Hysteroscopic Removal of Retained Fetal Bone Fragments After Second-Trimester Miscarriage

To study the hysteroscopic management of retained fetal bone fragments as a cause of secondary infertility and abnormal uterine symptoms, and to illustrate a fertility-preserving, minimally invasive approach using modern hysteroscopic instrumentation.

Minimally invasive gynecology unit of a tertiary referral hospital.

A 36-year-old patient with a history of prior cesarean delivery and recent dilation and curettage for a retained second-trimester miscarriage (two months before), presenting with abnormal and foul-smelling vaginal discharge.

Diagnostic transvaginal ultrasound revealed a linear hyperechoic doubletrack structure consistent with retained fetal spinal ossification centers ("railroad sign"). Office hysteroscopy was performed without any anesthesia. Retained fetal spinal fragments and additional embryonic remnants were identified, along with early signs of endometritis. Initial removal attempts using 5-Fr grasping forceps were unsuccessful. Extraction was ultimately achieved following radial cervical incisions of the internal os using radiofrequency electrical energy with a 5-Fr needle-tip electrode enabling successful removal with a 5-Fr tenaculum. Residual fragments were completely cleared using a 6-mm Tissue Removal System with a Dense Tissue Shaver without complications or need for additional surgical approaches. At the conclusion of the procedure, the uterine cavity was empty, with no residual bone or fetal tissue visualized. Endometrial preservation was maintained throughout the intervention.

Retained fetal bone fragments, though rare, represent a clinically significant and likely underdiagnosed cause of secondary infertility and abnormal uterine symptoms1-5. Transvaginal ultrasound, particularly when characteristic signs are present, allows prompt diagnosis, while hysteroscopy remains the gold standard for definitive management. Advances in hysteroscopic techniques and miniaturized instruments now permit complete, safe, and fertility-preserving removal of retained fetal bone fragments. This video-report represents, to our knowledge, the first documented hysteroscopic video demonstration of this condition and highlights the pivotal role of minimally invasive hysteroscopic surgery in restoring uterine health and reproductive potential.