Ultrasound-guided hysteroscopic uterine evacuation in cases of missed abortion

To describe the hysteroscopic, ultrasound-guided removal of missed abortion products of conception, emphasizing identification and resection of the different layers, visualization of the embryo and yolk sac, and maternal contamination-free direct sampling of the embryo and trophoblast.

Illustration of a step-by-step innovative ultrasound-guided surgical technique for uterine evacuation during optically directed embryo and trophoblast biopsy.

Women with missed abortion, with or without a history of infertility or recurrent pregnancy loss. The 7 patients included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, and scientific literature websites.

Missed abortion was diagnosed by transvaginal ultrasound confirming loss of fetal heartbeat. After informed consent, the patient was brought to the operating room. Under deep sedation, a 5-mm hysteroscope was inserted transcervically, and the uterine cavity was distended with normal saline (80-100 mm Hg). The implantation site was identified by direct visualization and transabdominal ultrasound. The gestational sac was opened with hysteroscopic scissors, and the extracoelomic cavity was entered. The yolk sac and embryo were visualized and evaluated. Embryo and chorionic villi sampling were performed with hysteroscopic forceps. After removal of the embryo, resection of the gestational sac was accomplished with hysteroscopic forceps and scissors.

Step-by-step educational video.

Optically identified embryonic and trophoblastic tissue and the corresponding cytogenetic result were obtained in all cases, without maternal cell contamination. There were no intraoperative complications. Patients' follow-up revealed no cases of retained products of conception or intrauterine adhesions. All patients who attempted pregnancy were successful, without complications.

Ultrasound-guided hysteroscopic removal of a missed abortion is noninvasive and potentially safer than conventional surgical techniques. It allows comparison of trophoblastic vs. embryo biopsy and resolution of, for example, mosaicism in placental pole preimplantation embryo biopsies. A potential disadvantage is the relative complexity of the procedure compared with routine dilation and curettage (1-5).