An echogenic mass (EM) is the most sensitive and specific predictor of retained products of conception (RPOC) following a pregnancy event, according to a recent study published in the American Journal of Obstetrics & Gynecology.1
Takeaways
- Echogenic masses (EM) show the highest sensitivity and specificity in diagnosing retained products of conception (RPOC) post-pregnancy, providing a reliable indicator for clinicians.
- RPOC diagnosis remains challenging because of varied clinical presentations and ultrasound findings, necessitating accurate predictors to guide management and avoid unnecessary surgical interventions.
- Symptoms of RPOC include postpartum hemorrhage, uterine enlargement, fever, hypomenorrhea, infection, open ectocervix, and pelvic pain, highlighting the importance of timely detection and intervention.
- Surgical treatment for RPOC poses risks such as uterine perforation and endometriosis, emphasizing the significance of accurate diagnosis to prevent adverse reproductive outcomes.
- The systematic review identified EM as the superior predictor of RPOC compared to endometrial thickness and color Doppler imaging, underscoring its clinical relevance in post-pregnancy care.
RPOC are often a diagnostic challenge following pregnancy events, with an incidence of 1% to 6% following term delivery and up to 15% after medical termination of pregnancy. Clinical presentation and ultrasound findings are often used to diagnose RPOC, but management is limited by a lack of accurate diagnostic predictors.
According to Cleveland Clinic, RPOC may lead to bleeding, infection, and other problems.2 Symptoms include postpartum hemorrhage, enlarged uterus, fever, hypomenorrhea, infection, open ectocervix, and pelvic pain.
Surgical intervention is often utilized to treat RPOC.1 This treatment is associated with uterine perforation, endometriosis, and intrauterine adhesions linked to adverse future reproductive outcomes, making accurate diagnosis of RPOC to avoid unneeded surgical intervention crucial.
To determine the best predictor of RPOC, investigators conducted a systematic review. Prospective and retrospective cross-sectional or cohort studies assessing ultrasound findings and histopathologic results of RPOC were included in the analysis.
Exclusion criteria included being a case-controlled or other review type study, reporting hysteroscopic evaluation of RPOC and other imaging modalities, reporting outcomes of incomplete miscarriage, and reporting the hysteroscopic appearance of RPOC only.
Participants included women with RPOC symptoms after a full-term or preterm vaginal delivery, cesarean delivery, miscarriage, or termination of pregnancy (TOP). Ultrasonic evidence of RPOC was reported as the index test, with ultrasonographic variables including EM, endometrial thickness (ET), and color Doppler flow.
Articles were found through searches of the Ovid SP, Cumulative Register to Nursing and Allied Health Literature and EBSCO, and grey literature databases. Two independent reviewers conducted the initial search on April 30, 2021, and a second search on November 4, 2022.
Title and abstract screening were also performed by 2 independent reviewers, with a third consulted to resolve disagreements. Afterward, full text screening and data abstraction were performed.
Extracted data included study identifier, authors, title, country, funding score, objectives, type, conflict of interests, participants, population description, year, inclusion and exclusion criteria, methodology, ultrasound features, number of participants, participant characteristics, statistical parameters, results, limitations, and conclusions.
The sensitivity and specificity of each ultrasonographic variable using a 2x2 table was reported as the primary outcome of the analysis. Study quality was determined using the Quality Assessment of Diagnostic Accuracy Studies 2 template.
There were 11 studies included in the final analysis, including 1567 participants aged a mean 28.1 to 31.8 years. The time between ultrasound examination and surgical intervention ranged from 0 to 8 days, and the mean reported gestational age was 9.2 to 38.8 weeks.
Cesarean delivery was reported in 50 patients, term or preterm vaginal delivery in 429, miscarriage in 451, and TOP in 42. EM was reported in 9 studies, ET in 4, and color Doppler imaging in 5.
EM had an estimated sensitivity of 0.915 and a specificity of 0.843. Additionally, a diagnostic odds ratio (DOR) of 57.787 was reported. The pooled sensitivity, specificity, and DOR were 0.897, 0.868, and 50.954, respectively. Finally, the heterogeneity for sensitivity, specificity, and DOR were 78.4%, 95.5%, and 86.7%, respectively.
In comparison, ET had a sensitivity of 0.667, specificity of 0.866, and DOR of 12.927. The pooled values were 0.430, 0.807, and 7.256, respectively, and the heterogeneity rates were 97.8%, 96%, and 93.8%, respectively.
For color doppler imaging, the sensitivity was 0.850, specificity 0.406, and DOR 3.893. The pooled values were 0.821, 0.442, and 3.963, respectively, and the heterogeneity rates were 66.9%, 92.9%, and 84.2%, respectively.
These results indicated EM had the highest sensitivity and specificity for diagnosis of RPOC. Investigators concluded EM is the best predictor of RPOC after a pregnancy episode.
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