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Case Report

Intrauterine Device Perforation

Sreedevi Sreenarasimhaiah, MD

CASE REPORT

A 25-year-old woman, gravida 1, para 1, was considering insertion of a levonorgestrel-releasing intra-uterine system (LNG-IUS) for contraception. She had undergone cesarean delivery of a full-term infant (due to fetal intolerance to labor) 1 year previously. She reported a long-term, monogamous relationship, and had no history of sexually transmitted infections or other medical problems.

After counseling and examination, the LNG-IUS was inserted with no apparent complications. The uterine fundus was sounded to 7 cm. The patient tolerated the procedure well, and was instructed to return in 1 month or after her next menses to check the LNG-IUS placement. The patient returned 4 weeks later, and reported no problems except for mild uterine cramping for 1 day postinsertion.

On examination, the guide strings of the LNG-IUS were not visible from the patient’s cervix. Gentle probing of the endocervical canal with a curette failed to locate the strings. Transvaginal ultrasonography was performed, and the LNG-IUS could not be identified within the uterine cavity. However, no uterine anomalies were detected. Abdominal plain-film radiography revealed the LNG-IUS in an intra-abdominal location (Figure 1).

Figure not available online

Figure 1. Radiographic image of the abdomen shows the LNG-IUS located near the patient’s left sacroiliac joint. LNG-IUS = levonorgestrel-releasing intrauterine system. Courtesy of Sreedevi Sreenarasimhaiah, MD.

The patient was scheduled for laparoscopy to retrieve the LNG-IUS, and underwent preoperative bowel preparation. She was afe-b-rile and asymptomatic. Intraoperative findings included an omen--tal adhesion to the anterior abdominal wall, which contained the LNG-IUS (Figure 2). The adhesion was presumed to be a result of the cesarean delivery. A perforation site was not readily visible in either the posterior or anterior aspect of the uterus. No bowel injury was noted. The LNG-IUS was easily removed from the omentum by using a grasper and twisting slightly. No adhesiolysis was required.

Figure not available online

Figure 2. The LNG-IUS is located in an omental adhesion. The uterus, cul-de-sac, and adnexa appear to be unaffected. LNG-IUS = levonorgestrel-releasing intrauterine system. Courtesy of Sreedevi Sreenarasimhaiah, MD.

The patient recovered from the procedure with-out incident, and subsequently selected another contraceptive option. Pathologic examination showed soft tissue surrounding the LNG-IUS, with chronic inflammation and a few foreign-body giant cells.

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DISCUSSION

Intrauterine devices (IUDs) are highly effective methods of con-traception that are used worldwide because of their favorable side-effect profile, duration of effect, cost-effectiveness, and high efficacy. However, uterine perforation remains a rare but significant complication of IUD use. The rate is estimated at 1/1,000 and typically occurs at insertion.1 The risk of perforation is related to the skill of the practitioner, and may be increased in the presence of undetected uterine abnormalities.2 Even more anatomic variations such as significant anteflexion or retroversion of the uterus may increase perforation risk. Furthermore, guide-lines recommend that a uterine cavity < 6 cm is a contraindication for IUD placement.3 In some cases, the perforation may initially occur with the tip of the IUD penetrating the myometrium, with subsequent uterine contractions propelling the IUD through the uterine wall to the abdom-inopelvic cavity.

Patients who experience IUD perforation may have symptoms ranging from severe abdominal cramping to no pain at all. Complaints of abdominal pain and discomfort that persist despite mild postinsertion analgesia mandate confirmation of the IUD’s position. Follow-up examination is essential, even after an uneventful IUD placement; this should include a pelvic examination to visua-lize the guide strings, with ultrasonography and/or radiography if the strings cannot be located. Both the LNG-IUS and the copper-bearing IUD currently on the US market are radiopaque.

Although some studies suggest cautious observation in the asymptomatic patient with confirmed perforation, standard practice dictates removal of the IUD by hysteroscopy, laparo-scopy, or lap-arotomy.4,5 Removal is certainly prudent given the risks of ad-hesion formation from reaction to a foreign body and concerns over medicolegal liability. On occasion, perforated IUDs have penetrated to the bladder and bowel.5 Appendiceal abscesses associated with intra-abdominal IUDs have also been described.6,7 Like other IUDs, an LNG-IUS that migrates intra-abdominally can cause adhesion formation.8,9 In addition, plasma levonorgestrel levels may increase due to intra-abdominal migration.10

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CONCLUSION

The case presented here provides a timely reminder of the importance of counseling and follow-up with intrauterine contraception. If the IUD guide strings are not visible at any time, an investigation should be initiated to locate the device. If perforation is diagnosed, prompt removal should minimize further complications.

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Sreedevi Sreenarasimhaiah, MD, is assistant professor, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas.

References

1. American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Gynecology. ACOG practice bulletin. Clinical management guidelines for obstetrician-gynecologists. No. 59, January 2005. Intra-uterine device. Obstet Gynecol. 2005;105(1):223-232.
2. Harrison-Woolrych M, Ashton J, Coulter D. Uterine perforation on intrauterine device insertion: is the incidence higher than previously reported? Contraception. 2003;67(1):53-56.
3. Berek JS, Adashi EY, Hilard PA, eds. NovakÍs Gynecology. 12th ed. Baltimore, Md: Williams & Wilkins; 1996:241.
4. Markovitch O, Klein Z, Gidoni Y, Holtzinger M, Beyth Y. Extrauterine Mislocated IUD: is surgical removal mandatory? Contraception. 2002;66(2):105-108.
5. Kassab B, Audra P. The migrating intrauterine device. Case report and review of literature [In French]. Contracept Fertil Sex. 1999;27(10): 696-700.
6. Ohana E, Sheiner E, Leron E, Mazor M. Appendix perforation by an intrauterine contraceptive device. Eur J Obstet Gynecol Reprod Biol. 2000;88(2):129-131.
7. McWhinney NA, Jarrett R. Uterine perforation by a Copper 7 intrauterine contraceptive device with subsequent penetration of the appendix. Case report. Br J Obstet Gynaecol. 1983;90(8):774-776.
8. Margarit LM, Griffiths AN, Vine SJ. Management of levonorgestrel-releasing intrauterine system (LNG-IUS) uterine perforation. J Obstet Gynaecol. 2004;24(5):586-587.
9. Haimov-Kochman R, Doviner V, Amsalem H, Prus D, Adoni A, Lavy Y. Intraperitoneal levonorgestrel-releasing intrauterine device following uterine perforation: the role of progestins in adhesion formation. Hum Reprod. 2003;18(5):990-993.
10. Haimov-Kochman R, Amsalem H, Adoni A, Lavy Y, Spitz IM. Management of a perforated levonorgestrel-medicated intrauterine device„a pharmacokinetic study: case report. Hum Reprod. 2003;18(6):1231-1232..

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