Uterine perforation caused by intrauterine devices: clinical course and treatment

Abstract

summary answer: Symptoms are mostly mild and 30% of women are asymptomatic. Surgical findings are mainly minimal; no visceral complications were found in this study. However, adhesions as well as pregnancies seem to be more common among women using Cu-IUDs. what is known already: Prior studies and case reports have suggested that uterine perforation by modern IUDs/IUSs is rarely serious. main results and the role of chance: The majority of patients (n ¼ 53; 71%) had mild symptoms of abnormal bleeding or abdominal pain or both, in combination with missing IUD/IUS threads. Asymptomatic patients (n ¼ 22; 29%) were examined because of missing threads or pregnancy. Failure to remove the IUD/IUS by pulling visible threads was the reason for referral in seven women (9%) requesting removal of the device. Eleven women (15%) were pregnant. Misplaced IUDs/IUSs were localized by a combination of vaginal ultrasonography (US) and X-ray, hysteroscopy or curettage. Only after this were patients treated by means of laparoscopy. The majority (n ¼ 44; 65%) of the 68 intra-abdominal devices were located in the omentum, the remaining 24 (35%) around the uterus. Partial perforation or myometrial embedding was diagnosed in all seven cases (9%) with visible threads, but unsuccessful removal by pulling. During laparoscopy, filmy adhesions were found in 21 patients (30%). Pregnancy (33 versus 7%, P ¼ 0.009) and intra-abdominal adhesions (58 versus 20%, P ¼ 0.002) were significantly more common in the Cu-IUD group. Infections were rare; one non-specific acute abdominal infection, later found to be unrelated to the IUD, led to laparoscopy and in four cases the IUD was surrounded by pus, but there were no symptoms of infection.limitations, reasons for caution: The study setting revealed only surgically treated symptomatic patients and asymptomatic women attending regular follow-up. Women not treated, but only followed or not attending follow-up, were not identified, excluding the possibility to analyse missed undiagnosed perforations, or conservative follow-up as a treatment option.wider implications of the findings: As surgical findings are minimal, asymptomatic women may need no treatment at all.An alternative form of contraception is, however, important as pregnancies do occur. If a woman plans a pregnancy, a misplaced LNG-IUS should be removed, as it may act as a contraceptive. study funding/competing interest(s): Helsinki University Central Hospital research funds. O.H. has lectured and designed educational events with Bayer AG and MSD, and serves occasionally on scientific advisory boards for these companies. S.S. has

Dislodged Levornogestrel-Intrauterine System Intra-Abdominally without Uterine Perforation: Is it Possible?

“…Majority of patients (73%) were symptomatic with mild abdominal pain or abnormal vaginal bleeding (8). Asymptomatic patients were diagnosed mainly because of missing IUD threads or unintended pregnancy.…”

“…Asymptomatic patients were diagnosed mainly because of missing IUD threads or unintended pregnancy. Up to 75% of patients had onset of symptoms within 24 hours of insertion (8). As the side effects of Mirena® were similar to presentation of uterine perforation, thus the mean time taken from insertion to establishing the diagnosis was around 5 months (0-69 months) (8).…”

“…Other imaging includes abdominal radiography, hysteroscopy and CT scan (8,9). Besides that, Banerjee et al described the use of fluoroscopy to help in localising the missing device when ultrasound, abdominal radiography and diagnostic laparoscopy failed to locate it (10).…”

“…via laparoscopic route (8). Most of these missing devices were embedded within the omentum (65%) or within the pelvic cavity (35%).…”

Malposition and displacement of intrauterine devices–diagnosis, management and prevention

“…IUDs that are too big for the small cavity, if not expelled, may embed resulting in patient discomfort, bleeding and may even advance to perforations [11][12][13][14]. Severe uterine distortion (e.g., fibroids) or a congenital malformation (e.g., uterus arcuatus or bicornus) may preclude the proper positioning of an IUD and cause displacement and migration of the IUD in and through the wall of the uterus.…”