Critical Care Obstetrics and Gynecology

Keywords

Case Report; Missing needle during episiotomy repair; Fishing for a needle; Complications of lost needle after suture of vaginal tear; Retained surgical needle in the perineum

Introduction

Episiotomy during vaginal delivery is a very common and simple surgical procedure; however, this simple procedure can have some uncommon but challenging complications [1]. One such complication is broken or missing needle during episiotomy or perineal tear repair. Removal of the needle could be an ordeal especially when patient is heavily bleeding. Not only excessive blood loss can lead to devastating consequences, leaving the foreign object behind has its own morbidity and medico-legal aspects [2]. Needle retrieval under fluoroscopy guidance can be a big help in such a dilemma reported below [3].

Case Report Narrative

A 33 years old Tunisian lady, primigravida, 38 weeks pregnant was admitted to our hospital on 11/1/2020 with the complaint of labor pain and spontaneous rupture of membranes.

The patient received epidural analgesia and had uneventful first stage of labor and was delivered by mid cavity forceps with episiotomy due to prolonged second stage. After the delivery of the baby and placenta, it was noted that the patient was profusely bleeding from the episiotomy site.

Uterus was well contracted. The suturing of the episiotomy started immediately. As the tissues were deep and bleeding was heavy, quick suturing was needed. During suturing, the thread snapped from the needle eye and needle got lost in the perineal tissues. The perineal area was explored but the needle could not be seen or felt. Estimated blood loss at that time was 1.2 liters.

The patient was immediately shifted to the operation room for better exploration of the tissues. The needle was not found despite thorough exploration. Portable X-Rays were done, and the needle was seen in the right Ischiorectal fossa. As the Patient was actively bleeding and had further lost 1.3 liters of blood in the OR, the second opinion from the second consultant on call was taken and both consultants agreed to suture the episiotomy to stop the bleeding and needle will be retrieved later.

Episiotomy was stitched in layers and hemostasis was secured. The patient lost a total of 2.5 liters blood and HB dropped from 11.4 to 7.9 and received 2 units of PRBCs in the OR.

The patient and family were debriefed about the incident and the plan. The patient was shifted to the recovery room on antibiotics and with a vaginal pack for 24 hours. The patient stayed stable during postoperative periods; the vaginal pack was removed after 24 hours. Pelvic USG showed no hematoma. She received 3 more units of PRBCs because of a low HB of 8.7.

MDT meeting was arranged on the same day involving Consultant Obstetrician, General surgery consultant, interventional radiologist consultant and anesthesia consultant. They all agreed that as the needle is not in close proximity of any vital structure or vessel and being curved in shape, chances of migration are also low, it’s better to let the wound heal and edema and inflammation to resolve.

The urgent intervention will only be done in case of abscess formation or severe pain otherwise needle retrieval will be tried after 6 weeks. The patient and family were debriefed about the plan. The patient was discharged in stable condition with weekly follow up.

The patient stayed symptom-free for the next 6 weeks and was re-admitted on 16/2/2020 for foreign body retrieval. A CT pelvis with contrast was done to localize the needle. The needle was present approx. 1.5 cm-2 cm infer medial to the right pubic ramus. Team of Intervention Radiologist and Obstetricians agreed to try percutaneous image guided retrieval and if not successful, then open tissue exploration will be done. Consent was taken. The needle was removed successfully in its intact form under the US and fluoroscopic guidance. The patient tolerated the procedure well and was discharged in stable condition on the same day.Patient was very satisfied with the care provided and happy to be able to get back to her normal routine despite the complexity of her situation (Figure 1).

Figure 1: X-ray imaging showing missing needle.

Discussion

Although the incidence of a lost needle or broken needle during episiotomy repair has been reported at 0.17% [4], there is not much literature available for this topic [5]. A review of the few case reports about the above-said complication showed that management varied according to the patient’s condition and available resources ranging from their immediate removal through a surgical incision to leaving the needle behind for safety reasons and retrieving it later. On one hand, finding a lost needle through tissue exploration in the deep perineal tissue especially when patient is actively bleeding can be a very stressful experience and has morbidity associated with long surgery time, blood loss, extended tissue exploration, prolonged hospital stays and slow recovery. On the other hand, leaving the needle behind can cause severe morbidity in the form of chronic pain, dyspareunia, infection, migration of needle to a vital organ or blood vessel, fistula formation and can also become a medico-legal issue. In this dilemma, involvement of interventional radiology can help us to avoid all these possible but undesirable outcomes by locating the needle with precision and removing it without lengthy and wide tissue exploration. [5]. The facilities not equipped with Interventional Radiology can transfer the patient after stabilizing to the hospitals offering image guided procedure rather than choosing extensive tissue exploration and prolong surgery.

Conclusion

Episiotomy could be a simple procedure but like all other surgical procedures, it is not completely risk-free and sometimes can have challenging complications. One of them is needle loss during episiotomy repair. The patient’s nurses and doctors should not try to deny, conceal, or underscore that the incidence has occurred. If needle retrieval is difficult due to heavy bleeding or deeper perineal tissue, trial of percutaneous image-guided retrieval can reduce the morbidity associated with open tissue exploration, prolonged surgery time; long hospital stays and slows recovery. Although, it needs the expertise of an interventional radiologist, it saves the patient from lengthy distress as well as the health professionals from the heavy cost of litigation.

This report will support previous case reports surrounding this topic to further reinforce the options of image guided retrievals involving lost surgical needles and will widen the circle of available options for the situations mentioned above.

Acknowledgements

The author Dr. Atef Elmatary managed the patient in immediate care. Both authors Dr. Atef Elmatary and Dr. Azra Kazmi collected and interpreted the results. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. The authors received no financial compensation for this case report.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the corresponding author of this case report.

References

1. Roychowdhury J, Samanta B (2008) Missing needle during episiotomy repair. Online J Health Allied Scs 6.
2. Ramakrishnan S (2019) Negligence alleged as broken needle removed from uterus. TNN.
3. Kleinpeter SJ, Kline RC, Finan MA (1997) Retained surgical needle in the perineum. Report of a case with a novel method of search and rescue. J Reprod Med 42: 303-305.
4. Hösli I, Tercanli S, Holzgreve W (2000) Complications of lost needle after suture of vaginal tear following delivery. Arch Gynecol Obstet 264: 159-161.
5. Thompson MO, Ojukwu O (2017) Fishing for a needle-missing suture needle during episiotomy repair. RCOG World Congress EP479.