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.

Tertiary-referral hospital.

A 36-year-old patient with a history of recent cervical dilation with suction evacuation using a Karman-cannula and subsequent curettage for a retained second-trimester miscarriage (two months earlier), presenting with abnormal foul-smelling vaginal discharge.

Transvaginal ultrasound revealed a linear hyperechoic double-track structure consistent with retained fetal spinal ossification centers ("railroad sign"). Office hysteroscopy was performed without any anesthesia or preoperative pain medication, with only verbal comunication and ongoing reassurance throughout the procedure ("vocal-local approach"). Retained fetal spinal fragments, embryonic remnants, along with early signs of endometritis were identified. Initial removal attempts using 5-Fr grasping forceps were unsuccessful. Extraction was achieved following radial cervical incisions of the internal os using radiofrequency electrical energy with a 5-Fr needle-tip electrode, enabling removal with a 5-Fr tenaculum. Residual fragments were completely cleared using a 6-mm Tissue Removal System with a dense tissue shaver. At the end of the procedure, the uterine cavity was empty. Endometrial preservation was maintained. The patient was discharged on the same day in stable condition and without complications.

Retained fetal bone fragments represent a clinically significant and likely underdiagnosed cause of secondary infertility and abnormal uterine symptoms [1-5]. Transvaginal ultrasound enables accurate diagnosis and selection of patients for successful office hysteroscopic management without anesthesia. Advances in hysteroscopic techniques and miniaturized instruments allow safe, complete, and fertility-preserving removal of retained fetal bone fragments. No complications related to radial cervical incisions have been observed in our clinical experience. 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.