Chronic Pelvic Pain and Infertility Resulting from Unrecognized Retained Laminaria

Abstract

Background In 2013, the abortion rate in the United States was found to be 200 abortions per 1,000 live births. Of these, the CDC estimates that nearly 49% were performed using unsafe measures. Even when these procedures are safely performed, patients are at risk for immediate or delayed complications. In second-trimester terminations, mechanical dilation with an osmotic dilator is common to allow for delivery of the fetus. The Japanese seaweed Laminaria japonica is used to achieve this purpose. Case A 28-year-old primigravida presented with chronic pelvic pain and infertility. She had irregular menstrual cycles and reported scant yellow discharge. A transvaginal ultrasound revealed an abnormally appearing endometrium with an elongated structure suspicious for a foreign body. The patient reported a voluntary termination of pregnancy twelve years earlier, for which laminaria were placed prior to the dilation and extraction. She underwent an operative hysteroscopy confirming our suspicion for retained laminaria. The pathology report demonstrated chronic severe endometritis and plant based material. Conclusion Retained laminaria are associated with chronic pelvic pain and chronic infertility. Since they can be difficult to detect on conventional imaging, proper counting prior to insertion and after removal is an essential physician responsibility.

Spontaneous Pregnancy After the Removal of Long-Term Retained Laminaria

“…Laminaria becomes larger with moisture and dumbbell-like in the uterine cervix, which can cause resistance to removal. The laminaria may then break off and remain in the uterine cavity [ 2 - 4 ]. When fragments of laminaria remain in the uterine cavity, it is very difficult to detect and remove them due to their small size and their severe adhesion to scarred endometrium [ 4 ].…”

“…Although dilator complications, such as impaction, displacement, and infection, have been reported, the long-term retention of laminaria tents seems to be quite rare [ 1 ]. Undetected long-term laminaria retention may cause complications such as menstrual abnormalities, dysmenorrhea, endometritis, and infertility [ 2 , 3 ]. When fragments of laminaria remain in the uterine cavity, it is very difficult to detect and remove them due to their small size and their severe adhesion with scarred endometrium [ 3 , 4 ].…”

Hysteroscopic removal of intrauterine-retained suture material causing pelvic inflammatory disease

“…The hysteroscopic examination of the patient revealed a retained intrauterine laminaria, and the patient was entirely cured after hysteroscopic removal of the material. [ 8 ]…”

Management of Postabortion Complications for the Emergency Medicine Clinician

“…60 In the few case reports of retained dilators, the patient presentations involved pelvic pain and vaginal discharge, with the retained foreign object visualized on imaging studies and requiring surgical removal. 61,62 Amniotic Fluid Embolism Amniotic fluid embolism after induced abortion has been reported rarely and occurs because of an abnormal maternal inflammatory response after exposure to fetal tissue. 63,64 The most common symptoms include hypotension, acute dyspnea, desaturation, pulmonary edema, cardiovascular collapse, and coagulopathy.…”