Retained products of conception through a perforated uterine wall following elective abortion: a unique case report

Excerpt

A 14-year-old G1P0010 elected to terminate an undesired pregnancy at approximately 17 weeks gestation at a mobile clinic. Five weeks after termination, the patient experienced two heavy menses associated with significant pelvic pain necessitating an emergency room visit to an outside hospital. An ultrasound examination at the outside facility was obtained, and the patient was diagnosed with a calcified fibroid as the cause of pelvic pain. The patient then presented to our facility 8.5 weeks after termination with the chief complaint of ongoing pelvic pain. Medical records from the mobile clinic where the patient initially underwent an elective abortion were not available for review; therefore, details of the procedure were unknown. At our facility, the patient’s labs were notable for a normal quantitative β-hCG at 2 mlU/mL (normal, <3 mlU/mL) and elevated alpha fetoprotein at 60.4 ng/mL (normal, 0.0–8.7 ng/mL). The patient’s history of prior elective termination of pregnancy, extreme pelvic pain on physical examination, and persistently elevated alpha fetal protein were concerning for retained products of conception (POC). A repeat pelvic ultrasound at our institution revealed a 4-cm heterogeneous round mass with rim-like and linear calcifications suspicious for extrauterine retained POC (Fig. 1). An MRI was obtained to evaluate the integrity of the uterus. The MRI revealed distortion and sharp angulation of the endometrial canal (Fig. 2). The apex of the distorted canal centered at the anterior lower uterine segment leading to a 4-cm rounded mass external and anterior to the uterus (Fig. 3). These findings were consistent with a uterine perforation with extruded products of conception. The mass had tissue signal consistent with bone and soft tissue, with associated cystic material. The patient underwent laparoscopy for removal of the mass and uterine perforation repair. At the time of laparoscopy, a large featureless, grayish mass was noted in the anterior cul-de-sac, with inflammatory fibrinous reactive tissue, free serous fluid, and significant bowel adhesions. The mass was adherent to a 4-cm anterior uterine defect in the lower uterine segment (Fig. 4). Pathologic examination of the mass revealed partially necrotic tissue with fragments of bone and immature cartilage consistent with retained POC, particularly a retained fetal head. The patient recovered from the surgery without complications and was counseled on pregnancy prevention.

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