Those of you with expertise please advise: can ultrasound detect small
retained placental fragments?

I am working with a woman who is 4 weeks postpartum. Despite all her (and
baby's) efforts she is producing a maximum 210 cc of milk per 24 hours.
(This is based on calculation of what she pumps plus considering amount of
abm baby is consuming.) She started using a pump at the end of week 1 (baby
was readmitted for three days to r/o sepsis = negative) and since that time
has been tandem pumping using a Classic Medela pump 8 times a day (mostly
after feeds). She has been using Fenugreek for the past two weeks. The baby
is gaining well, but I calculate he is getting mostly abm at this point.

Mom's medical history and lab profiles are unremarkable except for the fact
that she has been bleeding all this time; during week 3 she started passing
clots and now, at week 4, she is "bleeding normally" (her words). Her OB has
been underwhelming in response, with lots of reassurance (in the mother's
words the jist has been "now, now -- breastfeeding isn't all that
important." The patient finally got the OB to address the possibility of
retained placental fragment and an ultrasound was done yesterday, which was
negative. The OB advised the patient that the bleeding she is having is
return of menses. The patient asked me about Reglan, and after discussion
with a pediatrician the OB has reluctantly given an Rx for Reglan (10 day
taper).

I had a patient last month who started passing clots at week 3. She had a
D&C and a placental fragment the size of a fingernail was retrieved. After
the D&C the patient was amazed to report "My milk came in!" since she, also,
had been struggling with a negligible supply.

Would ultrasound detect a small fragment? Should I forget about retained
placental fragments in this case?

Margery Wilson, IBCLC
Massachusetts Institute of Technology
Medical Department
Cambridge, Massachusetts
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