Hysteroscopic removal of intrauterine retained fetal bones

Abstract

Fetus papyraceus is a well-recognized complication of missed abortion or intrauterine fetal death. However, prolonged intrauterine retention of parts of the fetal skeleton is not adequately reported in the literature. Prolonged retention of intrauterine bone is a recognized cause of secondary infertility. Literature regarding endometrial ossification contains more than 80 cases, with 80% occurring after pregnancy. Common symptoms include menorrhagia, menometrorraghia, pelvic pain and infertility. Several theories have been proposed to explain osseous tissue within the uterine cavity. The most widely accepted is that ossification represents retained fetal bones following spontaneous, missed, incomplete or therapeutic abortion, suggesting that the fetus achieved at least 12 weeks gestation in order for endochondral ossification to occur. In contemporary gynecology, transvaginal sonographic diagnosis of retained fetal bones is made and the bones removed with the help of a resectoscope. Hysteroscopy is invaluable in achieving a cure for these patients without resorting to more aggressive surgery. Gonadotropin-releasing hormone analogues (GnRHa) have many new uses in gynecology. Several clinical studies have demonstrated a mean decrease in uterine volume after about 3-6 months of therapy. These patients might be candidates for GnRHa therapy so that a smaller corpus with an atrophic endometrium might aid in hysteroscopic retrieval of the retained bony fragments.

Intrauterine bony fragments - An unexpected finding in the hysterectomy specimen

“…In all these studies and many other single case reports, [5][6][7] most of the females presented with infertility and had a history of prior abortion. Other cases presented with pelvic pain, vaginal discharge and, abnormal uterine bleeding.…”

“…Published literature shows that it is treatable by non-invasive hysteroscopy. 3,6,13 In the present case, the hysterectomy was performed because the female had completed childbearing.…”

Role of hysteroscopy in evaluating chronic pelvic pain

“…Moreover, office hysteroscopy may play a primary role in the resolution of many causes of CPP, such as M€ ullerian anomalies (28,62), intrauterine bone structures (34,35,40,(42)(43)(44)(45), endocervical ossification (46), and intrauterine abnormalities (51,52,62).…”

“…Retained bone fragments are displaced on an ultrasound as bright echogenic areas with posterior shadowing. Hysteroscopy has been demonstrated to be effective for confirming the diagnosis and achieving the successful removal of fetal bones (35,(42)(43)(44), either with a resectoscope or with grasping forceps inserted through the operative channel of a hysteroscope (34,40,45).…”

Endometrial Ossification: An Unusual Cause of Heavy Menstrual Bleeding (HMB)

“…It is important to take a detailed past history and obstetric history and keep in mind this diagnosis while evaluating a pelvic sonogram [6,7].…”