Hysteroscopic treatment of retained placental tissue
A 40-year-old nulliparous woman with no previous gynecological operations underwent at 39 weeks of gestational age a cesarean section due to breech presentation. The cesarean section was standard and uncomplicated. Twenty-four?hours postnatally, she developed postpartum hemorrhage (PPH). She was managed medically with Syntocinon and ergometrine initially followed by dilation and curettage. Retained placental tissue was removed. Hospitalization was uneventful, and she was discharged home 4?days after delivery.

Forty days later, on her routine postnatal follow-up, she complained for persistent spot bleeding. Transvaginal ultrasound revealed a hyperechoic inhomogeneous mass in the uterine cavity, within the fundus and posterior part of the endometrial cavity infiltrating also myometrium up to 10?mm from uterine serosa, suggestive of retained products of conception (RPOC). The mass measured 18 × 18?mm in diameter, and color Doppler ultrasound (US) excluded vascularization (color score 1). Hysteroscopy revealed a mass which grossly measured 1.5 × 1.5 × 2 cm. In order to separate and remove gently and selectively the placental remnant from the underlying endometrium, we used the loop of the bipolar resectoscope as a curette performing cold dissection.
During the procedure, minimizing the use of electrosurgery, and under transabdominal ultrasound guidance, remnants were successfully removed as close as the uterine serosal border.

The aim was to minimize thermal damage to the endometrium in order to reduce the risk of the formation of intrauterine adhesions, perforation, and bleeding. Figure 1 demonstrates the hysteroscopic view of the retained placental tissue and the ultrasound image of the uterus before the operation. The procedure lasted 23?minutes. At the end of the surgical procedure, the cavity appeared to be empty. The patient was fully recovered, and the follow-up was uneventful. Two months after the operation on routine transvaginal ultrasound examination, a normal-looking endometrial cavity was identified. The patient had no menstruation yet, due to breastfeeding.