Perforation of the uterus following IUD insertion in the puerperium

An Unusual, Delayed Presentation of a Migrated Intrauterine Contraceptive Device Into the Rectosigmoid Colon

The current literature suggests that serious complications after intrauterine contraceptive device (IUCD) insertion are rare. We present a rare case of a migrated IUCD into the rectosigmoid colon. A 33-year-old woman (parity one) presented to the emergency department with a three-day history of flank pain, upper urinary tract infection symptoms, and a low-grade fever. Differentials initially included renal colic or pyelonephritis. However, subsequent computed tomography of the kidneys, ureters, and bladder (CT-KUB) and magnetic resonance imaging of the pelvis (MRI-pelvis) showed a migrated IUCD posterior to the uterine body, with both ends closely abutting onto the adjacent proximal rectum. During further history-taking, she reported a past surgical history of an emergency caesarean section five years ago and the insertion of a copper-IUCD six weeks postnatally. She was subsequently referred to the gynaecologists. In view of the involvement of the bowels, the colorectal surgeons were consulted, and the patient was managed by a multidisciplinary team. The patient subsequently underwent diagnostic hysteroscopy, flexible sigmoidoscopy, diagnostic laparoscopy, removal of impacted IUCD, and repair of the rectum. Intraoperatively, her hysteroscopy noted a normal uterus with an intact cavity. Flexible sigmoidoscopy noted the horizontal arm of the IUCD abutting into the lumen of the rectosigmoid region; however, attempted removal with traction was unsuccessful. A partial rectotomy was done eventually to remove the IUCD. Migration of an IUCD is rare, with uterine perforation rates ranging from 0.04% to 0.2%. Albeit a rare complication, this case highlights the need for clinicians to be cognizant of complications arising from IUCD insertion, as symptoms are often non-specific and mild. This case also highlights the importance of a multidisciplinary discussion in the management of a migrated IUCD, which may include gynaecologists, colorectal surgeons, radiologists, and more. Many innovative ways were also discussed regarding the assessment of it, which includes preoperative imaging or endoscopic evaluation. Novel methods of removal of migrated IUCD in the rectosigmoid colon have also been proposed, including manual traction, proctoscopy, rigid sigmoidoscopy, and removal via a snare. They provide an alternative to the traditional diagnostic laparoscopy or laparotomy, thus reducing the need for general anaesthesia or operative intervention. Looking forward, long-term studies can be done to evaluate the need for intervention for asymptomatic patients where the risk of surgery may outweigh the benefits.

Comparison of efficacy and complications of IUD insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up

OBJECTIVE

This study aimed to compare immediate postplacental (IPP) and early postpartum (EP) intrauterine device (IUD) insertions with interval (INT) IUD insertions with respect to efficacy and complications.

METHODS

The study group consisted of 268 women in whom the following TCu 380A IUD insertions were performed: 84 IPP (less than 10 min), 46 EP (10 min to 72 h) and 138 INT (more than 6 weeks). The women were followed up 8 weeks, 6 months and 12 months after insertion. Complications and pregnancies encountered at the end of 1 year following IPP, EP and INT insertions were compared. The chi-square test and Fisher's Exact Test were used for the evaluation of the data.

RESULTS

Complications developed in 40.4% of the women in the IPP group, in 74.4% of the women in the EP group and in 19.2% of the women in the INT group (p<.001). Although no statistically significant difference was found between the groups for uterine perforation and infection (p>.001), there was a statistically significant difference between the groups in the incidence of complete and partial expulsion according to the time of IUD insertion. The overall cumulative pregnancy rate and frequency of pregnancy were found to be higher (p>.05 for both), which are both insignificant for the EP group (2 of 43 women), as compared with the INT (4 of 130 women) and IPP groups (2 of 84 women), and pregnancy rates at 1 year for all groups was 3.1% (8 of 257 women).

CONCLUSION

IPP and EP insertion of the TCu 380A IUD is an effective and convenient procedure, and expulsion rates in these groups are higher than in the INT group. Further studies are necessary to determine the cause of the higher expulsion rates and to find ways to reduce such rates.

Uterine perforation following manual removal of the placenta

We present here a case of uterine perforation following manual removal of the placenta during the third stage of normal labor. Total abdominal hysterectomy was performed, and the 4x3-cm perforation of the uterus and placenta accreta were confirmed. In this case, the round ligament covering the hematoma prevented bleeding into the peritoneal cavity and peritonitis. Manual removal of the placenta should be performed carefully following ultrasonographic assessment for placental abnormalities such as placenta accreta.

Perforations with intrauterine devices. Report from a Swedish survey

This survey comprised 50 consecutive perforations occurring with intrauterine devices (IUD) reported to the National Patient Insurance Scheme Register during 1990 to 1993. All 50 women were parous and > 20 years of age at the time of IUD insertion. Forty-two (84%) of the IUD were inserted by a midwife and eight by a gynecologist. A total of 45 women (90%) had their IUD inserted < 1 year after a full-term pregnancy and 31 women (62%) had their IUD inserted < or = 12 weeks after delivery. Of the 50 women, 27 (54%) reported that they were breastfeeding at the time of IUD insertion. No particular IUD was overrepresented in relation to its share on the market. In 31 cases (62%), severe pain at insertion and during the first 24 h was recorded. In 14 women (28%), the perforation was diagnosed early (i.e., within 1 month of insertion) and in 36 women (72%), the perforation was diagnosed > 1 month after insertion. Lower abdominal pain was the most frequent symptom at early diagnosis but in two cases, the main symptom was heavy bleeding. Among the 36 women in whom the perforation was discovered more than 1 month after insertion, the diagnosis was made when an unexpected pregnancy occurred in 20 women (56%). In 15 cases, the IUD strings were not visible during pelvic examination at a routine check-up, which led to efforts to locate the IUD. Thirty-two women (64%) underwent laparotomy for removal. We conclude that lactating women seem to be a risk group for perforation and that a national register of IUD perforations could provide a better means of quality control.

Colocolic fistula caused by a previously inserted intrauterine device. Case report

Uterine perforation remains the most serious complication of the intrauterine contraceptive device (IUD). It is more common in the puerperium, usually occurring at the time of insertion of a new device. Perforation may, however, also occur in the puerperium if a pre-existing device is not removed in early pregnancy or extruded at the time of delivery. The case is presented of a 30-year-old woman who became pregnant for the third time following insertion of an IUD in the puerperium of her second pregnancy. An uneventful pregnancy and delivery followed. Failure to detect the IUD at the time of delivery led to laparoscopy and laparotomy to locate the device. A colotomy was necessary to retrieve the device, which had formed a colocolic fistula. It is concluded that the puerperium remains the time of greatest risk of uterine perforation by an IUD. Although most occur at the time of insertion, this complication can also occur with a previously inserted device. Severe intra-abdominal complications may ensue if the device is not localized and removed. Laparotomy is justified if the laparoscopic removal is unsuccessful. A high degree of suspicion is necessary if serious consequences are to be avoided.

The pathology of intra-uterine contraceptive devices

The IUCD is a simple and effective way of producing contraception without the need for patient compliance. It is not rendered ineffective by other drugs, as may be steroid contraceptives, and its side-effects, for carefully selected patients, are considered by most practitioners to be acceptably low (Van Kets et al. 1989).