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==Background==
*Abbreviation: RPOC
*Fetal tissue or placenta that remains following abortion or delivery
*Incidence of 0.5-1% of induced abortions

==Clinical Features==
*'''[[Vaginal bleeding]]'''
**Typical following abortions; should consider abnormal if heavy or last >3 weeks
*'''[[Fever]]/[[pelvic pain|Pain]]'''
**Necrotic RPOC are prone to infection → uterine tenderness
**Fever abnormal following evacuation of uterus
**Consider possibility of uterine perforation/visceral injury if instrumentation used during abortion
**Clostridial [[toxic shock syndrome]] possible after 1st trimester miscarriages/termination
***↑↑ WBC on presentation
***Almost always fatal
*'''Amenorrhea'''
**Menses should resume within 6 weeks of miscarriage/termination
**Amenorrhea may be sign of remaining trophoblastic tissue

===Physical Exam===
*Uterine tenderness
*Heavy vaginal bleeding
*Uterine enlargement
*Cervical OS typically open

==Differential Diagnosis==
*Hematometra
*[[Ectopic pregnancy]]
*Traumatic termination
*[[molar pregnancy|Gestational trophoblastic disease]]

{{Postpartum emergencies DDX}}

==Evaluation==
===Workup===
*Type and screen
*bHCG (may be negative if tissue necrotic and not secreting hormone)
*GC/C
*CBC
*PT/PTT
*[[pelvic ultrasound (transvaginal)|Transvaginal US]]

===Diagnosis===

==Management==
*'''RPOC + hemodynamic instability'''
**[[IVF]] and [[pRBC]] as needed
**[[Misoprostol]] 800 mcg PR (theoretic benefit; not studied)
**Uterine evacuation
***If patient does not respond to above:
****Uterine tamponade
****Uterine artery embolization
****Hysterectomy
*'''RPOC + [[sepsis]]'''
**Emergent uterine evacuation
**Broad spectrum [[antibiotics]]
***If patient does not respond to above:
****Laparotomy +/- hysterectomy to evaluate for bowel injury, pelvic abscess, clostridial myometritis
*'''RPOC + [[Postpartum endometritis|endometritis]]'''
**[[Cefotetan]] 2 g IV + [[doxycycline]] 100mg IV or PO q12h
**Outpatient: [[Ceftriaxone]] 250mg IM + [[doxycycline]] 100mg BID x 14 days +/- [[metronidazole]] 500mg BID x 14 days
**If patient does not respond to above:
***Prompt uterine evacuation
*'''RPOC + prolonged bleeding (hemodynamically stable)'''
**''Uterine evacuation (preferred)''
***Indirect evidence supports use of prophylactic antibiotics
**''Medical management''
***Misoprostol
***Not studied in RPOC but reasonable in patient who refuses surgical management
**''Expectant management''
***RPOC likely to resorb without intervention → resolution of bleeding
***50-85% resolution at 1-2 week follow up
***90% resolution at 6 weeks follow up
***Use of prophylactic antibiotics not studied in RPOC patients

==Disposition==


==See Also==
*[[Postpartum emergencies]]
*[[OB/GYN antibiotics]]
*[[Septic abortion]]

==References==
<references/>

[[Category:OBGYN]]