Author Information
Supriya
Poonia*, Vibha More**, Shruti Panchbuddhe**, M. N. Satia
***
(*Third
Year Resident, ** Assistant Professor, *** Professor. Department
of Obstetrics and Gynecology, Seth GS Medical College and KEM
Hospital , Mumbai , India
Abstract
Intrauterine devices (IUD) are
amongst the most commonly used methods of contraception. Perforation of the
uterus and migration into the peritoneal cavity is one of its rare but serious complication. Here is a case with
IUD migration into recto-sigmoid mesentery with removal by laparotomy.
Introduction
IUD has been in vogue since 1965
for contraception.[1] Its
increase in use is due to their efficacy, easy reversibility, patient
satisfaction and minimal systemic side effects.[2, 3] Perforation occurs rarely with migration into
the organs intimately related to the uterus such as urinary bladder, rectum,
colon, peritoneum, ovary, appendix and wall of iliac veins. IUD is often the
method for lactating mothers as it does not affect the quality and composition
of milk. Removal of IUD may be done by hysteroscopy, laparoscopy or laparotomy.
Case
Report
A 26-year-old Para 2 Live issue 2
with previous cesarean section, six months postpartum was brought to emergency department
from peripheral maternity hospital with ultrasonography showing a misplaced copper –T in intraperitoneal cavity
on the right
side. Patient had copper T (Cu- T 380-A) inserted at peripheral hospital by an
auxiliary nurse midwife on day-5 of menses during lactation period. She complained of agonizing abdominal
pain. The threads were not felt the next day. Uterine
perforation was suspected and hence patient was referred to tertiary care center. Clinical examination revealed
stable vital parameters and a soft abdomen. Bowel sounds were present. On
speculum examination copper –T threads could not be seen. No tenderness was
elicited on
vaginal examination. Radiography with intrauterine sound showed IUD towards right side in the uterine cavity. Ultrasonography
of the abdomen and pelvis showed Copper-T in the right adnexa, close to the right ovary. In view of
discrepancy between X-Ray( lateral film was not available) and ultrasonography a computed tomography (CT) scan of the
abdomen and pelvis was done. It revealed the copper-T lying partially outside
the uterus in pouch of Douglas and one arm appeared embedded in the
uterine wall, abutting the
rectosigmoid colon. No air or free fluid was seen in the peritoneal cavity. A
hysteroscopy was performed, which did not any copper-T, but it was felt in the left uterine wall.
However, it could not be removed. In view of
suspected adhesions and bowel involvement exploratory laparotomy was done. Copper-T
was seen in pouch of Douglas on left
side embedded in mesentery of rectosigmoid colon It was removed and a small mesentery tear was sutured with polyglactin 910 no
2-0. Bowel was inspected. No
bowel injury was seen. A
small sealed 2 mm uterine perforation was seen on the fundus of uterus near
right cornua which was left untouched. Post procedure period was uneventful.
Patient was discharged
on the 7th postoperative day.
Figure 1. Anteroposterior radiograph
of abdomen and pelvis with uterine sound in situ. IUD is seen towards right side, probably in
the uterine cavity.
Figure 2. CT scan abdomen and
pelvis showing IUD (arrows) between uterus and rectosigmoid colon.
Figure 3. Copper-T (arrow) is seen lying in the recto
sigmoid mesentery on laparotomy.
Discussion
Since the
introduction in 1965, IUD is commonly used as effective, safe and economic
method of contraception. Incidence of migrated IUD is 0.5-1%/1000 IUD
insertions. [2] Incidence of misplaced
IUD is influenced by several factors such as parity, insertion time, previous
abortions, type and method(push out insertion technique) of insertion
technique, operator experience and position of uterus. IUD can be used in
lactating mothers as they do not effect milk composition. Thinning of uterine
wall due to hypoestrogenic state could be the cause of perforation as seen in
the lactation period. Sharp pain at the time of insertion, disappearance of IUD
thread and post procedure bleeding are suggestive of perforation
Perforation
may be complete where IUD migrate into peritoneal cavity or embed in nearby
structures or partial where part of it is retained in uterine cavity or wall.
Perforation mostly occurs during insertion especially owing to wrong push out
insertion technique. Less commonly perforation is due to chronic inflammatory
reaction caused by cytokines release, degradation of extracellular matrix by
matrix metalloproteinase resulting in gradual erosion of the uterine wall.
Translocated IUD induces a dense fibro elastic reaction necessitating a
laparotomy for its removal due to suspected adhesions.
Uterine
perforation by IUD may remain asymptomatic in 85% cases. It may present as
sharp pain at insertion time, disappearance of IUD at the time of
insertion, post coital bleeding.
Misplaced IUD may invade its neighboring
organs such as the adnexa, broad ligament, pouch of Douglas,
intestine(obstruction, stricture, adhesions), urinary bladder(vesical calculi),
peritoneum(omental mass or intraperitoneal bleed or abscess), appendix (
perforation mimicking appendicitis) rectum or recto-sigmoid mesentery as in our
case.[2,3,4,5,6,7] Often
these complications are due to faulty technique of IUD insertion which is push
out technique.
A plain
radiograph of the abdomen was previously the initial investigation of choice,
for verifying the presence of an IUD in the pelvis but now a days often
forgotten due to easy availability of
imaging modalities like ultrasound and CT scan. In our case only
anteroposterior X-Ray image was available and the lateral image was misplaced. So an ultrasound examination was done. It
shows the location of the IUD in
relation to the uterus without the need for an intrauterine sound which
is used to identify the uterine cavity in a radiograph.. CT Scan is indicated
when when there is discrepancy between
ultrasound and radiograph or when bowel involvement is suspected. In our case anteroposterior
radiograph was not sufficient to comment on IUD location and ultrasonography showed it to be lying
outside the uterus hence the need of the CT scan. Although X-Ray and
ultrasonography done revealed the copper-T on the right side; CT images and
direct visualization intraoperatively showed the IUD location on the left side. This can be due to
intraperitoneal migration of IUD which though rare is not uncommon. The
treatment of the misplaced IUCD is surgical, laparoscopy or laparotomy. In view
of suspected adhesions laparoscopic removal was not attempted and IUD was
removed by laparotomy. Withdrawal of the migrated IUD is advisable even if its
migration is asymptomatic, so that further complications like a bowel and
bladder perforation or a fistula formation may be prevented.[8]
References
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Citation
Poonia S, More V, Panchbuddhe S, Satia MN