Emerg Radiol (2012) 19:477–481 DOI 10.1007/s10140-012-1040-5

CASE REPORT

Retained products of conception through a perforated uterine wall following elective abortion: a unique case report Sonya Bhole & Matthew Earl Harris & Christopher Lee Sistrom & Roger Yale Shifrin & Margaret Sonya Mulvihill & Nash Sayed Moawad

Received: 21 February 2012 / Accepted: 19 March 2012 / Published online: 11 April 2012 # Am Soc Emergency Radiol 2012

Case 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

S. Bhole (*) Department of Radiology, Northwestern University, 676 N. St. Clair St., Ste. 800, Chicago, IL 60611, USA e-mail: [email protected] M. E. Harris : C. L. Sistrom : R. Y. Shifrin Department of Radiology, University of Florida, 1600 Archer Road, Gainesville, FL 32601, USA M. S. Mulvihill : N. S. Moawad Department of Obstetrics and Gynecology, University of Florida, 1600 Archer Road, Gainesville, FL 32601, USA

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.

Discussion There is a notable lack of scientific research within the past 20 years in our country regarding the complications and implications of elective abortion, specifically in adolescents. A PubMed search for articles related to complications of elective abortion originating in the USA between 1991 and 2011 yielded only 21 relevant articles, only 3 of which were limited to adolescents. Compared with adults, adolescents

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Fig. 1 Transvaginal ultrasound image demonstrates a heterogeneous rounded mass with a hyperechoic rim (curved arrow) and more linear hyperechoic components which were found to represent a retained fetal head with cranial bones and fetal facial bones, respectively

have a higher complication rate after abortion secondary to the higher incidence of delaying the abortion, resorting to unskilled persons to perform it, use of dangerous methods, and later presentation when complications arise [1]. In our case, the patient underwent a relatively late term abortion and subsequently delayed presentation to the emergency department. Therefore, we advocate that adolescents who present with potential abortion complications should be considered at greater risk than an adult in a similar situation. Our case demonstrated uterine perforation with retained extrauterine POC after a second trimester elective abortion. Perforation of the uterus occurs with elective termination of pregnancy at a rate of 0.07 to 1.2 % [2] and can lead to lifethreatening hemorrhage and injury to surrounding organs [3]. Additional short-term complications include cervical or vaginal lacerations, sepsis, hemorrhage, perforation of the bowel, tetanus, pelvic infection, or abscess [1]. Fig. 2 Sagittal T1 post-contrast image demonstrates the uterus with a distorted endometrial canal (curved arrow) and the retained fetal head (straight arrow) through the uterine defect (thin arrow)

Retained POC complicate approximately 1 % of pregnancies, higher with electively terminated pregnancies [4]. This condition may present as abnormal uterine bleeding, dysmenorrhea, infertility, pelvic pain, or abdominal pain [4, 5]. Retained POC must be differentiated from gestational trophoblastic disease with β-hCG measurements and can mimic arteriovenous malformations due to their vascular nature [6]. In our case, gestational trophoblastic disease and arteriovenous malformations were excluded with a negative β-hCG and no findings to suggest vascularity on ultrasound Doppler images, respectively. Due to our findings of an extrauterine calcified mass, a dermoid tumor was considered in the differential. Differentiation among these diverse entities is important because treatment is vastly different between these entities, i.e., D&C vs. chemotherapy vs. embolization [4] vs. surgical excision.

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Fig. 3 Axial T1 post-contrast image demonstrates the retained fetal head (straight arrow) through a ruptured uterine wall (curved arrow)

The imaging workup of complications of elective termination of pregnancy should begin with ultrasound. Reported diagnostic accuracy of ultrasound for identification of POC is variable [4]. The medical literature has described very few cases of extrauterine retained POC; therefore, a description of these findings is limited. Sonographic findings of retained intrauterine POC include expanded endometrial tissue with heterogeneous echotexture. Focal areas of hyperechogenicity may represent placental calcifications or retained fetal parts in the case of pregnancy termination. Doppler imaging of retained placental tissue demonstrates low resistance arterial flow, differentiating it from endometritis [7, 8]. Complex endometrial fluid is frequently present with retained Fig. 4 Intraoperative picture following lysis of adhesions and partial resection demonstrates the retained fetal head (thin arrow) which ruptured through the uterine wall. The thick arrow denotes the uterine fundus. The curved arrow demonstrates suture material status post-repair of the uterine wall defect

POC, but this finding is neither sensitive nor specific [9]. Uterine rupture most commonly occurs in the anterior lower uterine segment and can be suggested on ultrasound as an extruded amniotic sac, myometrial or endometrial defect (Fig. 5), extrauterine pelvic hematoma, or hemoperitoneum [7], but is often occult [10]. If ultrasound findings are indeterminate, MRI can be helpful, especially in further evaluation of the uterus itself. MRI has many advantages over ultrasound including being less operator dependent and providing a larger field of view, thus offering a more comprehensive examination. Additionally, the MRI may be more comfortable than ultrasound in a patient presenting with abdominal and pelvic pain [11].

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Fig. 5 Transverse transvaginal ultrasound image demonstrates a defect in the hyperechoic endometrial canal (straight arrow) with the extruded retained products of conception (curved arrow)

Products of conception are most frequently seen as variably enhancing soft tissue lesions in the uterine cavity on MR. There are typically varying degrees of myometrial thinning and obliteration of the junctional zone. T1-weighted signal in retained POC is typically isointense to slightly hyperintense to uterine myometrium. T2-weighted sequences show heterogeneous signal abnormality (Fig. 6) [4]. MR is helpful to delineate uterine anatomy and abnormalities [4, 6]. The primary imaging finding which helps to diagnose a uterine rupture is disruption of the normal anatomic continuity of the uterine wall [12]. A uterine rupture should be able to be differentiated from normal myometrium on T2-weighted by wall signal abnormality and myometrial Fig. 6 Sagittal T2-weighted HASTE image again demonstrates the endometrial canal distortion (curved arrow) secondary to the uterine rupture (thin arrow). There is a heterogenous appearance of the retained fetal head on the T2-weighted images (thick arrow). Note is made of the cranial plates and fontanelles on this image. A T2-weighted hyperintense adnexal cyst is seen inferior to the retained products of conception on this image (line)

defect. T1-weighted images may be hyperintense if blood products are present. Following the administration of contrast, uterine rupture should be hypointense on T1-weighted sequences due to its avascular nature unless there is acute extravasation at the time of imaging or retained POC within the rupture, [13] as was seen in our case. In our case, the retained POC caused a traction deformity of the endometrial canal focused at the uterine rupture site, possibly due to adherent inflammatory tissue or mass effect on the uterine myometrium (Fig. 2). The World Health Organization estimates that approximately 47,000 women per year are estimated to die from complications of elective abortion [14], and adolescents find

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themselves at particular risk of complication [1]. Imaging of all symptomatic women who have undergone recent elective abortion should be performed with a sense of urgency, with these considerations in mind. It is important for radiologists as well as other providers and technicians performing ultrasounds to be familiar with imaging findings of potential complications of elective abortion so that definitive therapy can be enacted in a timely manner and further complications can be avoided.

Conclusion This case demonstrates the usefulness of ultrasound and MRI imaging in evaluating the cause of pelvic pain in patients who have undergone elective abortions. Understanding and identifying potential complications of elective abortion can help expedite care of these patients, particularly in adolescents who may be presenting later with symptoms than their adult counterparts. References 1. Olukoya AA, Kaya A, Ferguson BJ, AbouZahr C (2001) Unsafe abortions in adolescents. Int J Gynecol Obstet 75(2):137–147 2. Kohlenberg CF, Casper GR (1996) The use of intraoperative ultrasound in the management of a perforated uterus with retained products of conception. Aust New Zeal J Obstet Gynaecol 36:482– 484

481 3. Amarin ZO, Badria LF (2005) A survey of uterine perforation following dilatation and curettage or evacuation of retained products of conception. Arch Gynecol Obstet 271(3):203–206 4. Noonan JB, Fergus VC, Qayyum A et al (2003) MR imaging of retained products of conception. Am J Roentgenol 181:435–439 5. Sahinoglu Z, Kuyumcuoglu U (2003) An unusual case of postmenopausal vaginal bleeding: retention of fetal bone. Arch Gynecol Obstet 267:160–162 6. Leyendecker JR, Gorengaut V, Brown JJ (2004) MR imaging of maternal diseases of the abdomen and pelvis during pregnancy and the immediate postpartum period. Radiographics 24(5):1301–1316 7. Kaakaji Y, Nghiem HV, Nodell C, Winter TC (2000) Sonography of obstetric and gynecologic emergencies, part I, obstetric emergencies. Am J Roentgenol 174:641–649 8. Zuckrman J, Levine D, McNicholas MM et al (1997) Imaging of pelvic postpartum complications. Am J Roentgenol 168:663–668 9. Durfee SM, Frates MC, Luong A, Benson CB (2005) The sonographic and color Doppler features of retained products of conception. J Ultrasound Med 24(9):1181–1186 10. Kamaya A, Ro K, Benedetti NJ, Chang PL, Desser TS (2009) Imaging and diagnosis of postpartum complications: sonography and other imaging modalities. Ultrasound Q 25(3):151–162 11. Hruska KM, Coughlin BF, Coggins AA, Wiczyk HP (2006) MRI diagnosis of spontaneous uterine rupture of an unscarred uterus. Emerg Radiol 12(4):186–188 12. Blinder E, MacKenzie JD, Cranmer HH, Ledbetter S, Rybicki F (2003) Uterine rupture with peritonitis in a nongravid uterus 8 weeks after cesarean section. Emerg Radiol 10(1):57–59 13. Gakhal MS, Levy HM (2009) Sonographic diagnosis of extruded fetal parts from uterine perforation in the retroperitoneal pelvis after termination of intrauterine pregnancy that were occult on magnetic resonance imaging. J Ultrasound Med 28:1723–1727 14. Shah I, Ahman E (2010) Unsafe abortion in 2008: global and regional levels and trends. Reprod Health Matter 18(36):90– 101