Author Information
Case Report
Figure 1. Copper IUCD surrounded with adhesions stuck to anterior abdominal wall.
Figure 2. Retrieving the copper IUCD after adhesiolysis.
Discussion
In most of the cases, uterine perforations are asymptomatic and hence are not recognized at the time of insertion.[4] Non operative management of a migrating IUD has been recommended in the past because of the morbidity associated with its removal. [4] But, a migrated IUCD can lead to pain, fibrosis, and adhesion formation and sometimes, may even result in penetration into adjacent organs like the urinary bladder, sigmoid colon, appendix, and small bowel. Perforation into the bowel is also a documented complication and can result in abscess formation, ischemia, or volvulus. Therefore, it has been advised that surgical exploration and IUD retrieval should be the primary therapeutic approach for patients with a misplaced IUCD. [4]
Literature suggests that Uterine perforation almost always occurs during insertion of IUCD. Its incidence is related to the timing of insertion, type of the device, the anatomy of the uterus and cervix, the skill of the person performing the insertion and other factors include soft uterine wall, a previous recent pregnancy or an abortion and the presence of a previous uterine scar, if any.[5] Secondary perforation of the uterus can occur by slow migration of the IUCD directly through the wall of the uterus, augmented by contractions of the uterus and urinary bladder.[6] Rarely, a migrated IUCD can be found in lower anterior abdominal wall.[7] The colon and the bladder are the adjacent structures of the uterus and a migrated IUCD is usually lodged in these structures. But as seen in this case, it is rare for an IUCD to avoid these adjacent structures and migrate into the lower anterior abdominal wall. Thus in our case, the bladder and the bowel were spared of any perforations, but adhesions were present engulfing the copper IUCD and attached to the anterior abdominal wall .A regular follow up for detection of misplaced IUCD is stressed as it can have an unusual presentation. Prevention is the best remedy; hence correct insertion by skilled surgeon is the required. Regular follow up should be made mandatory. If in doubt ultrasound or pelvic radiograph should be done. And an asymptomatic misplaced IUCD should be managed vigorously as delay can increase intraabdominal adhesions and make it difficult for its retrieval.
References
Shah NH, Paranjpe SH, Shah VN. Laparoscopic Retrieval Of Missing Copper Intrauterine Device Stuck To Anterior Abdominal Wall Presenting Along With 8 Weeks Of Pregnancy. JPGO 2015. Volume 3 No. 1. Available from: http://www.jpgo.org/2016/01/laparoscopic-retrieval-of-missing.html
Shah NH*, , Paranjpe SH**, Shah VN***.
(* Hon. Endosopic Surgeon Wadia Hospital & Railway Hospital (Byculla), ** Director: Velankar Hospital &Paranjpe Maternity Home, Chembur, *** Anesthesiologist, Mumbai, India.)
Abstract
IUCD is the second most common, safe and an effective method of contraception used for family planning. Various complications are listed and dealt with the use of intrauterine devices. These complications can assume an asymptomatic course or it may cause major complications like bleeding, uterine perforation and migration to peritoneal cavity with perforation or adhesion to adjacent organs and also to the omentum. Here we present a case of a 33 yr old woman who had inserted a copper IUCD, 7 months prior and presented with 2 months’ amenorrhea and a missing IUCD thread. During operative laparoscopy, the missing copper IUCD was seen stuck to the anterior abdominal wall with severe adhesions around it. After laparoscopic adhesiolysis, it was retrieved completely and intact from the anterior abdominal wall. Also to be kept in mind is that an extrauterine copper bearing devices be removed as early as possible after diagnosis to minimize the risk of adhesion formation.
Introduction
Being the 2nd most common contraceptive method adopted, copper IUCD has easy availability and low cost which makes it the most popular reversible method of contraception. Discontinuation rate in India is 20-40% in one year. The reasons for this are increased mensrual bleeding, inter menstrual bleeding, pain, pelvic inflammatory disease, IUCD expulsion, perforation, secondary infertility, failure of IUCD leading to ectopic pregnancy.[1] The incidence of IUCD migrations from the uterus is reported to be 0.5-1%/1000 IUCD insertions.[2] The presentation after perforation and migration of the intrauterine device is highly variable ranging from asymptomatic to acute abdomen due to infection, adhesion or bowel obstruction or perforation. The accepted method of treatment of displaced IUCD is surgical removal because it tends to form adhesions or damage to the bowel or urinary bladder. Its retrieval can be carried out hysteroscopically, or by diagnostic curettage, laparoscopy or laparotomy depending on its location and also the availability of equipment, and most importantly, the expertise of the health care provider.[3] Here we present a case of a 8 weeks pregnant woman with missing IUCD thread and its laparoscopic retrieval.
Case Report
A 33 yr old para 1 living 1 woman presented to us as 2 months amenorrhea and a missing copper IUCD thread since 6 months. After questioning, the patient disclosed that she had inserted a copper IUCD 7 months back from another hospital and did not follow up since then. The patient was apparently asymptomatic. Per speculum examination revealed the absence of any IUCD thread. UPT was positive and USG was done which showed a live intrauterine gestation of 8 weeks and an IUCD anterior to the uterus. The patient did not want to continue the pregnancy and hence a medical termination of pregnancy was done by dilatation and curettage upon which the products of conception were removed but the copper IUCD was nowhere to be found. Therefore a decision of diagnostic sos operative hysteron-laparoscopy was taken. Hysteroscopy revealed an empty cavity with no sign of the copper IUCD. During laparoscopy, the copper IUCD was seen stuck to the anterior abdominal wall with dense adhesions around it and to the omentum. Adhesiolysis was done and the copper IUCD was retrieved with a grasper form the 5 mm side port. The patient had an uncomplicated postoperative course and was discharged on the next day from the hospital and has no complaints on a follow up of 12 months postoperatively.
Figure 1. Copper IUCD surrounded with adhesions stuck to anterior abdominal wall.
Figure 2. Retrieving the copper IUCD after adhesiolysis.
Discussion
In most of the cases, uterine perforations are asymptomatic and hence are not recognized at the time of insertion.[4] Non operative management of a migrating IUD has been recommended in the past because of the morbidity associated with its removal. [4] But, a migrated IUCD can lead to pain, fibrosis, and adhesion formation and sometimes, may even result in penetration into adjacent organs like the urinary bladder, sigmoid colon, appendix, and small bowel. Perforation into the bowel is also a documented complication and can result in abscess formation, ischemia, or volvulus. Therefore, it has been advised that surgical exploration and IUD retrieval should be the primary therapeutic approach for patients with a misplaced IUCD. [4]
Literature suggests that Uterine perforation almost always occurs during insertion of IUCD. Its incidence is related to the timing of insertion, type of the device, the anatomy of the uterus and cervix, the skill of the person performing the insertion and other factors include soft uterine wall, a previous recent pregnancy or an abortion and the presence of a previous uterine scar, if any.[5] Secondary perforation of the uterus can occur by slow migration of the IUCD directly through the wall of the uterus, augmented by contractions of the uterus and urinary bladder.[6] Rarely, a migrated IUCD can be found in lower anterior abdominal wall.[7] The colon and the bladder are the adjacent structures of the uterus and a migrated IUCD is usually lodged in these structures. But as seen in this case, it is rare for an IUCD to avoid these adjacent structures and migrate into the lower anterior abdominal wall. Thus in our case, the bladder and the bowel were spared of any perforations, but adhesions were present engulfing the copper IUCD and attached to the anterior abdominal wall .A regular follow up for detection of misplaced IUCD is stressed as it can have an unusual presentation. Prevention is the best remedy; hence correct insertion by skilled surgeon is the required. Regular follow up should be made mandatory. If in doubt ultrasound or pelvic radiograph should be done. And an asymptomatic misplaced IUCD should be managed vigorously as delay can increase intraabdominal adhesions and make it difficult for its retrieval.
References
- Rajeshwari NV, Hasalkar JB. IUD retention in shimoga district of Karnataka. Journal of family welfare. 1996;42(1):44-9.
- Kriplani Alka, Garg Pradeep, Sharma Meenakshi, Agarwal Nutan. Laparoscopic removal of extrauterine IUCD using fluoroscopy guidance: a case report. Journal of Gynaecologic Surgery. 2005;21(1): 29–30.
- Markovitch O, Klein Z, Gidoni Y, et al. Extrauterine mislocated IUD. Is surgical removal mandatory? J Fam Plann Reprod Health Care. Contraception. 2002; 66(2): 105-8.
- Mederos R, Humaran L, Minervini D, et al. Surgical removal of an intrauterine device perforating the sigmoid colon: a case report. Int J Surg. 2008 Dec; 6(6):e60-2.
- Boyon C, Giraudet G, Guerin Du Masgenet B, Lucot JP, Goeusse P, Vinatier D. Diagnosis and management of uterine perforations after intrauterine device insertion: A report of 11 cases. Gynecol Obstet Fertil. 2013 May;41(5):314-21
- Singh Iqbal. Intravesical Cu-T migration: an atypical and infrequent cause of vesical calculus. Int Urol Nephrol. 2007;39: 457-59.
- B. Mülayim, S. Mülayim, N. Y. Celik, “A lost intrauterine device. Guess where we found it and how it happened?” Eur J Contracept Reprod Health Care. 2006 Mar;11(1):47-9.
Shah NH, Paranjpe SH, Shah VN. Laparoscopic Retrieval Of Missing Copper Intrauterine Device Stuck To Anterior Abdominal Wall Presenting Along With 8 Weeks Of Pregnancy. JPGO 2015. Volume 3 No. 1. Available from: http://www.jpgo.org/2016/01/laparoscopic-retrieval-of-missing.html