[ Editorials | Departments and Series | Index ]

Case Report

Asymptomatic Small Bowel Injury in a Pregnant Woman Via Intrauterine Device Perforation

Erich T. Wyckoff, MD; Michael T. Parsons, MD, MBA

Intrauterine devices (IUDs) remain the most popular form of long-term contraception worldwide.1 In the United States, approximately 3% of women use IUDs.2 IUDs are a safe and effective alternative to permanent surgical sterilization. The incidence of uterine perforation is reported to be approximately 1.6 in 1,000, with injury to surrounding structures less common.3 The timing for when to remove an IUD failure resulting in pregnancy is controversial. However, IUD perforation warrants evaluation of surrounding structures and organs for injury. Delay in diagnosis may result in significant patient morbidity and preventable death.

back to top

CASE PRESENTATION

A 35-year-old gravida 5 para 2-0-2-2 at 39 weeks’ gestation presented for a repeat cesarean delivery complicated with an IUD in situ. The patient’s health care was managed by a local midwifery group. Pertinent history included a successful vaginal birth after cesarean. Postdelivery, the patient’s chosen method of contraception was IUD. Her IUD, type TCu 380A, was inserted 6 weeks after delivery; insertion was reported as routine and uncomplicated. The patient returned for IUD surveillance 4 weeks later, at which time the IUD strings were visualized protruding through the external cervical os. She expressed no discomfort with her IUD, and it was assumed that correct placement had occurred. A menstrual period was noted 11 days after IUD placement, with no concerns of pregnancy.

Approximately 1 month after her last recorded menses, the patient presented for evaluation of missed menses of the following month. A urine specimen was obtained and tested positive for pregnancy. On pelvic exam, the IUD strings were once again easily visualized. Secondary to suspicion of an intrauterine pregnancy, an unsuccessful attempt was made to remove the IUD. When it could not be easily removed, a pelvic sonogram was ordered. The initial sonogram evaluation was remarkable for a linear echogenic structure protruding out of the myometrium posteriorly slightly to the left of the midline, consistent with IUD perforation. A tiny cystic structure was also noted that is representative of a gestational sac of approximately 4 weeks’ gestation. After discussion with the patient, the decision was made to continue the pregnancy. A follow-up ultrasound performed 3 months later was remarkable for a linear echogenic density noted within the dorsal uterus, representing the patient’s known IUD. Additional ultrasounds performed during the pregnancy all were remarkable for findings suggestive of an incorrectly positioned structure, consistent with an improperly positioned IUD and a viable intrauterine pregnancy.

Overall, the patient’s pregnancy was complicated only by severe anemia. She received multiple treatments of intravenous iron throughout the pregnancy. She did not experience any symptoms of gastrointestinal distress, febrile morbidity, intolerance of oral intake, excessive uterine irritability, or abdominal pain. At 39 weeks and 3 days, she presented for scheduled elective repeat cesarean delivery. The patient also consented to bilateral tubal ligation, removal of IUD, and all indicated procedures. Cesarean delivery with fallopian tube occlusion was performed in a routine fashion. A healthy, viable female infant was delivered. Search of the intrauterine cavity, as well as the placenta, did not reveal the IUD. The uterus was exteriorized and noted to be remarkable for small bowel adhered to the posterior uterine wall. Upon further examination, a foreign body suggestive of an IUD arm was noted; it had perforated the uterine wall and adhered to a loop of small bowel (Figure 1).

Click to enlarge

FIGURE 1. IUD perforating the posterior uterine wall with adhered small intestine.

Intraoperative surgery consultation was obtained. The small bowel was freed from the posterior uterine wall, at which time the uterine perforation was easily identified. Further examination of the small bowel was remarkable for the IUD perforating the small bowel lumen (Figure 2). Small bowel resection with reanastomosis was performed. The uterine defect was repaired with simple figure-of-8 suture.

Click to enlarge

FIGURE 2. Dissection revealing IUD perforation extending into the lumen of the small bowel.

The segment of bowel was sent to pathology for review and found to be remarkable as follows: “Segment of small bowel with embedded IUD. There is a surrounding organizing abscess cavity with fibrosis and granulomatous acute and chronic inflammation seen in the surrounding submucosa, muscularis propria, and serosa.” The placenta was remarkable for villous vessel, consistent with fetal thrombotic vasculopathy and placentamegaly. The woman’s preoperative hemoglobin was noted to be 7 g/dL, and postoperative hemoglobin was 6 g/dL. Her postoperative course was uneventful, and she was discharged from the hospital on postoperative day 6.

back to top

COMMENT

A review of the literature using PubMed and the terms “intrauterine device AND perforation AND bowel injury” identified 44 articles. Included were multiple episodes of IUD perforations resulting in bowel injury, with injury to large bowel reported more frequently than the small bowel. In one case of IUD perforation associated with pregnancy, the pregnancy was terminated at 8 weeks’ gestation. No other cases were identified describing IUD uterine perforation resulting in small bowel injury and a pregnancy that progressed asymptomatically to 39 weeks’ gestation.

In the United States, the predominant IUDs are the copper-containing and the hormone-releasing types. Uterine perforation occurs during IUD insertion and complicates 1 in 1,000 IUD procedures.2 Risk factors include clinician inexperience in placement, a retroverted or immobile uterus, myometrial defects, pelvic inflammatory disease, and insertion during the puerperium period. During the puerperium, the uterine wall is thin, thus increasing the risk of perforation.2 In the case of an embedded IUD, uterine contractions may increase the risk for perforation. Often perforation may not be recognized immediately.

The patient who has sustained an IUD perforation is not effectively protected from pregnancy by the IUD. In our case, pregnancy was the first indicator that uterine perforation had occurred. Despite uterine perforation, the IUD strings remained visualized. Extreme discomfort upon IUD placement and shortening of string length warrant suspicion of perforation that can be evaluated via ultrasound.

If ultrasound does not reveal the location of the missing IUD, an x-ray of the pelvis and abdomen should be obtained, since expulsion cannot be diagnosed reliably without x-ray documentation. IUD translocated into the peritoneal cavity may provoke peritoneal or omental adhesions, volvulus, uterocutaneous fistulas, and bowel perforation, leading to significant morbidity.4 An IUD that has completely transected the myometrium may be anywhere in the pelvis and/or abdomen. Most frequently, it is found encased in an abscess and adhered to the large bowel, or freely floating in the posterior cul-de-sac.

back to top

CONCLUSION

A high index of suspicion for IUD perforation and possible injury to surrounding structures is warranted in IUD failures resulting in pregnancy. Not all IUD perforations are diagnosed at the time of insertion. In this case, the patient’s IUD insertion was considered routine, and on follow-up the IUD strings remained visualized. One clue that IUD perforation has occurred may be a greater than expected level of difficulty upon attempted removal.

The authors report no actual or potential conflicts of interest in relation to this article.

back to top

Erich T. Wyckoff, MD, is Assistant Professor, Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology; and Michael T. Parsons, MD, MBA, is Professor, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, and Medical Director of Quality Management; both at the University of South Florida College of Medicine, Tampa.

References

1. Chi E, Rosenfeld D, Sokol TP. Laparoscopic removal of an intrauterine device perforating the sigmoid colon: a case report and review of the literature. Am Surg. 2005;71(12): 1055-1057.
2. Dean G, Goldberg AB. Management of problems related to intrauterine contraception. UpToDate. October 15, 2009. Available at: www.uptodate.com/home/content/topic.do? topicKey=gen_gyne/16221. Accessed January 29, 2010.
3. Mederos R, Humaran L, Minervini D. Surgical removal of an intrauterine device perforating the sigmoid colon: a case report. Int J Surg. 2008;6(6):e60-e62.
4. Stuckey A, Dutreil P, Aspiru E, Nolan TE. Symptomatic cecal perforation by an intrauterine device with appendectomy removal. Obstet Gynecol. 2005;105(5 Pt 2): 1239-1241.

back to top