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Case Report A Minimally Invasive Approach to an Iatrogenic Pelvic Mass

Margaret Mulvihill MD *, Nash Moawad MS, MD

Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL

a b s t r a c t
A case report describing an unusual complication following a 17-week elective termination of pregnancy in a pediatric patient that was managed laparoscopically. Key Words: Minimally invasive surgery, Laparoscopy, Pediatric, Elective termination of pregnancy, Retained products of conception, Pelvic mass


We present the case of a 14-year-old adolescent with a calcied pelvic mass, pelvic pain and abnormal uterine bleeding. The differential diagnosis of this clinical presentation, the work-up, and the minimally invasive management of this perplexing condition are addressed.


A 14-year-old adolescent presented to our Emergency Department (ED) for pelvic pain. Nine weeks earlier she underwent an elective termination of pregnancy at 17 weeks gestation by dilation and evacuation, at an outside facility. She had one other ED visit, to an outside facility, four weeks following her procedure, for evaluation of heavy menses and pelvic pain. Ultrasonography at that time suggested an ovarian dermoid cyst; germ cell tumor markers were subsequently ordered. She was discharged home with oral pain medication for presumed dysmenorrhea and advised to follow up with a gynecologist as an out-patient. When she presented to our ED ve weeks later she had pelvic pain of moderate intensity, vaginal bleeding consistent with menses, and a negative pregnancy test. Pelvic ultrasonography revealed a 4-cm round mass with rim-like calcication located anterior to the uterus. The bladder and both ovaries were visualized discrete from this mass. To further evaluate, a pelvic MRI was performed which demonstrated distortion and sharp angulation of the endometrial canal (Fig 1). The apex of the distorted canal centered on the anterior lower uterine segment and was contiguous with the 4-cm rounded mass located external and anterior to the uterus. The mass had tissue signal consistent with bone and soft tissue, with associated cystic material. Laboratory evaluation was notable for a normal quantitative b-hCG at 2 mIU/mL (normal !5 mIU/mL) and
The authors indicate no conicts of interest. * Address correspondence to: Margaret Mulvihill, MD, Obstetrics and Gynecology, Shands Hospital, Box 100294, Gainesville, FL 32610 E-mail address: (M. Mulvihill).

germ cell tumor markers included an elevated alpha fetoprotein at 60.4 ng/mL (normal 0.0e8.7 ng/mL). The clinical picture was concerning for a perforated uterus with retained products of conception suggestive of an extruded fetal head. Other considerations included an ovarian dermoid cyst, a calcied uterine broid or Tubo Ovarian Abscess (TOA). At the time of laparoscopy a large featureless, grayish mass was noted in the anterior cul-de-sac. The mass was encased in dense small bowel adhesions with associated inammatory brinous reactive tissue (Figs. 2, 3). It was adherent to a 4-cm defect in the lower uterine segment. We performed laparoscopic enterolysis, resection of the pelvic mass, repair of the lower uterine segment defect, over-sewing of the bowel serosa, diagnostic hysteroscopy, and cystoscopy. Pathologic examination of the mass revealed partially necrotic tissue with fragments of bone and immature cartilage consistent with retained products of conception. The patient was discharged home day of surgery and had an uneventful postoperative course.

Fig. 1. MRI Pelvis.

1083-3188/$ - see front matter 2012 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. doi:10.1016/j.jpag.2012.03.003


M. Mulvihill, N. Moawad / J Pediatr Adolesc Gynecol 25 (2012) e89ee91

Fig. 2. Initial operative ndings.


Almost 50% of pregnancies in the United States are unintended and half of these result in elective termination.1 One in seven of these abortions are performed on adolescents. While the vast majority of terminations occur in the rst trimester, 7% are performed at 14e20 weeks and 1% at O21 weeks.2 However, adolescents and non-white women are most likely to undergo abortion at O14 weeks. Potential barriers to earlier abortion include; expense, delay in recognition and conrmation of pregnancy, parental involvement laws, and lack of access to an abortion provider.3 Our case illustrates the challenges encountered with adolescent termination of pregnancy; our 14-year-old patient underwent a second trimester termination at an abortion clinic and developed a complication with a subsequent delayed presentation to the ED. There is a paucity of scientic research regarding complications and implications of elective abortion, specically in adolescents. A PubMed literature search for publications related to complications of elective abortion originating in the U.S. between 1991 and 2011 yielded only 21 relevant articles, three of which were specic to adolescents. Dilation and evacuation (D&E) procedures are the most common method of second trimester pregnancy

Fig. 3. Operative ndings following enterolysis

termination in the U.S.4 This procedure involves mechanically dilating the uterine cervix followed by evacuation of intrauterine contents. Studies comparing D&E to labor induction for cases of fetal anomalies or demise in the second trimester have demonstrated D&E to be signicantly safer and more effective than labor induction.5 Serious risks associated with termination of pregnancy, regardless of the method used, include uterine perforation, which may result in life threatening hemorrhage, and retained products of conception, with the risks approximating 0.6% and 1% respectively.6,7 Adolescents are at higher risk in comparison to adults because they are more likely to delay the abortion, to resort to unskilled persons to perform it, to use dangerous methods, and to present late when complications arise.8 Our patient underwent a dilation and evacuation (D&E) at a legal abortion clinic. We reviewed her outside records which documented an uncomplicated procedure with scant blood loss. The procedure was performed with ultrasonographic assistance; however, specic ultrasound ndings were not documented. She received methergine 0.2 mg 1 into the cervix and Cytotec orally and per rectum; the dose was not clearly documented. Her discharge medications included methergine and a 7-day course of metronidazole and doxycycline. The patient did not return for her 3-week post-operative visit. A number of measures can be taken to minimize procedure-related risks and this is especially important in the adolescent population. Two factors associated with a decreased risk of perforation during pregnancy termination are (1) performance by an experienced surgeon (inexperienced physicians have a 5.5-fold increase in perforations) and (2) use of preoperative cervical dilation with osmotic dilators.9 In addition, concurrent intraoperative ultrasonography should be arranged in cases of abnormal intrauterine contents (e.g., hydatidiform mole) or cervicouterine architecture (e.g., uterine anomaly, broids, cervical constriction). Routine use of intra-operative ultrasonography in adolescents undergoing second trimester surgical termination may be benecial but this has yet to be established. Minimally invasive techniques (MIS) to treat children and adolescents requiring surgery have increasingly become the standard of care.10 The feasibility and safety of a wide spectrum of laparoscopic procedures have been conrmed in numerous studies,11 and the evolution of advanced training and instrumentation, along with improved optical systems, has allowed surgeons to expand MIS to more complex procedures.12 Moreover, the advantages of laparoscopic procedures have been well documented and include decreased length of hospitalization, faster recovery times, decreased postoperative pain, reduced postoperative narcotic use, smaller incisions, and improved cosmetic results.11 The psychological impact of a laparotomy as compared to MIS, although difcult to assess, is of particular importance in the pediatric and adolescent population, where it is highly desirable to provide the least invasive approach, thereby minimizing the impact on their active lifestyle and their evolving body image. In the stable patient, such as ours, laparoscopy offers many benets; however, this option may not be as

M. Mulvihill, N. Moawad / J Pediatr Adolesc Gynecol 25 (2012) e89ee91


attractive in the hemodynamically unstable patient or when there is great concern for concomitant bowel injury. It is imperative that adolescents seeking medical care following an elective termination are considered at higher risk than an adult in a similar situation and are comprehensively evaluated with these considerations in mind. Clinical signs may be subtle; however, US and/or MRI imaging are useful diagnostic tools to evaluate for retained or extruded products of conception. When such a complication does arise, it is important to consider a minimally invasive approach where possible.
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3. Jones RK, Zolna MR, Henshaw SK, et al: Abortion in the United States: incidence and access to services, 2005. Perspect Sex Reprod Health 2008; 40:6 4. American College of Obstetricians and Gynecologists: Methods of midtrimester abortion. Washington (DC), ACOG Technical Bulletin #109, 1987 5. Bryant AG, Grimes DA, Garrett JM, et al: Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation. Obstet Gynecol 2011; 117:788 6. Grossman D, Blanchard K, Blumenthal P: Complications after second trimester surgical and medical abortion. Reprod Health Matters 2008; 16(31 Suppl):173 7. Wolman I, Gordon D, Yaron Y, et al: Transvaginal sonohysterography for the evaluation and treatment of retained products of conception. Gynecol Obstet Invest 2000; 50:73 8. Olukoya AA, Kaya A, Ferguson BJ, et al: Unsafe abortions in adolescents. Int J Gynaecol Obstet 2001; 75:137 9. Grimes DA, Schulz KF, Cates WJ Jr: Prevention of uterine perforation during curettage abortion. JAMA 1984; 251:2108 10. Broach AN, Mansuria SM, Sanlippo JS: Pediatric and adolescent gynecologic laparoscopy. Clin Obstet Gynecol 2009; 52:380 11. Mais V, Ajossa S, Piras B, et al: Treatment of nonendometriotic benign adnexal cysts: a randomized comparison of laparoscopy and laparotomy. Obstet Gynecol 1995; 86:770 12. Gargollo PC: Hidden incision endoscopic surgery: description of technique, parental satisfaction and applications. J Urol 2011; 185:1425