Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 27  |  Issue : 1  |  Page : 30-32

Hysteroscopic removal of retained intrauterine fetal bone causing chronic pelvic pain


1 Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital; Life Fertility Centre, Life Specialist Hospital Limited, Nnewi, Anambra State, Nigeria
2 Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria

Date of Web Publication20-Apr-2018

Correspondence Address:
Prof. Joseph I Ikechebelu
Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Nnewi Campus, Anambra State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njss.njss_24_13

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  Abstract 


It is generally believed that bones retained freely in the endometrial cavity could behave as an intrauterine contraceptive device. We report a case of retained fetal bone causing chronic pelvic pain in a 29-year-old single Para 0 + 1 female. This followed the termination of a 16-week pregnancy through dilatation and curettage 8 years earlier. Pelvic ultrasound suggested the presence of two highly echogenic objects in the uterine cavity and uterine synechia. Hysteroscopic adhesiolysis and removal of the embedded fetal bone fragments (confirmed by histology) with insertion of size 10 Foleys catheter was performed. She was subsequently placed on estrogen (progynova 2 mg twice daily) for 6 weeks. Her menstruation returned 2 months after the hysteroscopy with complete resolution of the pelvic pain.

Keywords: Amenorrhea, chronic pelvic pain, dilatation and curettage, fetal bone, hysteroscopy, uterine synechia


How to cite this article:
Ikechebelu JI, Eleje GU, Eke NO. Hysteroscopic removal of retained intrauterine fetal bone causing chronic pelvic pain. Niger J Surg Sci 2017;27:30-2

How to cite this URL:
Ikechebelu JI, Eleje GU, Eke NO. Hysteroscopic removal of retained intrauterine fetal bone causing chronic pelvic pain. Niger J Surg Sci [serial online] 2017 [cited 2019 Sep 15];27:30-2. Available from: http://www.njssjournal.org/text.asp?2017/27/1/30/230694




  Introduction Top


Intrauterine retention of bone fragments after the termination of pregnancy is an uncommon gynecologic entity. It may be associated with such gynecological complaints as irregular bleeding, pelvic pain, vaginal discharge, spontaneous passage of bone fragments during menstruation, and infertility.[1],[2] The incidence of retained intrauterine fetal bones has remained largely unknown.[1],[2]

Such retention of a bony structure in the endometrial cavity or ossification of the endometrium may prevent conception by an intrauterine device-like effect.[3],[4] Hysteroscopy is required for definitive diagnosis and removal.[1],[3]


  Case Report Top


A 29-year-old single Para 0 + 1 female who presented to Life Specialist Hospital Limited Nnewi with a 7-year history of chronic pelvic pain, and 1 year history of secondary amenorrhea and dyspareunia. She attained menarche at 13 years of age. Her menstrual periods had been normal and regular until the termination of a pregnancy at about 16 weeks of gestation by dilatation and curettage (D and C) in a clinic 8 years before presentation. Eleven days after the procedure, she developed severe lower abdominal pain associated with vaginal discharge which was treated with antibiotics and occasionally with nonsteroidal anti-inflammatory agents. The vaginal discharge persisted for months, and over time the menstrual flow became scanty. Eventually, the foul smelling vaginal discharge subsided, but the pain never did except temporary relief with analgesics. She visited several hospitals where she was told after an ultrasound that she had retained fetal bone in utero and had cervical dilatation and uterine evacuation for removal of the bone fragments but to no avail.

General and pelvic examination did not reveal any abnormality, but pelvic ultrasound suggested the presence of two highly echogenic objects in the uterine cavity. Hysterosalpingogram showed uterine synechia. Hysteroscopy revealed two retained/embedded fetal bones about 2.0 cm long [Figure 1], intrauterine adhesions, and stenosed cervical os. Hysteroscopic adhesiolysis and removal of the retained fetal bones with hysteroscopic forceps was performed. A size 10 Foleys catheter was inserted intrauterine and inflated with 3 mls of normal saline. She was placed on antibiotics for 10 days and continuous estrogen-progynova 2 mg twice daily for 6 weeks. The Foley catheter was removed 10 days later without complications.
Figure 1: Retained fetal bone removed from the uterine cavity

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The bone fragments were sent for histology. The histology result confirmed that the specimens included mature osseous tissue and bone marrow consistent with fetal bone. Two months after the hysteroscopy, her menstruation returned.


  Discussion Top


This case report illustrates one of the complications of second-trimester termination of pregnancy through D and C-retained fetal bones. Apart from the very high risk of excessive hemorrhage and uterine perforation, the evacuation of the uterus at such gestations is very likely to be complicated by retained products including fetal bones unless it is done under ultrasound guidance. Fetal bones can be retained freely in the endometrial cavity. On the other hand, they can be totally or partially embedded in the myometrium.[1],[3]

The usual symptoms of retained fetal bones are secondary amenorrhea, abnormal uterine bleeding, dysmenorrhea, dyspareunia, chronic pelvic pain, and secondary infertility.[4],[5] These symptoms were variously demonstrated by this case with the exception of the abnormal uterine bleeding and infertility. Furthermore, retained bones may be completely asymptomatic and discovered only during pelvic ultrasound scan as part of routine gynecological assessment as in the present case. A high index of suspicion must, therefore, be maintained for those patients who have a history of mid-trimester termination of pregnancy by D and C, in order not to miss the diagnosis.

The risk of amenorrhea depends on whether the retained piece of bone is embedded in the myometrium or lie freely in the endometrial cavity. There is some evidence that the presence of an intramural bony fragment per se does not seem to compromise menstruation if it is completely embedded.[3],[4] On the other hand, retained fetal bones lying freely in the endometrial cavity or those that are only partially embedded are associated with a high risk of amenorrhea. It is speculated that the presence of the bones may induce “uterine synechia” or act as an “Intra-Uterine Device” and thus prevent pregnancy.[5] It is also possible that the presence of bones near the fundal region (where blastocyst implantation frequently takes place) can lead to the elevation of endometrial prostaglandins (e.g., F2alpha) and thus impair implantation.[6],[7]

Apart from history and examination, imaging studies are very important in the diagnosis. Pelvic ultrasound scan, especially with the vaginal probe, is particularly reliable. Hysterosalpingogram is useful in outlining the endometrial cavity and in determining the state of the  Fallopian tube More Detailss, but its usefulness in the diagnosis of retained fetal bones is limited. In one series that consisted of 11 women with secondary infertility after mid-trimester abortions, hysterosalpingogram missed the diagnosis in 10 cases whereas transvaginal ultrasonography revealed the presence of intrauterine bones in all the 11 cases.[8],[9]

In our case, an HSG done before the hysteroscopy, for example, could not detect the presence of the bones. However, hysterosalpingogram, if done properly with a control film or under fluoroscopic guidance, should theoretically be able to reveal the retained fetal bones. After injecting the contrast, the bones may be covered and so may not be visible.

Hysteroscopy has both diagnostic and therapeutic values. Expectedly, hysteroscopy should be the most accurate diagnostic tool. Hysteroscopic removal of the bony pieces should be regarded as the gold standard of treatment since it enables a complete removal of the bones under direct vision. However, this service is unavailable in many centers in Nigeria. In the absence of hysteroscopy, blind dilatation and evacuation of the uterus, followed postoperatively by an ultrasound to confirm complete removal of the bony pieces, is fairly satisfactory. In such case, provided there are no additional complications such as endometrial synechiae, the chance of a resumption of normal menstruation is high.

Apart from retained intrauterine bones after second trimester D and C, endometrial calcified lesions and the presence of ectopic bones can also occur by metaplasia in association with chronic inflammation and tissue destruction, which are likely to be present after repeated spontaneous or therapeutic abortions.[10],[11]

This case also emphasizes the need for thorough history taking. In patients presenting with chronic pelvic pain, persistent vaginal discharge, and changes in menstruation subsequent to the termination of pregnancy retained intrauterine fetal bony or cartilaginous tissue should always be a part of the differential diagnosis. If transvaginal ultrasound indicates that such materials are present, then hysteroscopy should be undertaken to remove them.

Intrauterine fetal bone retention is a treatable cause of chronic pelvic pain. In the present case, the patient's fertility could not be evaluated because she was single and had not attempted to become pregnant again following the D and C.


  Conclusion Top


Hysteroscopic removal of retained intrauterine fetal bone is an effective treatment of chronic pelvic pain associated with this condition. It is suggested that retained fetal bones should be considered in the differential diagnosis of women presenting to gynecologic clinics with chronic pelvic pain and secondary amenorrhea when there is a history of mid-trimester termination of pregnancy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Goldberg JM, Roberts S. Restoration of fertility after hysteroscopic removal of intrauterine bone fragments. Obstet Gynecol 2008;112:470-2.  Back to cited text no. 1
    
2.
Lanzarone VF, Pardey JM. Retained intrauterine fetal bone as a rare cause of secondary infertility. Aust N Z J Obstet Gynaecol 2009;49:700-1.  Back to cited text no. 2
    
3.
Van den Bosch T, Van Schoubroeck D, Timmerman D, Deprest J. Uterine intramural bone after mid-trimester termination of pregnancy may not affect fertility: A case report. Ultrasound Obstet Gynecol 2003;22:407-8.  Back to cited text no. 3
    
4.
Verma U, Chong D, Perez I, Medina C. Fetal bones retained in the uterine cavity as a rare cause of chronic pelvic pain: A case report. J Reprod Med 2004;49:853-5.  Back to cited text no. 4
    
5.
Dawood MY, Jarrett JC 2nd. Prolonged intrauterine retention of fetal bones after abortion causing infertility. Am J Obstet Gynecol 1982;143:715-7.  Back to cited text no. 5
    
6.
Moon HS, Park YH, Kwon HY, Hong SH, Kim SK. Iatrogenic secondary infertility caused by residual intrauterine fetal bone after midtrimester abortion. Am J Obstet Gynecol 1997;176:369-70.  Back to cited text no. 6
    
7.
Acharya U, Pinion SB, Parkin DE, Hamilton MP. Osseous metaplasia of the endometrium treated by hysteroscopic resection. Br J Obstet Gynaecol 1993;100:391-2.  Back to cited text no. 7
    
8.
Louis LS, Kingman CE, Cochrane GW. Heterotopic intrauterine bone formation. J Obstet Gynaecol 2007;27:208-9.  Back to cited text no. 8
    
9.
Roth E, Taylor HB. Heterotopic cartilage in the uterus. Obstet Gynecol 1966;27:838-44.  Back to cited text no. 9
    
10.
Marcus SF, Bhattacharya J, Williams G, Brinsden P, Hamou J. Endometrial ossification: A cause of secondary infertility. Report of two cases. Am J Obstet Gynecol 1994;170:1381-3.  Back to cited text no. 10
    
11.
Samraj S, Crawford S, Singh N, Patel R, Rowen D. An unusual case of pelvic pain: Retention of fetal bone after abortion. Int J STD AIDS 2008;19:353-4.  Back to cited text no. 11
    


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