Surgical abortions, including dilation and evacuation (D&E), are considered overall to be very safe [1]. Complication rates are low, ranging from 0.5–4.0%, and may include hemorrhage, infection, cervical lacerations, and uterine perforation. Uterine perforation is one of the most serious complications that can arise; however, recent studies show perforation rates only ranging from 0.2–0.8% [1]. Translocation of retained products of conception (RPOC) into the abdominal cavity is a rare but serious complication of uterine perforation. If abdominal translocation of RPOC occurs, initial transvaginal ultrasound may be sub-optimal in detecting this phenomenon, leading to increased morbidity and mortality for patients.

To our knowledge, only a few case reports have been published showing unrecognized RPOC translocating into the abdominal cavity [2],[3],[4]. Other reports have also described omental/bowel injury after a surgical abortion that was initially unrecognized [5],[6],[7]. In each of the cases listed, dedicated abdominal imaging was required to identify the pathology, and surgery was required for management in all cases.

In many reported cases, D&E procedures were performed in outpatient or clinic settings, where operative records were often unavailable. Although standard protocols exist to minimize the risk of RPOC (including thorough fetal tissue examination and optional ultrasound or digital assessment) [8], gaps in documentation and follow-up can hinder early recognition. According to a retrospective review of 184 cases, approximately 1% of second-trimester surgical abortions result in retained products [9]; however, the proportion that go unrecognized remains unclear and no systematic reviews have been done supporting this data. During a D&E, it is imperative that examination of the fetal tissue is completed to confirm evacuation of all contents. For any procedure above 14 weeks gestation, this includes identifying thorax, spine, calvarium, all four extremities, and placenta. If it is unclear, an ultrasound or digital exam of the uterine cavity is recommended for confirmation [8].

Here, we present a case of abdominal RPOC with possible mesenteric injury in the setting of persistent vaginal bleeding following initial D&E.

A 29-year-old G3P1112 elected to terminate an undesired pregnancy at approximately 17 weeks’ gestation. Her procedure was complicated by a vaginal hemorrhage for which she was transferred to an outside hospital. She was initially hypotensive with a blood pressure of 89/72 requiring administration of uterotonics and 1L of packed red blood cells. There was also concern for post-operative infection in the setting of tachycardia to the 130s, a white blood cell count of 22.1, and a tender abdomen. The patient was given ceftriaxone, doxycycline, and metronidazole. Initial transvaginal ultrasound did not show any RPOC, although there was a right ovarian complex cyst measuring 5.6 × 5.0 × 5.5 cm (Figure 1). She was hospitalized for six days in which her white blood cell count normalized to 10.9 and her vital signs were within normal limits. Her hemoglobin dropped from her baseline of 12.3 down to 7.0–8.0 during this admission and remained in this range until discharge. Her hospital course was also complicated by an incompatible blood transfusion and pneumonia.

Eight days later, the patient re-presented to an outside facility for fevers/chills and right lower quadrant abdominal pain. Her white blood cell count was still stable at 7.8 and her hemoglobin further dropped to 6.3, requiring an additional blood transfusion. Vital signs were stable. Initial computed tomography (CT) scan showed concern for a pulmonary embolism and showed an unusual bowel loop-like structure in the pelvis. Transvaginal ultrasound at this time redemonstrated a right adnexal complex cystic structure with posterior acoustic shadowing. A CT with contrast was then performed and noted that the aforementioned abnormal bowel loop was “not part of the gastrointestinal tract but instead appeared to be a collapsed fetal skull and the abnormal structure probably represented a fetal body with gas from necrosis” (Figure 2). She was then transferred to our facility for further surgical management.

Medical records from the clinic that performed the patient’s original procedure were unavailable. Due to the patient’s history of recent elective termination of pregnancy and right lower quadrant abdominal pain, and given her abdominal CT findings, intra-abdominal retained products of conception were suspected. A magnetic resonance imaging (MRI) study was then ordered to better evaluate the suspected diagnosis, however, could not be completed in time prior to the scheduled surgical procedure. Diagnostic laparoscopy revealed a 4 × 4-cm mass between the right anterior uterine fundus and anterior abdominal wall that was noted to have thick fibrinous walls with a surrounding inflammatory ring. Purulent gray-yellow thick fluid was evacuated. There was also a thin piece of tissue resembling fetal calvarium (Figure 3). A loop of sigmoid colon was densely adherent to this mass with an approximate 1-cm defect noted within the mesentery of the sigmoid colon, presumed to be a pre-existing sequela of the uterine perforation and instrumentation of previous D&E (Figure 4). General surgery was consulted intra-operatively and performed a rigid proctoscopy with air leak test that did not show air bubbles, supporting an intact bowel lumen. It was thus deemed unnecessary to repair the defect and the decision was made to observe the patient post-operatively. Chromopertubation was then performed and there was no leakage of methylene blue dye from the uterus (Figure 3). Pathologic examination of the mass revealed fetal tissue with degenerative changes.

The patient’s post-operative course was complicated by a post-operative fever on day three with a new cough in the setting of previously treated pneumonia. White blood cell count was 12.7 and presumed to be mildly elevated due to previous surgical procedure. She was initially on oral Augmentin and Flagyl and was transitioned to intravenous (IV) Zosyn and Flagyl to penetrate any remaining intra-abdominal infection. By post-operative day six, she was switched back to oral Augmentin and Flagyl and remained afebrile with normal vital signs, white blood cell counts, and hemoglobin trends. The patient was discharged home on post-operative day seven without further complication.

After a second trimester D&E, it is critical to confirm evacuation of all products of conception. Standard protocol includes a detailed examination of fetal tissue, and in cases of uncertainty, confirmation via ultrasound [8]. Initially, in this case, there was low suspicion for RPOC being the source of hemorrhage as the initial transvaginal ultrasound showed only a right adnexal complex structure, ruling out any intra-uterine retained product. We presume that visual inspection of all components of fetal tissue was not performed in the setting of emergent vaginal bleeding and immediate transfer to an outside hospital. This highlights the importance of adhering to standard protocol when performing a D&E. Other factors that can cause hemorrhage after a second trimester surgical abortion include uterine atony, abnormal placentation, mechanical injuries, and coagulopathies [10]. These pathologies became lower on the differential as bleeding was initially effectively managed with uterotonics at the outside facility.

In this case, obtaining advanced imaging earlier in the clinical course would likely have aided in the diagnosis sooner. Although we were unable to utilize MRI imaging, according to the literature, the most sensitive imaging modality for extrauterine RPOC is MRI. Magnetic resonance imaging of the abdomen is favored in complex gynecological/abdominal surgical cases because soft tissue contrast and multiplanar imaging capabilities allow for superior visualization of anatomy and extrauterine pathology. Magnetic resonance imaging is less susceptible to artifact caused by factors such as bowel gas and obesity when compared to ultrasound, and intra-operator variability in image quality is minimized [11]. Abdominal MRI should be considered when transvaginal ultrasound and CT imaging are unrevealing, especially when clinical suspicion is high.

Lastly, this case highlights the risk of bowel injury associated with second trimester D&E. Our patient fortunately did not have any sequela from this injury as the bowel lumen remained intact, but dense adhesions and a mesenteric defect suggested prior trauma. To our knowledge, no studies have critically evaluated the risk of bowel injury during a second trimester surgical abortion, though some case reports have described unrecognized omental/bowel injuries status-post surgical abortion [5],[6],[7]. We want to highlight that bowel injury is a risk and that certain factors put patients at higher risk. The level of physician training has been shown to be one of the most significant risk factors for uterine perforation and associated bowel injury. Unfortunately, in this case, we were unable to collect this specific information. Additional risk factors include advanced maternal age, retroverted uterus, history of prior uterine surgery including surgical abortions and cesarean sections, greater parity, history of previous cervical procedures (such a cold knife cone), failure to use ultrasound, and underestimation of gestational age [12]. Our patient was young with no prior surgical history and an anteverted uterus, and it is therefore difficult to ascertain why this mesenteric defect occurred. Though rare, clinicians should maintain high suspicion for bowel injury in patients presenting with gastrointestinal symptoms post-abortion, especially when uterine rupture and RPOC are being considered.

Ultimately, the decision to proceed with diagnostic laparoscopy with equivocal imaging and persistent symptoms is difficult. In the setting of persistent pain and fevers after a surgical abortion, regardless of a thorough workup, we propose that surgical management via diagnostic laparoscopy should always be considered, especially when clinic documentation of the procedure cannot be obtained.

This case demonstrates a rare but serious complication of a second trimester D&E—abdominal RPOC with suspected mesenteric injury secondary to uterine perforation. It demonstrates the importance of adhering to post-abortion guidelines, including thorough fetal tissue assessment, appropriate documentation, and clear interfacility communication. Magnetic resonance imaging should be considered when conventional imaging is inconclusive. Lastly, persistent abdominal or gastrointestinal symptoms post-abortion should prompt evaluation for uterine perforation and possible bowel injury, and diagnostic laparoscopy should not be delayed when clinical suspicion remains high.