Aberrant oviduct pathway following vacuum aspiration: A case report and literature review.

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Intrauterine vacuum aspiration is a routine procedure that can be complicated by uterine perforation and abdomino-pelvic organ incarceration. This case report emphasizes, that even if rare, fallopian tube incarceration should be part of the differential diagnosis of thickened endometrium with or without AUB, in cases of history of vacuum aspiration.

The prevalence of abdominopelvic organ involvement during vacuum curettage is difficult to estimate as it is a rare occurrence that could go unrecognized. Intrauterine oviduct incarceration is a rare complication that can occur after procedures such as vacuum curettage, often performed for miscarriages, abortion or trophoblast remnants. In one case report, a patient experienced chronic abdominal pain after a first-trimester pregnancy abortion which required dilatation and vacuum aspiration. Both imaging and hysteroscopy combined to peroperative laparoscopy revealed the right fallopian tube had been iatrogenically pulled through the myometrium at the uterine fundus, resulting in its incarceration [ 2 ]. The patient had to undergo surgery to extract the fallopian tube from its fundal insertion site. In another case report, the diagnostic hysteroscopy was possible and showed indeed fallopian tube fimbriae within the uterine cavity [ 4 ]. Fallopian tube incarceration remains a difficult diagnosis. In a case report published in 2011, suction curettage in the puerperium resulted in an oviduct incarceration misdiagnosed as placental residue [ 3 ]. While pelvic ultrasound, when used alongside magnetic resonance imaging (MRI), can help clarify ambiguous cases, this type of complication can still go unrecognized. As shown in a case report published in 2018, fallopian tube incarceration was misidentified by MRI as a hydrosalpinx with a fimbriae lesion and an endometriotic nodule [ 5 ]. Typically, hysteroscopy and laparoscopy are the primary diagnostic tools, with ultimate confirmation provided by a pathology report. Conversely, uterine perforation also may contain bowels or the omentum as reported by Xholli and colleagues [ 6 ], who published a diagnostic and therapeutic guide for omental incarcerations. Such cases highlight that most postcurettage perforations go unnoticed, as the clinical manifestations related to fallopian tube or omental incarceration are nonspecific. While there is no proof that ultrasound-assisted curettage could diminish this type of complication, peroperative ultrasound guidance could be a valuable tool when available. If organ incarceration occurs, surgery is required to remove the entrapped organ and repair the uterine wall.

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The incidence of uterine perforation after dilatation and curettage is less than 0.2% [ 1 ] . Subsequent complications of the vacuum aspiration leading to incarceration of an oviduct into the uterine cavity are rare and are limited to a few case reports [ [2] , [3] , [4] , [5] ]. We describe the case of an intrauterine fallopian tube incarceration found 4 years after the initial uterine perforation. A 40-year-old woman presenting symptoms of abnormal uterine bleeding (AUB) since a few months, was referred to our Fertility Clinic for secondary infertility lasting 1 year. The patient was gravida 1 para 1, she delivered vaginally 4 years ago. The patient experienced placental retention, which required an emergency vacuum curettage to remove residual trophoblastic material. She had no reports of chronic pelvic pain nor dysmenorrhea. Upon physical examination, the abdomen was nontender and painless, the gynecologic examination was painless as well, and no obvious bleeding was observed during the speculum exam. Transvaginal ultrasound showed a hyperechogenic thickened endometrial lining (doppler score 2) suggesting at first sight the presence of an isthmic endometrial polyp of 13 millimeters ( Figs. 1A and B ). Fundal lesions were also seen, suspicious of adenomyosis and intrauterine adhesions ( Fig. 1 , Fig. 1 ). Fig. 1 Pelvic ultrasound during initial evaluation. Fig 1: Pelvic ultrasound during initial evaluation. Both assessments of saline infusion sonohysterography (SIS) and diagnostic hysteroscopy failed due a stenosis of the cervical orifice. Thus, a pelvic magnetic resonance imaging (MRI) was performed which concluded to an endometrial polyp associated with a nodular subserosa fundic mass in communication with the uterine cavity, as well as a left hematosalpinx and suspicion of endometriotic lesions ( Figs. 2A and B ). Fig. 2 Magnetic resonance imaging during initial evaluation. Fig 2: Magnetic resonance imaging during initial evaluation. The MRI protocol was subsequently discussed in a multidisciplinary meeting with fertility specialists and pelvic gynecology surgeons. As a result, an operative hysteroscopy for polyp excision and a concomitant laparoscopy for suspected hematosalpinx and endometriotic lesions were scheduled. The first step of the surgery was the operative hysteroscopy to identify and remove intracavitary lesions. Upon hysteroscope introduction, uterine cavity distention was impossible as the cavity shared multiple uterine adhesions evoking Asherman syndrome. While removing adhesions, parts of abdominal fat were visualized suggestive of uterine perforation. Per operative ultrasound also showed saline leak towards the abdominal cavity. Secondly, a laparoscopy was performed to identify the site of uterine perforation. Pelvic inspection showed an incarcerated right fallopian tube into the myometrial wall continuing into the uterine cavity ( Figs. 3 A and B). The incarcerated oviduct was removed ( Figs. 3 C and D), and bilateral salpingectomy was performed, due to the presence of a left hematosalpinx. No signs of endometriotic lesions were found during the laparoscopic inspection. The uterine wall defect was sutured using Vicryl 0 absorbable sutures. Finally, uterine wall integrity was confirmed by hysteroscopy. Fig. 3 Laparoscopic findings and oviduct extraction. Fig 3: Laparoscopic findings and oviduct extraction. To summarize, both operative hysteroscopy and subsequent laparoscopy confirmed fallopian tube incarceration into the uterine cavity. Pathologic findings revealed chronic salpingitis lesions in the right oviduct and hydrosalpinx in the left oviduct. A 6-week postoperative diagnostic hysteroscopy showed normal endometrial lining as well as a small fundal septum ( Fig. 4 ). Fig. 4 The 6-week postoperative diagnostic hysteroscopy. Fig 4: The 6-week postoperative diagnostic hysteroscopy.