Hysteroscopic Removal of Retained Products of Conception Implanted Over a Focal Area of Adenomyosis: A Case Report

Abstract

Study objective: To describe a technique for hysteroscopic removal of retained products of conception (RPOC) implanted over an area of adenomyosis.

Design: A case report (Canadian Task Force classification III).

Setting: RPOC is an unfortunate complication that may occur after the resolution of a normal pregnancy; it is more common after early pregnancy termination or spontaneous miscarriage [1]. Immediate consequences of RPOC include persistent vaginal bleeding, abdominal pain, pelvic infection, fever, and dilated cervix. Moreover, known long-term complications include the formation of intrauterine adhesions (IUAs) with the potential creation of Asherman syndrome resulting in adverse reproductive outcomes caused by subfertility, chronic pelvic pain, menstrual disturbances, and severe pregnancy complications such as abnormal placentation including the placenta accreta spectrum [2,3]. A recently published American Association of Gynecologic Laparoscopists practice report on IUAs suggests that the surgical approach used to treat intrauterine pathology could have an impact with greater risk for IUA formation when blind versus procedures under direct visualization are performed [4].

Interventions: A 35-year-old patient who presented with persistent bleeding for over 5 weeks. The patient has a long history of dysmenorrhea and heavy menstrual bleeding. Magnetic resonance imaging revealed the presence of adenomyosis. She had an unfortunate spontaneous abortion at 8 weeks of gestation. On physical examination, she was found to have a dilated uterine cervix with persistent vaginal bleeding; there were no signs of infection. Pelvic ultrasound revealed an intrauterine hyperechogenic vascularized area of 2 × 2, 8 × 2 cm implanted over a focal area of adenomyosis, which is consistent with the presence of RPOC. With the aim of minimizing possible acute complications such as bleeding, infection, and uterine perforation, a hysteroscopic approach was taken to avoid performing a blind dilation and curettage. A secondary benefit of a hysteroscopic approach is a lower incidence of long-term complications such as IUAs and the consequent Asherman syndrome. We describe a hysteroscopic technique in which the use of electrosurgery is limited to minimize thermal damage of the endometrium, highlighting important tips and tricks of the procedure.

Conclusion: Hysteroscopic removal of RPOC is a feasible and safe management option of this complication of pregnancy. We strongly suggest avoiding performing blind procedures such as dilation and curettage and favor the adoption of this modality that allows the removal of retained products of conception under direct visualization.

Keywords: Adenomyosis; Hysteroscopy; Retained products of conception.