Introduction
Foreign bodies in the uterus can be presented in any female age group. It may be placed accidentally or iatrogenic.1 It may present as bleeding, copious foul smelling vaginal discharge and pain in the lower abdomen. It can lead to complications such as pelvic inflammatory disease, infertility, necrosis with fistula formation and vaginal stenosis.2 In cases of non-significant pelvis examination, imaging with X-ray and/or pelvic ultrasonography may be performed. 3 In some patients with deeply impacted foreign bodies not amenable to diagnosis by other modalities, 3D multiplanar CT scans may be necessary to reach the clinical diagnosis.4 Our aim is to report a rare case foreign body in uterus with primary infertility.
Case Report
A 25-year-old female visited department of Obstetrics & Gynecology at Career Institute of Medical Sciences & Hospital, Lucknow in October 2024. She is a housewife by profession and belongs to lower socioeconomic class. She is residing in Muttakipur, Lucknow after marriage. She has been married for 6 years.
She came to OPD with chief complaint of unable to conceive since past 5 years. On further elaboration she told she took treatment for infertility from some local doctor/quack. As per the patient, for initial 3 years she was given oral tablets for conceiving but she did not conceive. According to her all her investigations were done and was normal but no documentation was available at the time she visited our OPD. Later, she put into picture that, she was given per vaginal tablets / instrumentation was done by the doctor every month. She was not sure of proper instrumentation or vaginal tablets but she said doctor used to put something per vagina.
Upon further investigating at our hospital for primary infertility, ultrasonography was advised which revealed hyperechoic structure with posterior acoustic shadowing in uterus. Further on X-Ray we found a V-shaped radio-opaque shadow in pelvis, most likely a foreign body (Figure 1). Then she was planned for Hysteroscopy. After her Pre-Anaesthetic Checkup, she was taken up for hysteroscopy October 2024. In the OT patient was laid in lithotomy position after giving spinal anaesthesia. Bladder was emptied. Parts were painted, draped and cleaned. Further Sims Speculum was used to retract posterior vaginal wall. Anterior Vaginal Wall Retractor was used to retract anterior vaginal wall. Anterior lip of cervix was held with Valsellum. Uterine sound & Hegar’s Dilator was used to dilate the os. Hysteroscope was inserted and metallic nail was visualized (Figure 2 ). Nail was too big to be grasped by hysteroscope. Then by using C-ARM foreign metallic nail with hook was visualized (Figure 3). It was pulled by Artery Forceps but could not be removed as there was bent and a broad width of the metallic nail. Therefore, after pulling it down incision was given on anterior lip of cervix of about 3 cm at 2 o clock position (Figure 4, Figure 5). Metallic nail of 6-7 cm length which was bent at 4-5 cm, width 3-4cm was removed (Figure 6). Cervical incision was repaired by Vicryl 2-0 continuous interlocking sutures (Figure 7). Cervical os patency was checked. Hemostasis achieved. Packing done by gauze, betadine and soframycin. Patient withstood the procedure well and was shifted to Gynecology ICU for further management.
Post procedure
Her pack was removed after 4 hours. There was no active bleeding. She was started on Antibiotics and Anti-inflammatory medications. After 3 days of admission she was discharged on 4th day with clear indications for regular checkups and measuring cervical length in future pregnancy to rule out risk of cervical incompetence. Patient was further counselled for the same and was guided to visit specialist for any illness. She was further guided for her future pregnancies about risk of cervical incompetence. As of now she was asked to use contraception for 3-6 months before planning to conceive. She was further advised to take Folic Acid tablets whenever she planned to conceive and also show her discharge ticket to whoever doctor she visits for planning pregnancy. As on discharge ticket we clearly mentioned about the cervical repair which can cause mid trimester abortions and complications in pregnancy.
Discussion
It was very unfortunate to see a metallic foreign body in uterus leading to complications in a young married woman. This was a rare case which was very shocking to see as it is very difficult to insert an object of such width in a nulliparous woman. It was a very atypical case of metallic nail foreign body which could have led to complications such as perforation during removal or patient might have landed in laparotomy or any other major complication could have happened. Foreign objects such as uterine sound, curette, catheter douche, canula, knitting needle, crochet hook, hair pin and bamboo sticks are introduced into the uterine cavity by quacks for abortion and treatment of menstrual irregularities.5 These objects when retained in the uterine cavity may become a nidus for infection. Cases have been reported where abortion sticks were not expelled along with abortus and lead to serious complications such as septicemia and death. A rare case in which patient placed straw in the uterine cavity to drain menstrual blood which perforated the uterine walls and entered abdomen causing pain and infection highlights the need for health education.6 Female infertility is a major public health problem and there is an urgent need to regulate all infertility clinics run by both qualified and unqualified practitioners to ensure the quality and affordability of services.7
Conclusion
Foreign body when comes in contact with uterine tissue illicit an inflammatory reaction leading to complications such as infertility. Patient may be unaware of its presence which leads to delay in treatment. Early detection and management increase the chances of reversal to normal condition. Patients with medical aids such as pessaries and intra-uterine devices should be vigilant and should come for proper follow up.
