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Dr. C.
Dr. C., Board Certified
Category: OB GYN
Satisfied Customers: 3064
Experience:  30 yrs experience, awarding winning educator
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there I hope you can help as I am very worried. I lost

Resolved Question:

Hi there
I hope you can help as I am very worried. I lost mono-mono twins at 13 weeks at the end of November. I found out on a scan and there was no sign of a miscarriage happening so I had an ERPC on 3 December. Three weeks later, I was still spotting and cramping, so I went back to the EPU and had a follow-up scan. This showed endometrial thickness of 13mm and RPOC but the doctor wasn't too concerned - she thought the tissue would come out with my next period. I was given antibiotics and continued to bleed lightly. I had maybe two days without any bleeding, then I felt premenstrual and 27 days after the ERPC, I had what I thought was a period. One morning it was fairly heavy but then it slowed to a steady light trickle for the next five days. I've had no bleeding for the past week. At another scan last week, five weeks after the ERPC, I was found to *still* have 9mm of RPOC and some small blood clots. I was told I hadn't had a period after all, it was just continued post-ERPC bleeding. But apparently my endometrium looked normal. I am under the care of a fertility consultant separately, and he was very concerned my gynae hadn't decided to perform a hysteroscopy to remove the RPOC. He also felt I probably *had* had a period and was worried it was so light, thinks I may have some uterine scarring. I am now terrified. I've booked to see my gynae next week but I'm so scared and confused. Do you think it sounds like I had a period? Could i have Asherman's? I'm 40, had to have a previous ERPC in July last year after a missed miscarriage and don't have any children yet.
Submitted: 2 years ago.
Category: OB GYN
Expert:  Dr. C. replied 2 years ago.
Dr. C. :

Hi and welcome to the site. My name is***** and I'll be providing your medical information today.

Dr. C. :

If there are still retained POC it's impossible to say anything realistically about the bleeding pattern.

Dr. C. :

The decision to remove retained POC or not is a judgement call based on the degree of bleeding and how much tissue seems to be left.

Customer:

thanks. So would retained products mean I wouldn't necessarily expect a normal period?

Dr. C. :

If the bleeding isn't heavy and the tissue doesn't seem like much, it's ok to watch it and perhaps give some methergine medication to cause the uterus to contract and push the remaining tissue out.

Dr. C. :

If the bleeding is heavy, persistent or the amount of tissue seems significant (a visual judgement call), it's safer to repeat suctioning and remove the tissue. Normally this wouldn't require hysteroscopy.

Dr. C. :

Unless there was a clear infection at the time of suctioning or curretting, the risk of Ashermans is very low.

Dr. C. :

Ashermans develops in the context of both instrumentation of the uterus ALONG with an infection.

Dr. C. :

The episode of light bleeding so soon after a procedure that's having some complications doesn't say anything about the presence of Ashermans or not.

Dr. C. :

Ashermans is actually quite uncommon.

Dr. C. :

It's something we think about more than we actually see.

Dr. C. :

My recommendation is to go by the amount of bleeding and repeat ultrasound as to whether there is enough tissue left to warrant reinstrumentation. If there is no infection in any tissue, the risk of Ashemans is VERY low.

Dr. C. :

I'm sorry that you've had this situation to deal with. It's very sad.

Dr. C. :

Please reply with your questions so I can clarify or provide more details as needed.

Dr. C. :

I see you're typing now.

Customer:

Thanks. I've lost two pregnancies in eight months and the twin one was very hard to deal with as it was a TRAP sequence pregnancy, so I had a procedure to try to save it the week before the pump twin died. So yes, it's been hard. thank you.
I was told Ashermans is quite rare but having just had a TRAP sequence pregnancy (seen in 1:35,000 pregnancies) I find it quite hard to trust I'll be on the right side of statistics! I have no bleeding now, haven't had any since the period-like bleed which tapered away last Tues. But I know from the scan on Thurs that I still have RPOC. It's only 9mm, so very small, yes. I'd be grateful if you could explain why I might have had a light period - or would it have been a period at all?

Dr. C. :

Yes, people who've been on the wrong side of statistics so remain skeptical for life.

Dr. C. :

9mm is small.

Dr. C. :

It's impossible to say much about the light bleeding because it was so soon after this sequence of events.

Dr. C. :

It can take 1-2 full cycles to reset the lining properly to function in regular response to the hormones.

Dr. C. :

Also at age 40, there will start being some natural variation from cycle to cycle in the hormone levels that can impact the amount, duration and timing of the flow.

Customer:

Thanks, ***** ***** I do understand about my age but my periods have always been bang on time, and a pretty steady amount - I know it could change at any time now but it would seem a coincidence for that to happen for the first time now? (I was only 40 two weeks ago, just after the ERPC - not a very happy birthday!) So just to clarify, it may just be that the womb lining wasn't fully reset after the op and that's why I had a light bleed? I also wondered if it was light because I hadn't really stopped bleeding properly after the surgery. I wasn't sure if bleeding after the ERPC was caused by an irritated womb lining or by left over tissue.

Dr. C. :

Yes correct. Your understanding is spot on.

Dr. C. :

It could be any of those.

Dr. C. :

So the real thing is to wait for and see what the next few cycles are like.

Dr. C. :

If you're planning on more reproductive treatment, it's better to have 1-2 normal cycles first.

Dr. C. :

Research has been showing that allowing for the lining to reset completely before doing another repro cycle, reduces risk of miscarriage.

Dr. C. :

At age 40, the risk is already fairly high so anything that can be done to reduce that risk should be done.

Customer:

Thank you. I haven't actually had any reproductive treatment, I conceived both times naturally but started panicking after turning 40 so went to see a consultant this week - he isn't suggesting treatment right now, just wants us to try naturally again. But I'm assuming we also shouldn't try anyway until the RPOC has cleared, is that right?

Dr. C. :

Oh, that's great.

Dr. C. :

Spontaneous pregnancies is a good sign, but risk of miscarriage is about 40%. Yes if you have 1-2 perfectly normal cycles, that will be a sign that the PCO has passed.

Dr. C. :

Anything else I can help with today?

Customer:

I'm hoping I've had my share of the miscarriages but I know it doesn't work like that! I don't know how I'll get through another first trimester. Anyway, thanks, ***** ***** reassuring.

Dr. C. :

Yes again it's the statistics thing. You should have had your share by now for sure.

Dr. C. :

Good luck with the future. I hope good odds start coming your way.

Dr. C. :

Anything else?

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