Author
Information
Puri J *, Gupta AS
(* Second Year
Resident, ** Professor, Department of Obstetrics and Gynecology, Seth GS Medical College & KEM
Hospital , Mumbai , India
Abstract
Intra Uterine Contraceptive Device (IUCD)
is most commonly used for long-term contraception. Long-standing in utero Copper
T has been found to cause endometrial changes, abnormal uterine bleeding (AUB),
complications like perforation, migration into peritoneal cavity and resultant
pelvic infections. Our patient is a case of menorrhagia, which when examined,
was found to have a nude IUCD, forgotten in utero for 22 years.
Introduction
Intra Uterine Contraceptive Device is the
most common method of reversible contraception worldwide. An estimated 150 million
women use IUCDs worldwide. It is the second most common method of contraception
after female sterilization. Government of India advocated the use of
Cu-T-200B for 4 years during the time period of 1975 to 2002. Cu-T-200B should
either be replaced or removed not later than 4 years from the date of
insertion. Cu-T-380A is being supplied in the Indian states and Union Territories
Case
Report
A 48 year old female, gravida 4, para 4,
living 4, had come to the gynecology outpatient department (OPD) with a complaint
of menorrhagia for the last 6 cycles. On obtaining history, patient gave the
history of having an Intra Uterine Contraceptive Device (IUCD) inserted after
her last childbirth about 22 years back. She had developed similar complaints
of menorrhagia one year after the IUCD insertion. She had gone to a private
practitioner who removed the IUCD. However, on redirect questioning it was
found that the IUCD was not shown to the patient after its removal. The
complaints of the patient had subsided. The patient also gave a history of not
using any contraception after the Copper-T was removed. It was after 22 years that
patient had developed symptoms of menorrhagia again, six months back, when she
had gone to a private practitioner again, who started her on Tab.
Norethisterone. She took the medication for about two months and then stopped
taking it on her own. She relapsed with menorrhagia, for which she came to our
Gynecology OPD. On examination, her abdomen was soft, without any guarding,
tenderness or rigidity. On speculum examination bleeding through cervical os
was present, black colored threads were seen coming through the cervical os. The
cervix and vagina were healthy. On bimanual pelvic examination, a normal sized,
anteverted, mobile, nontender uterus was palpated, there was no forniceal
masses or tenderness. The vagina and the cervix were then swabbed with Povidone-Iodine
and the threads were pulled with a sterile straight hemostat. There was no
resistance, and painless extraction of an IUCD was done. There was a forgotten
intrauterine IUCD in the patient for 22 years, which looked like as is shown in
Figure 1.
Figure 1:
Nude Copper-T 200B.
There was no copper left on the
polyethylene base of the Copper-T. The patient was shown the retained IUCD. The
patient was admitted in the ward for injectable Tranexemic acid therapy. Her Hb
was 6.6 g/dl. She improved symptomatically after Inj. Tranexemic acid IV
therapy and was discharged on Tab. Ferrous Sulphate 200 mg tds. She did not have
any menorrhagia subsequently.
Discussion
In 1965, Lippes’ loop was introduced as
the IUCD, under National Family Welfare Programme. Copper T 200B was introduced
in 1975, which was replaced with Copper T 380A in 2002,[2] as Copper
T 380A was found more efficacious and safer for longer duration of use as
compared to Copper T 200B.[3] The fragmentation of copper was
reduced because of addition of Silver in Copper T 380A without affecting its
dissolution. Our case is a patient of forgotten IUCD for 22 years, which was
Copper T 200B, which was used around 22 years back. Copper T 200B has 120 mg of
copper, wound around the vertical limb of the IUD in the form of a 0.25 mm
diameter copper wire. The exposed surface area of copper is 200 mm2.
The copper from the IUD is released at the rate of 50 mcg per day. The copper
in the IUCD should get dissolved in 6.57 years by that calculation.[4]
USFDA approved lifespan of Copper-T 200B is 4 years.[5] The patient
had not used any contraception even after the completion of days of use of the
Copper T 200B. Luckily the patient did not conceive even after expiration of
the usage time of Copper T 200B probably because of Copper absorption even
after the expiry date, as the amount of copper left could not be estimated, or
because of the copper T was acting as an inert IUD, and also contributory
factor of declining fertility in an aging woman. IUCD can cause complications
like menorrhagia, pelvic pain, pelvic infection, perforation of uterus and
hence translocation of IUD. Longstanding IUCDs have been reported to wander in
the peritoneal cavity into the Pouch Of Douglas, perforating rectum, appendix
and urinary bladder, causing bladder stones.[6] Long-standing IUDs
also cause endometrial changes. A study shows the endometrial changes like
interstitial hemorrhage in 72% of IUCD users versus 65% in control; glandular
hyperplasia in 6% and atrophy in 5% of IUCD users in the study was observed
with no incidence of either glandular hyperplasia or atrophy in the controls.[7]
Asynchronism between the cyclical phase and histologic phase of endometrium by
4 days in IUCD users was found to be 61%. This asynchronism is found to have
antifertility action in IUCD users. Hyperplasia is mostly found in women with
IUVDs inserted for more than 5 years.[5]
To ensure the acceptance of IUCDs as
method of contraception by many more women, health care providers should take
measures in satisfactorily counseling women about the procedure of insertion,
to encourage them to ask questions, and answer them. Regular follow-up data
sheet should be maintained. The patient should be called for regular follow-up
at 1st then 3rd month for the IUCD thread check[1]
and yearly thereafter, as the chances of expulsion are maximum during the first
year.[8] The patient should be shown the Copper T that was there
inside at the time of removal, when it’s removed, which in our case the patient
was not shown. Either the older Copper T was not removed or a fresh Copper T
was inserted for which a fresh consent was not obtained, either verbal or
written. Each time the patient comes up with a fresh complaint or before
starting her on a new treatment, she should be examined, unlike our patient who
was started on T. Norethisterone without examination. Examination would have
diagnosed the cause of her AUB. Such clinical practices should be condemned.
Luckily, in this case, the patient had no serious complications like
perforation of the uterus or any other vital organs.
References
- Chaturvedi GC,
IUCD Reference Manual for Medical Officers. Family Planning division, Ministry
of health and family Welfare. Government of
- World
Contraceptive Use- 2005, Director, Population Division, Department of Economic
and Social affairs. United Nations,
- Sharma RS,
Rajalakshmi M, Jeyraj DA, Current Status of Fertility Control Methods in
- Chaudhuri SK.
Practice of fertility control- A comprehensive approach. 7th ed.
- Nigam A, Biswas R, Mishra A. Misplaced Intrauterine Contraceptive Device: an enigma. Open Access Journal of Contraception. 2011; 2: 1-3
- Lee YB, Kim CS, Ro JY, Kwak HM, Song CH. Long term effects of IUD on Human Endometrium- Histologic, histochemical and ultrastructural studies. Yonsei Medical Journal. 1983; Volume 24 Number 2: 141-148
- Kaneshiro B, Aeby T. Long-term safety, efficacy, and patient acceptability of the intra-uterine Copper T- 380A contraceptive device. International Journal of Women’s health. 2010; 2: 211-220.
Citation
Puri J, Gupta AS.