka: So this happens across the board. You name it, it could happen.

Dr. Fox: Yeah. And it’s…

Dr. Melka: D&C, miscarriage, at term it can happen after a vaginal delivery, it can happen after C-section.

Dr. Fox: I think people are, number one, surprised that this is something that can happen. Number two, they’re surprised that it happens as commonly as it does. And number three, I think they’re surprised to learn that it’s not our fault.

Dr. Melka: Not everyone believes that last part.

Dr. Fox: Listen, this can happen in the best of hands. It can happen from a very straightforward procedure and not happen after a very complicated one. I mean, we do C-sections and we’re looking at the inside of the uterus and we clear it out. You know, we take out the placenta. We clean out the uterus. We’re looking at it. We see nothing. And then, four weeks later, there’s, like, a little piece of placenta left behind and we’re like, where was that from? And it’s just remarkable because, I mean, placenta histologically is different from blood clots or any other tissue. But, you know, there’s bleeding and there’s blood clots and it’s hard to always know what is left in the uterus and what’s gonna come out and what isn’t. And it’s really just a fascinating idea. But I would definitely say for people who have had this happen to them, it does not mean your doctor or midwife or whoever did anything wrong, right. They could have done everything perfect by the book and this can absolutely still happen. It’s happened to patients of mine, no question about it.

Dr. Melka: Same.

Dr. Fox: No really. Any gynecologist who said it’s not happened to them, either has not done one of these procedures, not done enough or they’re…

Dr. Melka: Liars.

Dr. Fox: …liars or forgetful. Misremembering, as I think the correct term is…

Dr. Melka: Ah, that’s what it is. Yes.

Dr. Fox: …to misremember. So it can definitely happen. And I think also, it causes a lot of distress for people, both logistically, maybe concerns medically. But I think for the vast majority of people, it ends up again being something to sort of get through and figure out and take care of, but not really a big, long-term issue for them, fortunately. So let’s start with first trimester. So someone has a miscarriage, or they have an, you know, abnormal pregnancy and they have a D&C, or they have a miscarriage and they need a D&C because there was extra bleeding, or they have a termination of pregnancy. And so, we’re done. How at the time of the procedure, again, assuming it wasn’t just a spontaneous miscarriage, do we do our best to prevent this from happening?

Dr. Melka: We often don’t and this is why it happens. The one big thing we often can have at these procedures is sonogram. So you can do a sonogram, look at the uterus, look at the lining. But even then, that has limitations because there’s gonna be increased blood flow to the entire lining. These are often, like, small, 1-centimeter little areas of tissue that sort of look like the rest of the lining. So it’s not always immediately obvious.

Dr. Fox: Right. So we do the procedure in a way that we think everything is out, and then sometimes we even check by ultrasound that it appears that everything is out. And again, when that’s the case, probably what, 95% to 97% of the time, everything is out. And then, about, let’s say, 3% to 5% of the time, there is gonna still be some tissue remaining. And how would someone know that? How would they find that out to know that they even have retained tissue?

Dr. Melka: Typically bleeding. Usually bleeding that either worsens in the next few days or continues for longer afterwards than it usually would otherwise.

Dr. Fox: So what would be usual after a first trimester loss or procedure?

Dr. Melka: Two to four weeks. Sometimes even up to six. But typically, bleeding by two to four weeks will stopped.

Dr. Fox: So there’s definitely people who have irregular bleeding and they’re like, either we think it’s unusual, they think it’s unusual, whatever it is. Or like you said, they could have heavy bleeding early, which is again, not typical. But then, ultimately, the way we make the diagnosis, unless we’re so suspicious of it clinically, is by ultrasound. And so, we do an ultrasound and they come to us and we take a look. And usually, if the person doing the ultrasound knows what they’re doing, they’re gonna be able to make that diagnosis. So what we do is we do the ultrasound, we look at the uterus, we look at the lining. And typically if there’s retained tissue, number one, we’ll see something inside the cavity that’s not typically there. And then, we measure it, right, two dimensions, three dimensions, whatever it is. And so, let’s say 1 centimeter, 2 centimeters, that’s usually the size that we’re talking about, like, the size of a fingertip or thumb tip, something like that. And then, sometimes it’s not easy to tell is this tissue versus a blood clot and if it’s tissue, is it still attached to the uterine wall or detached. And so, the way we do it in ultrasound is we use color flow, which the ultrasound can sort of distinguish blood flow. And if through we can see blood flow going from the uterus to the endometrium into this structure, like, there’s direct blood flow from the uterus to the structure, we know it’s attached, in which case it’s not a blood clot. And typically, we’re gonna say, “All right. We have retained tissue, retained placenta. Again, retained products of conception,” whatever we call it. And then, we’ll say the size and that there’s blood flow. So that’s how we make the diagnosis and that’s to be distinguished from when we see it and there’s no blood flow, when we’ll say either it’s just blood clots or maybe it’s a little portion of placenta that’s kinda floating around in there but is gonna pass on its own because it’s no longer attached. So that’s how the diagnosis is ultimately made.

Dr. Melka: And these sonograms, since they’re being done a few weeks after the procedure, are so much better than when you’re looking at the time of procedure.

Dr. Fox: Yeah. Absolutely.

Dr. Melka: Because again, the uterus has shrunk in size a little bit. Some of that blood flow has decreased. So it’s much easier to pick these things up afterwards.

Dr. Fox: Right. So let’s say we’ve made that diagnosis. Someone had a first trimester loss, procedure, whatever it is. Then they call the office or they come for their two-week visit and something’s unusual about the bleeding. You send them down for an ultrasound and I see them and I say, “Melka, there’s a, you know, 1 by 2-centimeter piece of tissue placenta that’s still attached to the anterior wall with blood flow,” and I send her back to you for counseling about what to do about it. Because I’m busy and I’m not doing that. I send her back to you. Your patient.

Dr. Melka: You’re not a gynecologist. [inaudible 00:07:47]

Dr. Fox: Right. Well, I do my best. So how do you go about discussion that with a patient about what it means and what the options are for her at that time?

Dr. Melka: Sure. So you sort of mentioned this before, this ends up being very distressing to patients. They’re really upset and the initial reaction is always like, why did the doctor do this? How did this happen? How did somebody leave this behind? So I sort of review why it happens and it’s that D&Cs are done blindly. You know, we’re not looking in the uterus to remove things. We’re putting, like, a little tube in and sort of cleaning out the uterus. And if you do that too aggressively, you could lead to scar tissue in the uterus, which then impacts future fertility and future pregnancies. So when you do these procedures, you’re finding this balance. So this happens sometimes. You manage these typically based on the size, based on the appearance and what the patients’ preferences are.

When the tissue is about a centimeter or a centimeter and a half or smaller, there’s a very good chance that it comes out on its own, typically with the next period. The lining of the uterus sheds with menses, the tissue comes out and then they’re cured. The downside of that is that’s a very unpredictable timeline, you know. They could get their next period in three weeks, it could be two months and that ends up being a lot of waiting around.

Dr. Fox: Right. And it may or may not work.

Dr. Melka: Exactly. Yeah. There’s an option for medication, misoprostol, which helps the uterus to cramp and contract. That’ll work a little bit better if it’s, there’s not a lot of blood flow where you don’t really think it’s that attached.

Dr. Fox: Right, it’s just minimally attached.

Dr. Melka: Exactly. Or doing a procedure. Typically what we do with these is what’s called hysteroscopy, where instead of doing a blind D&C, you’re going in through the cervix with a camera to look at the tissue and take it out.

Dr. Fox: Right. So let’s talk about that because I think that traditionally, the treatment was just a repeat D&C, whether in the office or whether in the operating room. Again, when we say D&C, just for terminology, it’s D and C, it’s not the Democratic National Convention. So D stands for dilation to open the cervix a little bit and curettage is sort of the traditional procedure, which was this instrument called a curette which would basically scrape the line of the uterus. We don’t typically even use those so much anymore. It’s more a suction tube, so I think probably the correct nomenclature should be D&A for aspiration. But we colloquially say D&C. Everyone says D&C. But we sorta know that we’re not really doing a lot of C-ing. It’s more aspirating. And so, that’s the terminology. So that’s, I would say, traditionally what was done for someone with retained tissue. But you’re saying to actually look inside with a camera and do hysteroscopy. So the question is, is that what everyone recommends and does or is that sort of unique to your practice, and if so, why?

Dr. Melka: It’s all very much, obviously, case by case. If somebody has a lot of tissue, you’re gonna look in and just see a lot and not be able to get it all out. If it’s a tiny bit, you worry the opposite, that if you did a curette, you could miss it. I think more of us nowadays lean toward doing a camera because it’s also, one, you’ll know that you get everything out, you can get a full look at the cavity, make sure there’s nothing else that you’re leaving behind that maybe doesn’t get seen on sonogram. And decreasing risk of scar tissue.

Dr. Fox: Because it’s targeted.

Dr. Melka: Exactly.

Dr. Fox: You’re not doing, like, a global scraping or aspiration. You’re really looking and saying, “All right, there’s that thing. let’s pluck it out.” And it makes sense and I think it’s great that that’s sort of how most of the doctors in our practice will do it. Again, maybe that’s not the right procedure for everybody but it’s for a lot of people that it’s offered and I think that a lot of times it may not just be available for people in the same way. And so, this is something that we’re fortunately able to do relatively quickly. And I think people are, again, like you said, there’s the medical aspect of it, which is generally, fortunately not such high risk, but then there’s sorta like the distress. Oh, God, I got to deal with this. And, you know, just had miscarriage, just had a procedure and now I’m not even done. I got to do it again. It’s just annoying, right. Who wants that? And so, to say, “All right, we’re gonna be like, we’re gonna go in, we’re gonna see it, we’re gonna remove it. You’re gonna be done.” And that’s very, very, very likely to be the case. And so, in your experience, do people typically want the procedure and they want it more aggressive or they want to be less aggressive and wait and see? Or does it really sorta depend?

Dr. Melka: People are usually pretty mixed. You know, I don’t think anyone really wants a procedure. They just want to be done, you know. And when they hear procedure, their instinct is, no, I don’t want to go to the operating room again. But then, when you talk about medication or waiting, and it might work and it might work, and you don’t even know how long it’s gonna take, and they could be coming back in two months and still have tissue and then need to do a procedure. A lot of times at the point, they’re like, forget it. I’m done. Sometimes they wait a week or two. They may want to try medication. Luckily, these typically aren’t emergencies. So this isn’t, like, okay, you have to go the ER now or, like, you have to clear your schedule tomorrow and do this. So there is some leeway to schedule it.

Dr. Fox: Right. The only time it’d be an emergency if, again, they were hemorrhaging or we thought they were infected, which people worry about the risk of infection with retained products and it can happen, but it’s actually pretty unusual.

Dr. Melka: So rare.

Dr. Fox: Almost always the patient has no symptoms other than irregular bleeding, and sometimes not even that. I think what you were saying about people’s choices, it’s really very similar to the decision people make sometimes when we diagnose, like, a miscarriage, an abnormal pregnancy in the first trimester, and they have an option to either sort of wait and it’ll eventually pass on its own, or take medication or do a procedure. And they’re all totally reasonable options and they all have very low chance of major complications. And a lot of it’s just a personality decision. Some people are like, you know, I want this done yesterday. And they sign up for the procedure. And others are like, I’m really a hands-off kind of person. I’d rather just wait and see what happens. I don’t like doctors, procedures. So then, you wait and I think it’s probably a very similar type of personality. Maybe the person who is less interventional, if they’re going through this, they might become more. I mean, who knows. Or the opposite. They may say, you know, it didn’t work the first time. Let’s just wait this time around and across the board. And again, it rarely is something that we’re gonna push them one direction or another medically. Maybe we’ll say, “I don’t think this one’s gonna work and this one’s better.” But, you know, that’s just a judgment call.

Now what about after a full-term birth? All right. Someone’s had a delivery. They’ve had, same concept. Either vaginal delivery, they had a C-section. How would they know they had a retained placenta?

Dr. Melka: That is usually more heavier bleeding in the weeks after delivery or bleeding past about six to eight weeks.

Dr. Fox: Right. And so, sorta the same concept. If it’s suspected, we’ll do the ultrasound. It’s the same things we use to make the diagnosis. By the time you’re six to eight weeks out, the uterus is the same size as it would be after first trimester loss. So it actually looks very, very similar. And the crazy thing with this is sometimes we see very large portions of placenta that remain behind. We’re like, oh, my god, how the hell did that stay there? Because we take out the placenta, we took at it, seems whole [inaudible 00:15:21] delivery. And all of us have been surprised from time to time. Again, usually it’s small and sometimes it’s bigger.

And then, the concern, and sometimes there’s a lot of overlap between this happening and the condition called placenta accreta. And it’s very complicated for people because they’ll say, “Oh, yeah, you know, I had a… They’ll tell me a story. Like, I had a placenta accreta. I was like, “Oh, really? Tell me what happened.” And they’ll say, “Well, I had a baby and I delivered vaginally and three weeks later, I had a little bit of irregular bleeding or heavier bleeding. I went and they saw that there’s a little piece of placenta that remained behind and they had to do a hysteroscopy and take it out and it was stuck to the uterus so I had a placenta accreta.” I’m like, well, how big was this thing that they took out? Like, a centimeter or two. And I’ll be like, “All right. So maybe histologically, that portion of placenta was stuck to your uterus in the same way that we would call an accreta, but that’s a really small percentage of the placenta. That’s under 5% of the size of placenta. When we think placenta accreta, we’re thinking, like, full blown, like half or a full placenta, and people are hemorrhaging, they need hysterectomies. It’s a totally different thing.” So it’s sorta like you could think of it as a mini accreta, a partial accreta, a very small type of accreta, but it doesn’t have the same implications for someone’s heath. Like if you Google accreta, you’d be like, oh my God. This is, like, life-threatening. Where having that, the little portion remaining behind, should not be life-threatening.

But there is overlap. And so, people who have had this are at an increased risk in the next pregnancy of either having this again or, like a small portion remains behind, or a full-blown accreta, either because they had it the first time or because of all the procedures that needed to be done in order to get this out and you have to sorta, you know, shave the uterus, scrape the uterus, whatever it is, that maybe that’ll lead to more scar tissue. Who knows. And it’s one of these things where we can’t be so clear about the chances of that because it’s hard to quantify. But we definitely think a little bit differently about someone when we’re delivering them if they have a history of something like this happening. So what would you do potentially at delivery if someone had a history of something like this and you were more worried that this could happen?

Dr. Melka: So you could do a manual feel of the uterus. You know, assuming the patient has an epidural with good pain control or after the placenta comes out, you can reach in and feel the entire uterus. But again, it can get missed in that case because, you know, the uterus is big and you’re looking at sometimes these tiny, 1-centimeter pieces. There’s also sonogram, with the same limitations if not more, just because everything is so enlarged and there’s so much more blood flow. These things don’t always show up as easily as they would weeks afterwards.

Dr. Fox: Yeah. And sometimes, if we have deliveries that are suspicious for this, potentially, like they’re delivery and there’s more bleeding than usual, and we think that there’s retained placenta, and we sorta get it out either manually or with a procedure at the time of delivery, or whatever it is that there’s certain things that might be suspicious to us, or they have a lot of risk factors, we’ll sometimes just right at that time, say, “All right, when she comes for a postpartum visit, let’s do, like, a saline sonohysterogram. Let’s do a [inaudible 00:18:36] ultrasound. Let’s just make sure at that time that everything is out and clear so that she’s not gonna have problems moving forward. And again, sometimes they will have presented with issues before that happens with bleeding. But even if they didn’t, we’ll always, not always, but often double-check just sort of proactively to make sure that’s not going on. And again, similarly, what to do about it depends on what we see, what her symptoms are, what are our future fertility plans and moving forward with that. But it’s a pretty common phenomenon. Are there any things people can do to prevent this from happening?

Dr. Melka: I wish.

Dr. Fox: Yeah. It’s tough. I mean, ultimately, I mean…

Dr. Melka: It’s embarrassing to a doctor when this happens, because you would think it’s the most basic thing. Deliver a baby, deliver the placenta or, like, do a surgery, take everything out. You think it should be the most basic thing, but it’s not. I’ve done D&Cs or had placentas where I’m like, there’s gonna be something left behind. I just know it. And then, I scan them two weeks later and they’re fine. And then, I’ve had the opposite, you know. Deliver a placenta. Feel the uterus. Everything’s empty. Do a sonogram. Look, everything’s empty. And then, you still find something weeks later.

Dr. Fox: Yeah. As far as we know, there isn’t a great way for people to prevent this from happening. I mean, the more procedures you have inside uterus, the more likely this is to happen. But the procedures people have in the uterus is because they need them, right. It’s not, like, elective, right. So if someone needs a procedure, they need a procedure. So again, like you said, if we’re doing, someone has a miscarriage or doing a D&C, we try to do the least amount necessary to prevent the likelihood of scar tissue that might increase the chance that a little portion remains behind. But it might decrease the chance of scar tissue. And this is, you know, there’s a tough balance. If you, you know, spend, you know, an hour and a half making sure you do every single thing, then you’re gonna increase the chance of future problems the next pregnancy. So it is a balance. But as far as we know, there isn’t anything really people can do to lower the chance of this happening to them. From the doctor’s side, you know, we train to do them in a very precise way and a very careful way that should minimize the chance of this happening, but I don’t think anybody has 100% success rate with getting out placentas in any trimester or pregnancy just unfortunately.

Dr. Melka: Sometimes, we even do these procedures with sonogram guidance, real-time. So not just do the procedure and look afterwards, but while you’re doing the procedure, someone looking abdominally and you can see exactly where your catheter is, exactly what you’re taking out. And even then it’s not a guarantee.

Dr. Fox: Yeah. All right. So for those of you out there who have had this happen to you, we hear you. It happens. It is more common than people think. Does not mean anything went wrong. And fortunately, it’s quite treatable and the prognosis is excellent. All right, Melka.

Dr. Melka: Cool. Thank you.

Dr. Fox: Thanks for coming back.

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