Abstract
Abstract
Introduction
Cases
Case 1
A 36-year-old para 0030 female was seen in our clinic for evaluation and management of infertility. Despite a regular menses and frequent intercourse with her partner, she was unable to conceive in 3 years. Her past medical history was significant for polycystic ovary syndrome (PCOS) and obesity. She had an elective termination of pregnancy in 1993, and two spontaneous abortions in 1995 and 1997. Although the patient reported a history of normal pap smears, she had a cone biopsy in 2001 for reasons that were unknown to her. The patient took 850 mg metformin PO twice daily for PCOS and 120 mg xenical PO three times daily for weight loss. There was no history of infertility in her family, and diethylstilbestrol was not used during her mother's pregnancy with her. On physical examination, she showed hirsutism, acne on her face, and acanthosis nigricans; the rest of her exam was non-contributory. All of her laboratory tests were within normal limits.
Hysterosalpingogram was attempted and not completed because of cervical stenosis. A thin natural laminaria tent was therefore placed to dilate the cervix for the hysterosalpingogram. A betadine packing was then placed in the vagina. The patient was instructed to abstain from sexual activity. She was given 250 mg zithromax PO twice daily for 1 day and once daily for 5 days. The next day, the patient was seen in the clinic, and the betadine packing was removed. All efforts to remove the laminaria failed; only 2.5 cm of it was retrieved, while the rest remained in the endocervical canal. A transvaginal sonogram was done to locate the remaining laminaria segment in the endocervical canal. The distance from the exocervix to the laminaria was measured and found to be 1.8 cm. The patient was then started on 500 mg flagyl PO twice per day. In the operating room, straight Rochester-Pean hysterectomy forceps (25.4 cm) were inserted into the endocervical canal and advanced approximately 1.8 cm. The forceps were then opened within the endocervical canal to break the scarred area without dislodging the retained segment. The forceps were maintained in the open position, advanced further, and used to grab and remove the laminaria from the cervical canal without fragmentation. The length of the retrieved piece was 4.5 cm. Concurrent use of sonography during the retrieval process was deemed unnecessary given the care taken to measure the distance from the exocervix to the laminaria prior to forceps insertion. The uterus was irrigated with normal saline. A hysteroscopy was then performed and demonstrated a normal uterus with no evidence of any more retained laminaria segments.
Case 2
A 28-year-old para 1021 female was seen in our clinic at 10 weeks gestation for elective termination of pregnancy. Preoperative evaluation revealed that the patient had no significant past medical history. Her obstetrical history was significant for two previous elective terminations of pregnancy in 2005 and 2008, and one cesarean section in 2007. She denied smoking and illicit drug use but reported occasional alcohol use. On physical examination, the patient was alert and oriented. Her vital signs were within normal limits. Cardiovascular, lung, abdominal, and extremity examinations were non-contributory. Preoperative labs revealed a hemoglobin of 12.2 g/dL, hematocrit of 36.7%, sodium of 135 mEq/L, total bilirubin of 1.1 mg/dL, and beta-HCG of 55,720.5 mIU/mL. All other laboratory tests were within normal limits. The patient was counseled on the risks and benefits of and alternatives to termination of pregnancy, and informed consent was obtained. The evening prior to the procedure one medium-sized natural laminaria tent was placed in the cervix.
The patient was taken to the operating room for a dilation of the endocervix and suction evacuation of the products of conception. Intraoperative evaluation revealed the following: a 12-week size, anteverted, and soft uterus; free bilateral adnexa; and a firm, closed cervix with a laminaria tent in place. Attempts to remove the laminaria resulted in its fragmentation. Initial attempts to retrieve the retained laminaria fragment via suction were unsuccessful, and the fragment was inadvertently advanced into the uterine cavity. Despite this complication, the dilation and evacuation was completed, and oxytocin and methergine were administered. Dr. Muneyyirci was then consulted to advise on the best means of laminaria removal. The decision was made perform a hysteroscopy and irrigate the uterus with normal saline to identify the laminaria fragment. The laminaria was found transverse in the uterine fundus. Initial attempts to dislodge and remove the segment with the hysteroscope were unsuccessful. A resectoscope was then used to dissect the fragment in half to ease evacuation. This instrument was also used to rotate the laminaria fragments. Finally, a 12-mm straight suction curettage was used to assist the removal of the bifurcated segments from the uterine cavity. Two laminaria fragments, measuring 3.5 cm and 4 cm, were successfully retrieved. Given adequate visualization of the fragments with both the hysteroscope and resectoscope, the concurrent use of sonography was deemed unnecessary. A postoperative hysteroscopy revealed a clean, clear endometrium. The patient received broad-spectrum bacterial coverage. She reported minimal abdominal discomfort postoperatively, managed effectively with Percocet and Tylenol. Her postoperative course was uncomplicated, and she recovered well.
Conclusions
Cervical dilation may be achieved using laminaria, synthetic dilators, misoprostol, or rigid dilators. Laminaria has been found effective in achieving preoperative cervical dilation and further operative dilatation. 7 These segments also decrease the risk for cervical injury and uterine perforation.7,8 Such benefits, however, must be weighed against the extremely rarely occurring complications associated with laminaria use, including fragmentation or retention in the uterine cavity, toxic shock syndrome, pelvic inflammatory disease, and hypersensitivity reactions. 6
Prior manipulation of the cervix and subsequent scarring of the endocervical canal may increase the risk for difficult laminaria removal. Our first patient reported a history of one termination of pregnancy and one cone biopsy, while our second patient reported a history of two terminations of pregnancy and one cesarean section. These procedures may have caused scarring of the endocervical canal. The scarred region of the cervical canal most likely compressed the central portion of the laminaria, causing the distal free ends of the laminaria to expand within the more elastic, unscarred endocervical canal. The overall effect of this process resulted in “dumbelling” of the laminaria or the “hourglass effect.”3,6
Since laminaria retention is associated with severe consequences, immediate evacuation of these segments from the uterus should be pursued. Laminaria retention in the endocervical canal was successfully managed with sonography for visualization and forceps retrieval. Forceps also proved effective in breaking the regions of endocervical scaring.
Care should be taken when extracting the segment from the canal to prevent its advancement into the uterine cavity, as spontaneous passage of these segments seems unlikely.3,9 While this event occurred in our second case, the laminaria segment was visualized after hysteroscopy and normal saline irrigation, and was successfully retrieved after dissection and suction. This approach not only provided a minimally invasive means of laminaria removal but was also associated with fewer postoperative complications than the alternative, hysterotomy. 6 Furthermore, the hysteroscope may be superior to the sonogram in laminaria detection, particularly in cases where the laminaria has been advanced into the uterine cavity. As two published reports suggest, the sonogram is not be able to distinguish intrauterine laminaria from endometrial tissue or blood clots, increasing the risk of prolonged retention.3,10
This report is the first to describe the use of a resectoscope and suction combination in the evacuation of large laminaria segments from the uterine cavity. Further fragmentation of the laminaria was prevented by the maintenance of suction until the entire segment was removed.3,9 This technique also ensured that fragments not directly visualized were evacuated. A repeat hysteroscopy was performed to inspect the entire cavity, including the tubal ostia, as the literature recommended. 3 Such vigilance may have accounted for our patients' uncomplicated postoperative courses.
The successful management of our cases suggests that sonography plus forceps removal or hysteroscopy plus resectoscope and suction removal provide alternative modes of management in cases of endocervical and uterine cavity laminaria retention respectively.
Footnotes
Acknowledgments
The authors would like to acknowledge Jessie Walsh for helping in the preparation of the manuscript.
Disclosure Statement
No competing financial interests exist.