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 [log in to unmask]