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Article

Retained Products of Conception

Spectrum of Color Doppler Findings

Aya Kamaya, MD, Ivan Petrovitch, MD, Bertha Chen, MD,

Carrie E. Frederick, MD, MPH, R. Brooke Jeffrey, MD

Objective. The purpose of this study was to characterize color Doppler imaging features of retained
products of conception (RPOC) with gray scale correlation. Methods. Clinically suspected cases of RPOC
between January 2005 and February 2008 were reviewed. Patient data and relevant color Doppler and
gray scale features were recorded. Results. A total of 269 patients referred for sonographic evaluation
for RPOC were identified. Thirty-five patients had confirmed pathologic diagnoses, 28 of whom had
RPOC. In those with RPOC, 5 (18%) were avascular (type 0); 6 (21%) had minimal vascularity (type 1);
12 (43%) had moderate vascularity (type 2); and 5 (18%) had marked vascularity (type 3). Peak systolic
velocities ranged from 10 to 108 cm/s (average, 36.1 cm/s). Resistive indices in arterial waveforms
ranged from 0.33 to 0.7 (average, 0.5). Five (45%) of the patients with type 0 vascularity had RPOC; 6
(86%) of those with type 1 had RPOC; and 17 (100%) of those with types 2 and 3 had RPOC. An
echogenic mass had a moderate positive predictive value (80%) but low sensitivity (29%) for RPOC.
Conclusions. Color Doppler evaluation of the endometrium is helpful in determining the presence of
RPOC. Endometrial vascularity is highly correlated with RPOC, whereas the lack of vascularity can be
seen in both intrauterine clots and avascular RPOC. Key words: color Doppler sonography; postpartum;
retained products of conception; uterine arteriovenous malformation; uterus.

I
Abbreviations
AVM, arteriovenous malformation; EMV, enhanced
myometrial vascularity; hCG, human chorionic
gonadotropin; PPV, positive predictive value; PSV, peak
systolic velocity; RI, resistive index; RPOC, retained prod-
ucts of conception
Received February 19, 2009, from the Departments
of Radiology (A.K., I.P., R.B.J.) and Obstetrics and
Gynecology (B.C., C.E.F.), Stanford University
Medical Center, Stanford, California USA. Revision
requested March 23, 2009. Revised manuscript
accepted for publication April 22, 2009.
We thank Jeslyn A. Rumbold and Naveen N.
Parti for assistance with manuscript preparation,
Jarrett Rosenberg, PhD, for statistical analysis, and
David Hovsepian, MD, for valuable feedback.
Address correspondence to Aya Kamaya, MD,
Department of Radiology, Stanford University
Medical Center, 300 Pasteur Dr, H1307, Stanford,
CA 94305 USA.
n the subacute postpartum setting, abnormal bleed-
ing related to uterine atony can be difficult to differen-
tiate from retained products of conception (RPOC).
Normal postpartum bleeding (lochia) occurs in the
first 24 hours postpartum, with a gradual decrease in the
amount of bleeding over the next several weeks. Uterine
contractions during the birthing process are thought to
cause constriction of the spiral arteries supplying the
decidua, helping decrease the amount of bleeding.1 In
cases of spontaneous abortion, dilation and curettage, and
cesarean delivery, uterine contractions may not naturally
occur, thereby foregoing the normal hemostatic process.
This lack of hemostasis can lead to greater-than-expected
bleeding, which may simulate RPOC.
Pelvic sonography plays an important role in determin-
ing the source of abnormal bleeding and is the first-line
imaging modality in evaluation for RPOC. The diagnosis
should be made promptly because retention of placental
remnants and decidua can act as a source of prolonged

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Retained Products of Conception
bleeding or as a nidus for infection. Evacuation of
RPOC often requires dilation and curettage; how-
ever, this procedure should be used judiciously
because there is a risk of uterine adhesions after
dilation and curettage as well as a risk of uterine
perforation in the setting of endometritis. An
accurate assessment of the likelihood of RPOC is
therefore important.
Several studies have looked at different gray
scale sonographic features of RPOC, including
the presence of an intrauterine mass,2 endome-
trial thickness,3,4 and echogenicity.5 These prior
studies did not focus on the color Doppler fea-
tures of RPOC, and in fact, color Doppler imaging
was not routinely performed in many of the
study patients. Two prior studies by the same first
author looked at the postpartum uterus with
color Doppler imaging.6,7
In the last few years, several case reports of
RPOC mimicking arteriovenous malformations
(AVMs) have been published,8,9 raising the suspi-
cion that RPOC can have variable color Doppler
appearances, including a highly vascularized
appearance. Only a few studies have evaluated
the utility of color Doppler sonography for
RPOC, and the role of color Doppler imaging in
this setting is still not clear. We present our find-
ings and have identified 4 types of color Doppler
appearances of RPOC. Recognition of the differ-
ent appearances of RPOC may provide guidance
in the management of postpartum hemorrhage.
Materials and Methods
Patients
Institutional Review Board approval was
obtained before the retrospective retrieval of
sonograms and patient information; consent
was waived for this retrospective review. A search
of the radiology database between January 2005
and February 2008 was performed to find cases
referred for pelvic sonography for suspected
RPOC, and a total of 269 patients were identified.
Medical records were then reviewed to deter-
mine whether pathologic specimens were
obtained after the sonographic examinations. A
total of 35 examinations were included in the
final analysis group.
Patient data were collected, including the
maternal age, gravida status, gestation of preg-
1032
nancy at the time of the event (miscarriage, dila-
tion and curettage, or delivery), number of days
postpartum at the time of sonography, indica-
tion for sonography, and β-human chorionic
gonadotropin (hCG) levels at the time of sonog-
raphy.
Imaging Techniques
All patients underwent sonographic imaging
with Acuson Sequoia 512 ultrasound machines
(Siemens Medical Solutions, Mountain View,
CA). Transabdominal images were obtained
using either a vector or curved transducer with
frequencies ranging from 3 to 6 MHz and har-
monic imaging. Transvaginal images were
obtained using a vector transvaginal probe with
frequencies ranging from 5 to 7 MHz and har-
monic imaging. Images were retrospectively
reviewed independently by 2 board-certified
radiologists, who were both blinded to the patho-
logic diagnosis, on a picture archiving and com-
munications system color monitor. Video clips
were reviewed when available. Interpretations
differed in 2 cases, which were then reviewed,
and a consensus interpretation was obtained.
Images were assessed for the uterine size and
thickness of the endometrium. An endometrial
mass was defined as an intrauterine mass dis-
tinct from the rest of the endometrium, measur-
able in 3 dimensions in 2 orthogonal planes. If an
intrauterine mass was present, the echogenicity,
size, and location of the mass were recorded. If a
separate mass was not visible, the endometrial
thickness in the anteroposterior dimension was
measured on sagittal midline views.
The presence of a color Doppler signal and the
amount of endometrial vascularity were assessed
as none, minimal, moderate, or marked. An avas-
cular color Doppler appearance was defined
as undetectable vascularity in the endometrium
(type 0). Minimal vascularity was defined as
some detectable color Doppler flow in the
endometrium but less than in the myometrium
in the same image section (type 1). Moderate
vascularity was defined as vascularity equal to or
near equal to that in the myometrium in the
same image section (type 2). Marked vascularity
was defined as marked endometrial vascularity
greater than that in the myometrium in the same
image section (type 3).
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Spectral tracings of vascularity in the endo-
metrium were analyzed. The tracings were char-
acterized as arterial, venous, or both. The highest
peak systolic velocities (PSVs) for arterial and
venous waveforms were recorded in centimeters
per second. If arterial waveforms were present,
resistive indices (RIs) were calculated as (PSV –
end-diastolic velocity)/PSV.
Statistical Analysis
Quantitative measures were compared by
Wilcoxon tests. Counts were compared by Fisher
exact tests. A significance level of P < .05 was
used. All statistical analyses were done with Stata
release 9.2 (StataCorp, College Station, TX).
Results
Demographics
Thirty-five sonograms in 35 patients were ana-
lyzed. Twenty-six patients underwent transvagi-
nal and transabdominal sonography of the pelvis.
Nine patients underwent only transabdominal
sonography of the pelvis. The average age of the
imaged patients was 29.8 years (range, 15–46
years). Three patients were post vaginal delivery
at term; 1 was post cesarean delivery at term; 1
was postpartum at 24 weeks; 3 were post thera-
peutic abortion; and 27 were post miscarriage.
The average gestational age of the fetus at the
time of the event (delivery, miscarriage, or termi-
nation) was 15.3 weeks (4 term, 12 second
trimester, and 18 first trimester). Clinical indica-
tions for sonographic evaluation included 22
patients with vaginal bleeding, 6 with pelvic pain,
3 with missed abortion, and 7 with no history
other than “rule out RPOC.” In those with RPOC,
the average gestational age of the fetus was 14.4
weeks (2 term, 10 second trimester, and 16 first
trimester), whereas the average gestational age
those without RPOC was 28.8 weeks (2 term, 2
second trimester, and 3 first trimester). The aver-
age interval between the event and the sono-
graphic examination was 15.3 days (range, 0–170
days; RPOC, 16.9 days; non-RPOC, 9.1 days).
Laboratory Values
There was no significant difference in β-hCG val-
ues between patients with RPOC and those with-
out RPOC. β-hCG levels averaged 2842 mIU/mL
J Ultrasound Med 2009; 28:1031–1041
Kamaya et al
(range, 1–21,431 mIU/mL) for RPOC and 2336
mIU/mL (range, 1–3419 mIU/mL) for non-
RPOC (Table 1).
Pathologic Findings
Twenty-eight of 35 patients had RPOC. Of these,
27 cases were pathologically proven, and 1
patient was serially followed with clinic visits and
sonographic examinations until she passed a
calcified mass, at which point her symptoms
resolved. The calcified mass was assessed by the
gynecologist, but not by a pathologist, as RPOC.
Seven of 35 patients did not have RPOC on
pathologic examinations. The presence of RPOC
was assessed both on gross specimens and by
microscopic evaluation. The presence of chori-
onic villi on the pathologic specimen was con-
sidered a positive finding for RPOC.
Gray Scale Findings
Uterine dimensions were obtained in anteropos-
terior, transverse, and longitudinal axes, with the
uterine volume roughly estimated as a prolate
ellipse by the formula anteroposterior × trans-
verse × longitudinal × 0.53. The average uterine
volume was 243.4 cm3 (RPOC, 242 cm3; non-
RPOC, 248 cm3). The average endometrial thick-
ness was 21.6 mm, with no significant difference
between RPOC and non-RPOC (RPOC, 21.9 mm;
non-RPOC, 20.6 mm; Table 2).
Ten patients had discrete intrauterine masses,
8 of which were seen in RPOC and 2 in non-
RPOC. Masses in RPOC were located in the fun-
dus (1), body (3), lower uterine segment (2), and
cervix (2). Masses in non-RPOC were located in
the body (1) and lower uterine segment (1). The
average long-axis diameter of the intrauterine
masses was 4.1 cm (range, 1.4–6.9 cm), and the
average short-axis diameter was 2.4 cm (range,
1.1–3.8 cm).
Table 1. Means, SDs, and Range of Laboratory Values
β-hCG, mIU/mL
Condition (P = .58a)
RPOC 2842 ± 4786
Non-RPOC 2336 ± 1378
Total 2737 ± 4278
(1–21,431)
a
Wilcoxon test comparing RPOC and non-RPOC.
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Retained Products of Conception

Table 2. Means, SDs, and Ranges of Gray Scale findings (PPV) of various imaging features of RPOC; this
Uterine Endometrial lack of a consensus may be due in part to the
Volume, cm3 Thickness, mm changing technology of ultrasound. Gray scale
Condition (P = .97a) (P = .89a) detail and color Doppler imaging have greatly
RPOC (27 patients) 242 ± 118.3 21.9 advanced in the last decade, and nuances in the
Non-RPOC (7 patients) 248 ± 144.8 20.6 appearance of the endometrium and myometri-
Total 243.4 ± 121.8 21.6 ± 9.9
um are better depicted with newer higher-
(78.7–487.6) (7–56)
resolution images. Color Doppler imaging has
a
Wilcoxon test comparing RPOC and non-RPOC.
likewise improved and is now part of our stan-
dard pelvic sonographic examination. Additional
Doppler features such as spectral Doppler trac-
Color Doppler Findings ings and power Doppler evaluation are often
In 28 patients with RPOC, 5 patients (18%) had used and provide further valuable information.
type 0 vascularity (Figure 1); 6 (21%) had type 1 Our study differs from other prior studies in the
(Figure 2); 12 (43%) had type 2 (Figures 3 and 4); literature in several important ways. First, we
and 5 (18%) had type 3 (Figures 5 and 6). In examined only those patients with confirmed
patients without RPOC, 6 had type 0 vascularity diagnoses. Second, our study population was
(Figures 7 and 8), and 1 had type 1 (Figure 9). The composed of recent (2005–2008) sonographic
presence of vascularity was highly correlated pelvic examinations of patients referred for
with RPOC (P = .04, Fisher exact test).
Spectral Doppler waveforms of endometrial Figure 1. Type 0 vascularity: avascular endometrium. A, Trans-
vascularity were obtained in 14 of the 24 patients abdominal sagittal image showing a mildly enlarged postpartum
with detected endometrial vascularity. In patients uterus with a slightly heterogeneous endometrium (arrowheads);
no vascularity is shown. B, Transvaginal transverse image better
with RPOC, 6 had only arterial waveforms; 2 had
depicting the thickened endometrium (arrows), measuring 2 cm
only venous waveforms; and 7 had both arterial (measurement not shown); no vascularity is shown despite low
and venous waveforms. In the 1 non-RPOC patient flow settings. The patient was pathologically proven to have RPOC.
with minimal (type 1) endometrial vascularity, A
spectral waveforms were both arterial and venous
in appearance.
Peak systolic velocities were recorded in
patients with spectral Doppler tracings; none of
the velocities were angle corrected. In those with
both arterial and venous waveforms (12 patients),
the highest PSV was recorded. In those with only
venous waveforms (2 patients) the detected
venous PSV was recorded. The average PSV was
34.4 cm/s. In patients with RPOC, the average
PSV was 36.1 cm/s (range, 10–108 cm/s). In the 1
patient without RPOC but with minimal (type 1)
vascular flow, the PSV was 12.6 cm/s. In the B
patients with arterial waveforms, RIs were calcu-
lated on the basis of a representative waveform.
The average RI was 0.5 (RPOC, 0.5; non-RPOC,
0.58; Table 3).

Discussion

Prior studies have examined the sonographic

features of RPOC but without a clear consensus
on the sensitivity and positive predictive value

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Figure 2. Type 1 vascularity: minimally vascular endometrium.
A, Transabdominal sagittal gray scale image of a uterus show-
ing an endometrium distended to 2 cm (arrows). B, Color
Doppler sagittal view of the uterus showing small areas of min-
imal vascularity (arrow). C, Spectral Doppler image of an area of
minimal vascularity (arrow) shown to be venous. The patient
was pathologically proven to have RPOC.
A The presence of any vascularity in the
B Color Doppler imaging of the uterus opens a
J Ultrasound Med 2009; 28:1031–1041
Kamaya et al
RPOC. Because of our relatively recent cohort of
patients, all of our examinations used both gray
scale sonography with harmonic imaging and
color Doppler imaging. Third, our study had
pathologic confirmation to correlate with report-
ed imaging findings.
endometrium (types 1–3) had a high likelihood
of representing RPOC, with a PPV of 96%. When
type 2 and 3 vascularity studies were considered
separately, all had positive findings for RPOC.
Because blood clots and debris can mimic RPOC
on gray scale imaging, detection of intrinsic vas-
cularity is helpful in distinguishing simple clots
and decidua from RPOC. Vascularity may be
confirmed with spectral tracings, which will
separate clear arterial or venous flow from arti-
facts related to uterine contractions and other
nonvascular causes of motion.
new dimension in the evaluation for RPOC,
which has only been studied to date in limited
Figure 3. Type 2 vascularity: moderate. A, Sagittal gray scale
image showing an endometrium (arrows) mildly thickened to
1.2 cm (measurements not shown). B, Color Doppler sagittal
image showing vascularity in the endometrium similar to that in
the myometrium. The patient was proven to have RPOC.
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Retained Products of Conception
detail. In 2005, Durfee et al2 described their gray
scale and color Doppler features of RPOC with
a cohort similar to ours. However, only 17% of
their patients had color Doppler evaluation,
and no spectral Doppler findings were reported.
Furthermore, they had pathologic confirmation
in only 26% of the study population; the remain-
ing 74% without pathologic confirmation were
assumed to have negative findings for RPOC.
This assumption may have led to an abnormally
high false-positive rate for color Doppler findings
in their analysis.2 In 2002 and again in 2008, Van
den Bosch et al6,7 examined the color Doppler
appearance of the postpartum uterus. Their find-
ings agreed with our results that the presence of
color Doppler signals was highly correlated with
the presence of RPOC. They did not, however,
have pathologic correlation in all cases.6,7
Type 0 vascularity does not completely exclude
the presence of RPOC, which agrees with the
findings of Durfee et al.2 In our study, avascular
Figure 4. Type 2 vascularity: moderate, different patient from
the patient in Figure 3. A, Transvaginal sagittal gray scale image
showing an echogenic endometrium thickened to 2.3 cm. B,
Color Doppler image showing moderate vascularity (arrow) sim-
ilar to that in the adjacent myometrium. The patient was proven
to have RPOC.
A
1036
endometrial echoes were more commonly seen
in patients without RPOC. The finding of avas-
cularity should be counterbalanced by other
less specific imaging findings such as the pres-
ence of an echogenic mass, endometrial thick-
ness, and, most importantly, the degree of
clinical suspicion for RPOC. Although the latter
findings are not necessarily sensitive nor specif-
ic in isolation, a combination of many of these
findings may in fact still be regarded as “suspi-
cious” for RPOC. One important question to con-
sider for further investigations is whether an
avascular endometrium will likely spontaneous-
ly pass without the need for surgical interven-
tion even if RPOC are present.
Figure 5. Type 3 vascularity: marked. A, Color Doppler image
showing a focal area of marked endometrial vascularity (short
arrows) extending into the myometrium (long arrow). The
degree of vascularity was so great that an AVM was considered.
B, Spectral Doppler image showing arterial waveforms with
high-velocity flow, proven to represent RPOC.
A
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Figure 6. Echogenic mass and type 3 vascularity. A, Trans-
abdominal sagittal image of a uterus showing that the endome-
trial cavity is distended by a large echogenic mass (arrows and
calipers). B, On color Doppler imaging, this is highly vascular
(arrow) and categorized as type 3 vascularity. C, Spectral Doppler
tracings showing arterial waveforms. The patient was proven to
have large RPOC.
A reports.2 Two possible reasons for improved detec-
B cases with endometrial vascularity very near the
C areas of necrosis in the retained placenta.9
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Kamaya et al
Type 1 vascularity was seen more commonly in
RPOC (86%) than non-RPOC (14%) and was the
only subtype of endometrial vascularity seen in
patients without RPOC (Figure 9). We theorize that
better detection of minimal vascularity may have
led to higher sensitivity for RPOC than in previous
tion of this subtype of vascularity are improved
ultrasound technology and the fact that our sono-
graphers routinely perform color Doppler evalua-
tions during all pelvic sonographic examinations
and thus may be more skilled in detection of flow.
Type 2 vascularity was the most common
appearance of endometrial vascularity, and was
seen only in those with RPOC. Type 2 vascularity
is defined as endometrial vascularity equal to
that in the normal myometrium. Because there
may be some subjective differences in whether
something is exactly “equal,” we included those
vascularity in the myometrium.
The type 3 color Doppler appearance was only
seen in RPOC. The cause of a highly vascular area
in the endometrium (and often extending to
the immediately adjacent myometrium) is likely
related to the site of placental implantation. This
appearance was previously described by Van den
Bosch et al,6 who also found a high correlation of
this type of vascularity with RPOC. It is theorized
that a retained placenta maintains its vascular
connection to the uterus and when prolonged (>6
weeks) may be associated with hypertrophied per-
itrophoblastic vessels that communicate via
Figure 7. Type 0 vascularity: avascular endometrium in a patient
pathologically proven not to have RPOC. The endometrial thick-
ness was 10 mm.
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Retained Products of Conception

Type 3 vascularity may be so exuberant that the
color Doppler appearance can mimic a uterine
AVM.8–10 Diagnosis and management of this find-
ing have been controversial in the literature.
Several case reports have described postpartum
AVMs and have stressed the theoretical danger of
hemorrhage related to dilation and curettage.11,12
However, many of these reports may have simply
represented highly vascularized RPOC with per-
itrophoblastic flow rather than true AVMs
because most disappeared after passage of the
retained products.13 In these cases, the clinical
setting is quite helpful: a postpartum patient
with bleeding and a highly vascular uterine
lesion (endometrial or myometrial) is most likely
to have RPOC. A true uterine AVM is exceedingly
rare and should persist after RPOC have been
excluded. Interestingly, RPOC can have very high
velocities, which may contribute to the erro-
neous diagnosis of an AVM; we found velocities
of up to 108 cm/s in RPOC, which were higher
than previously reported in the literature.
In RPOC with type 3 vascularity, the obstetri-
cian should be made aware of the highly vascular
nature, which in turn may alter management.
For instance, at our institution, a longer trial of
uterotonics is often allowed for spontaneous
passage of RPOC if the patient is hemodynami-
cally stable. If bleeding is excessive, or if visualized
vessels are of a substantial caliber, then dilation
and curettage, if undertaken, should be per-
formed with caution.14–16 In our series, patients
with type 3 vascularity were followed serially with
sonography and either treated with uterotonics
or dilation and curettage without complications.
Occasionally, we encountered cases in which,
in addition to the vascular endometrium, por-
tions of the myometrium had greater vascularity
than other areas. This is presumably related to
the retained products in the implantation site of
the former pregnancy. This finding occurred
mainly in type 3 vascularity. In these cases, the
myometrium not immediately adjacent to the
vascular area of the endometrium but in the
same plane of imaging was used as a comparison
because the adjacent myometrium can be con-
sidered part of the same vascular process affect-
ing a highly vascular endometrium. Vascularity
of the myometrium itself was not evaluated in
Figure 9. Type 1 vascularity: minimally vascular endometrium.
A, Transvaginal transverse color Doppler image of a uterus
showing a wide endometrial complex measuring 2 cm (mea-
surement not shown) with a focus of vascularity (arrow), which
on spectral Doppler imaging (B) was proven to represent venous
flow. This was the only patient with endometrial vascularity in
our study who was not pathologically proven to have RPOC.
A

B
Figure 8. Echogenic mass with type 0 vascularity. The endome-
trial cavity is distended by a well-delineated echogenic mass
(arrows), which is avascular on color Doppler imaging. This mass
measured 5.6 × 3.2 cm (measurement not shown). Retained
products were not found on the pathologic specimen.

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this study beyond using it as a comparison con-
trol for endometrial vascularity.
Myometrial vascularity was assessed by Van
Schoubroeck et al17 in a study of the sonograph-
ic appearance of the uterus in 93 postpartum
women. Our type 3 vascularity likely had some
overlap with what they termed “enhanced
myometrial vascularity” (EMV). They defined
EMV as an area of enhanced vascularity in the
myometrium ranging from focal lesions to large
areas of hypervascularity and found that most of
their cases of EMV were associated with retained
placental tissue and more frequently seen after
instrumental removal of the placenta, in patients
who needed blood transfusion in the early post-
partum period, and in multigravid patients. They
did not, however, comment on the associated
endometrial vascularity or endometrial thick-
ness, features that we focused on in our study.17
Our results showed that the presence of an
echogenic mass distending the endometrial cav-
ity was not a sensitive finding (29%) in diagnosis
of RPOC but had a moderate PPV (80%). This
result differs from that of Durfee et al,2 who con-
cluded that an echogenic mass was the most
sensitive finding for RPOC. Hertzberg and
Bowie18 also reported that an echogenic mass
was a sensitive finding in a small study group of
11 patients with RPOC. A recent study reported
that the presence of “hyperechoic material” was
the best predictor of RPOC.5 The differences
between our findings and those described above
may be related to differences in definition. We
used a strict definition of an intrauterine mass as
being measurable in 2 planes, distinct from the
adjacent endometrium, and distending the
endometrial cavity, whereas prior reports may
have been less strict in their definition to include
a distended endometrial cavity. Our findings
show that presence of endometrial vascularity is
a more sensitive finding for RPOC than the pres-
ence of an intrauterine mass. An intrauterine
mass may be either a blood clot or RPOC, but the
intrinsic vascularity is what can differentiate the
two entities. Moreover, a vascular thickened
endometrium may also have RPOC, which may
not appear as a distinct mass on gray scale
sonography. The RPOC in these cases are better
detected on color Doppler imaging. In our study,
intrauterine masses were seen in 28% of patients
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Kamaya et al
Table 3. Means, SDs, and Ranges of Spectral Doppler Findings
Condition PSV, cm/s RI
RPOC (13 patients) 36.1 ± 30.9 0.5 ± 0.1
Non-RPOC (1 patient) 12.6 0.58
Total 34.4 ± 30.3 (10–108) 0.5 ± 0.1 (0.33–0.7)
without RPOC and in 29% with RPOC. This find-
ing agrees with a study of normal postpartum
women without RPOC, which found that 51%
had an echogenic mass at 7 days.19
Several studies have used threshold criteria for
endometrial thickness, varying between 8 mm
(34% false-positive rate)3 and 13 mm (85% sensi-
tivity and 64% specificity).4 One suggested
threshold is 10 mm for endometrial thickness,
although this had a low reported sensitivity,
specificity, and PPV.2 In our study, endometrial
thickness in the two categories was very similar
(RPOC, 21.9 mm; non-RPOC, 20.6 mm) and in
part may have been related to a selection bias
due to the requirement of pathologic correlation.
The endometrial thickness is an important dis-
criminatory finding. In our routine clinical prac-
tice, we consider an avascular endometrial
thickness of 10 mm or less unlikely to represent
RPOC. If, on the other hand, the endometrium is
thickened and vascularity is present, this
markedly raises our suspicion for the presence of
RPOC. Several patients in our study with type 1
and 2 vascularity had gray scale appearances of
the endometrium that, aside from mildly thick-
ened endometrial echoes, were otherwise unre-
markable on gray scale imaging (homogeneous
echo texture and no masses). In these patients,
the presence of color Doppler signals was very
helpful in the diagnosis of RPOC.
The fact that only those with pathologic corre-
lation were included in the final analysis group
may have been a strength as well as potential
limitation of our study. Because all cases had
pathologic correlation, our sonographic findings
could be compared against an absolute refer-
ence standard. On the other hand, the require-
ment for pathologic confirmation may have
created a selection bias because patients with
abnormal sonographic findings were more likely
to undergo surgical treatment. Finally, the
requirement for pathologic correlation created a
narrowed subset of patients whom we were able
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Retained Products of Conception
to include in the final analysis group. Many
patients had specimens collected in the emer-
gency or gynecology department, which were
proven to represent RPOC, but then were
referred to radiology for evaluation for any resid-
ual RPOC. Because the pathologic specimens
were collected before sonography, we could not
include this group in the final analysis. Another
subset had no follow-up notes after the clinical
and sonographic examinations; therefore, the
final diagnoses were not pathologically deter-
mined. Several patients did undergo dilation and
curettage, but the specimens were not sent for
pathologic examinations, and they were not fol-
lowed after sonography, so we could not include
them in our study. The criteria for inclusion were
strict but ensured that the sonographic data were
correlated with a reference standard.
Another limitation of our study was that it was
a retrospective review of cases performed.
Therefore, standardization of the examinations
was not possible. For example, a minority of
our examinations did not include transvaginal
sonograms or spectral tracings of the areas of
endometrial vascularity seen on color Doppler
imaging. Our daytime sonographers are trained
to obtain these images. However, some of the
cases were performed on an emergent basis in
the middle of the night, when cases were not
reviewed by an attending radiologist. In addition,
video clips were obtained inconsistently accord-
ing to the sonographer’s judgment.
In conclusion, we have described the color
Doppler appearance of pathologically confirmed
diagnoses in patients suspected to have RPOC. In
those with type 0 vascularity, the likelihood of
RPOC was less than 50%. Even if RPOC are pre-
sent, the lack of visible vascularity suggests that
the contents are predominantly devascularized
tissue, and we hypothesize that it may pass spon-
taneously or with the help of uterotonics. Types 1,
2, and 3 vascularity still have a vascular connec-
tion to the uterus and are highly likely to repre-
sent RPOC. Type 3 vascularity has a large vascular
communication with the uterus, which can even
be mistaken for an AVM; in such a case, the
obstetrician should be made aware of the vascu-
lar nature of the lesion and the theoretical risk of
bleeding. Detection of an intrauterine mass has a
moderate PPV for RPOC but is not very sensitive.
1040
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