Retained Intraabdominal Fetal Parts Following Dilation and Evacuation

Purpose: (1) Presentation of a case of uterine perforation and resultant abdominal extrusion of fetal parts following an elective second-trimester dilation and evacuation (D&E). (2) Investigation of potential complications of elective terminations and associated patient risk factors. (3) Discussion of early identification and management of uterine perforation with retained intraabdominal fetal parts using similar reported patient cases. Case: A 24-year-old G2P1011 presented to the emergency department (ED) with suprapubic abdominal pain and vaginal bleeding. This began two days prior, but only a few hours after she underwent an elective 15-week D&E. During evaluation in the ED, she had normal vitals, suprapubic tenderness without rebound or guarding, a moderate amount of dark blood in the vagina, and fingertip cervical dilation with no tissue at the os. Pertinent lab results included hemoglobin 10.6 g/dL and quantitative hcg 3,200 mIU/mL. Pelvic ultrasound revealed uterus 12.6 cm in size with 28 mm heterogenous endometrium. Outside of the uterus there was noted to be fetal spine present. A CT of the abdomen/pelvis showed a 15-week fetus present outside the uterus. She underwent an exploratory laparotomy, removal of fetal tissue, primary repair of a posterior uterine perforation, and suction dilation and curettage (D&C) of remaining placental tissue. According to the surgeon who performed the initial D&E, the only fetal tissue returned was an arm, foot, and amniotic fluid. The procedure was stopped due to difficulty with curettage passage through the cervix, and another dose of misoprostol was given with the plan to return for a second attempt upon further cervical ripening. During observation, however, the patient developed bleeding and cramping and passed a large clot in the bathroom. She was returned to the procedure room and ultrasound revealed an empty uterine cavity, so it was thought she had passed the fetus spontaneously and she was discharged. Following her exploratory laparotomy, the patient returned to the PACU in stable condition and had a routine post-op course with discharge on day 2. Discussion: According to the Center for Disease Control (CDC), about 600,000 legal induced abortions occurred in the US in 2021. This excludes intrauterine fetal death, early pregnancy loss, ectopic pregnancy, and retained products of conception. The majority of these are completed medically in the first trimester, with only approximately 5-6% occurring beyond the first trimester. First trimester surgical abortion is one of the safest surgical procedures performed in the US, with a total complication rate of around 2%. The most common side effects of surgical abortion are pain, post-procedural spotting, and infection. More serious complications include uterine atony and hemorrhage, uterine perforation, injury to adjacent organs, failed abortion, septic abortion, and disseminated intravascular coagulation (DIC). These risks increase with second-trimester surgical abortion, especially septic abortion and DIC. Second-trimester surgical abortion is safest when completed with cervical dilation and instrumental uterine evacuation (dilation and evacuation). Conflicting data exists regarding use of intra-operative ultrasound (US) guidance to reduce complication rates. Some studies have found that rates of uterine perforation are reduced with US guidance, while others have found that rates of infection and placental morbidity are increased. Further, studies suggest that US of the uterus is a poor predictor of retained products of conception. Overall, the rate of uterine perforation with second-trimester D&E is around 2%. The risk of uterine perforation increases with advanced gestational age, multiparity, retroverted uterus, and history of prior abortion or cesarean section. Rates of resulting intraabdominal fetal-part extrusion are 10 times less, around 0.2%. Still, cases of uterine perforation and extrusion of fetal parts following D&E have been reported. In general, these patients presented with abdominal pain and otherwise unremarkable physical exam and lab findings a few days following an elective second-trimester D&E. One of which was complicated by intraoperative hemorrhage and another retained products of conception requiring an additional pass. All patients initially underwent pelvic US imaging before CT or MRI was done to better characterize the extent of injury followed by exploratory laparotomy to repair the perforation and remove fetal tissue. Conclusion: Ultimately, uterine perforation and potential extrusion of fetal parts should be suspected in any women presenting a few days after elective abortion with abdominal pain or vaginal bleeding, regardless of physical exam or lab findings. Suspicion should be particularly high in those whose procedures were complicated by hemorrhage or retained products of conception, though it can occur in seemingly uncomplicated procedures too. Although ultrasound can be a sensitive and efficient initial imaging modality, follow-up imaging with CT or MRI can help better identify the location of retained fetal parts and the extent of uterine injury. Exploratory laparotomy is usually required to remove fetal tissue and repair the uterine defect, while further dilation and curettage may be necessary to remove remaining products of conception within the uterus.