Coincidental spontaneous perforation of the small intestine following operative hysteroscopy: A case report

OBJECTIVE

Operative hysteroscopy is a common gynecologic procedure, but it carries the risk of complications. Spontaneous small intestine perforation is rare and fatal, especially in young adults. We present a spontaneous small intestine perforation after operative hysteroscopy with mimicking sign of uterine perforation after operation hysteroscopy.

CASE REPORT

A 30-year-old nulligravida woman underwent Truclear® hysteroscopic polypectomy in the morning in LMD. She suffered from upper abdominal pain in the afternoon. Subsequently, progressive abdominal distention and imminent shock occurred the next morning. Initially, it was supposed to be a case of uterine rupture with internal bleeding. She was transferred to the emergency department of our hospital. Complete biochemistry data and abdominal CT were performed. The CT revealed pneumoperitoneum and ascites. Emergent laparoscopy was arranged. The abdominal cavity was full of intestinal fluid and the myomatous uterus was intact. The surgeon performed a laparotomy, two sites of spontaneous perforation of the small intestine were detected. The patient underwent laparotomic segmental resection and anastomosis and was discharged 14 days after surgery without incident.

CONCLUSIONS

The risk of uterine perforation during hysteroscopy is up to 1.6%. The use of non-thermal intrauterine morcellator device (Truclear®) has been shown to significantly reduce the risk of perforation and thermal injury. As this case highlights, we suspected the possibility of uterine perforation immediately after hysteroscopic surgery. However, it happened to be rare spontaneous perforation of small bowel. The patient recovered well after timely transfer and management. Hysteroscopy is a very common procedure in gynecologic clinics, but even relatively safe intrauterine morcellator devices carry risk of complications. As a healthcare provider, we should beware of any comorbidity, for sometimes it would be catastrophic.

[Not Available]

Intra-abdominal displacement of an intrauterine device (IUD) is a rare but serious complication. This is a case report of a 44-year-old woman who was referred to a surgical department with intermittent abdominal pain. Gynaecological examination and ultrasound failed to identify the patient's IUD. An abdominal CT scan confirmed the diagnosis of the intra-abdominally migrated IUD and the device was extracted by laparoscopy. Surgical removal of the migrating IUD is recommended to prevent long-term complications such as intra-abdominal adhesions, organ perforation, and fistula formation.

Retrait endoscopique d'un dispositif intra-utérin perforant le côlon sigmoïde: à propos d'un cas

Le dispositif intra-utérin (DIU) reste le pilier principal des mesures de planification familiale dans les pays en développement, néanmoins il est associé à des complications graves telles que les saignements, les perforations et les migrations vers des organes adjacents. Bien que la perforation de l'utérus par un DIU ne soit pas rare, la migration vers le côlon sigmoïde est exceptionnelle. Nous rapportons ici un cas de migration d'un stérilet vers le côlon sigmoïde qui a été retiré par voie endoscopique basse. Il s´agit d´une femme de 45 ans, porteuse d'un stérilet, se présente 6 ans plus tard, avec des douleurs pelviennes à type de pesanteur. L´examen clinique était sans anomalies et l´exploration scannographique avait objectivé le DIU qui était incrusté dans la paroi du colon sigmoïde. Une laparoscopie à visée diagnostique et thérapeutique a été réalisée; elle avait objectivé une perforation intestinale par le dispositif, qui était partiellement incrusté dans le côlon sigmoïde, mais elle avait échoué de l´extraire. Le dispositif avait été retiré lors d´une coloscopie par une anse diathermique (15mm de diamètre).

Uterine perforation during intrauterine procedures and its management

OBJECTIVE

Uterine perforation is a potential, not rare complication of all intrauterine procedures and may be associated with injury of surrounding organs and structures. The incidence, risk factors, possible prevention, dia-gnosis, management and impact on future reproduction is reviewed here.

METHODS

Systematic review of available sources on the topic was carried out using the PubMed database and textbooks of Czech authors.

CONCLUSION

Some risk factors that make access to the uterine cavity difficult may be prevented, however, others remain unpreventable. For patients in whom the perforation occurred during sondage, dilatation or insertion of blunt and cold instrument, without significant bleeding and who are hemodynamically stable, observation is recommended rather than immediate abdominal exploration. The exception are young women planning pregnancy in whom endoscopic suture is indicated. Abdominal exploration is required in patients who have been injured by electrosurgical or sharp device, laser, vacuum curette, who are hemodynamically unstable or show signs of severe bleeding or visceral injury.

Rectal Perforation by an Intrauterine Device Leading to Fatal Intra-Abdominal Sepsis and Necrotizing Fasciitis

BACKGROUND

Colorectal injury from an intrauterine device (IUD) is rare but may lead to major complications.

CASE

A 55-year-old woman presented to a tertiary care hospital with 4 days of generalized weakness, confusion, dysuria, and lower back pain. She provided a vague history of an unsuccessful attempt to remove an IUD 30 years prior. A computed tomography scan demonstrated an IUD in the rectal lumen, with gluteal and pelvic gas and fluid collections. Emergency surgery found necrotizing fasciitis. Despite multiple debridements, sigmoidoscopic IUD removal, and long-term intravenous antibiotics, the patient died from sepsis and multiorgan failure.

CONCLUSION

IUDs require proper monitoring and timely removal to prevent potential complications associated with organ perforation.

Levonorgestrel-Releasing Intrauterine Contraceptive Device in the Peritoneal Cavity: A Report of Two Cases

BACKGROUND

In modern gynecology an intrauterine device (IUD) with levonorgestrel is often used as a method of contraception. The levonorgestrel-releasing intrauterine system is small and T-shaped. In Slovenia, only a gynecologist may insert it. CASES: We present 2 clinical cases in which, despite strong evidence that no perforation had occurred during insertion, the IUD was found outside the uterus. If the IUD threads are not visible or the IUD cannot be located in the uterine cavity, an X-ray of the abdomen must be performed. If the IUD is found in the abdominal cavity outside the uterus, removal by laparoscopy is carried out.

CONCLUSION

Given the large number of inserted IUDs, the complications associated with the levonorgestrel-releasing intrauterine system are quite rare, and therefore it remains one of the most widely used contraceptive methods.

[COMPLICATION AFTER UNRECOGNIZED ECTOPIC PREGNANCY--A CASE REPORT]

The authors present a clinical case of performing an abortion at patient with unrecognized ectopic pregnancy and subsequent complication- perforation of the uterus and the colon and life-threatening haemoperitoneum.

TRANSMIGRATION OF INTRA-UTERINE DEVICE, EXPLORATORY LAPAROTOMY, RETRIEVAL AND REPAIR OF PERFORATED UTERUS

BACKGROUND

Perforation of the uterus following transmigration of Intra-uterine devise (IUD) is an uncommon finding of insertion of IUD. There is associated increased risk of accidental pregnancy,morbidity and mortality.

AIM

To report a rare clinical condition in which there was uterine perforation following migration of IUD and to increase awareness of this condition in our environment.

CASE REPORT

A 37 year old para 6⁺⁰ woman (all alive) who presented with a ten day history of lower abdominal pains following IUD insertion. Examination revealed tenderness in the suprapubic region and non-visualization of IUD thread per vaginam. Pelvic USS showed an empty uterine cavity while an abdominopelvic x-ray following tracer IUD insertion showed the IUD to be outside the uterine cavity. She had an exploratory laparotomy for retrieval of transmigrated IUD and repair of perforated uterus.

CONCLUSION

Transmigrated IUD with uterine perforation is distressing uncommmon clinical condition, and it is reported with the hope of increasing the awareness and possibly prevent this avoidable uncommon complication.

Uterine Perforation During Dilation and Evacuation Prior to Fetal Extraction--Now What? A Case Report

BACKGROUND

Uterine perforation is an infrequent but serious complication of dilation and evacuation (O&E). The purpose of this case report is to describe management strategies once a uterine perforation is identified.

CASE

A 15-year-old female at 15 weeks' gestation presented to a freestanding clinic for elective abortion. After serial cervical dilation, omentum was seen in the suction curette. The patient was transferred to a nearby hospital, she underwent an exploratory laparotomy. A 1.5-cm anterior uterine perforation was found. The uterus was evacuated under direct visualization prior to repair of the defect.

CONCLUSION

Uterine perforation during D&E often requires laparotomy to repair the defect and to evaluate for injury to adjacent organs. Evacuation can be completed transcervically under direct visualization or through the perforation site.

Removal of an incarcerated intrauterine device in the sigmoid colon under the assistance of hysteroscope and laparoscope: a case report

BACKGROUND/AIMS

To explore the value of hysteroscope and laparoscope in removing an incarcerated or ectopic intrauterine device (IUD).

MATERIALS AND METHODS

A 33-year-old woman was admitted to the present hospital on May 22nd, 2013. An incarcerated IUD was proven by ultrasonography. An IUD had been implanted in October 2011. Clinical case report of an incarcerated IUD in the sigmoid colon.

RESULTS

An IUD was successfully removed with the assistance of hysteroscope and laparoscope.

CONCLUSION

Ultrasonography should be performed in the follow-up of the patients after IUD implantation. Ectopic or incarcerated IUD can be successfully removed with the assistance of hysteroscope and laparoscope with minimal trauma.

[Rare complication of a late abortion: a case report]

We report the case of a young woman who presented with acute abdomen at our hospital. The control revealed the presence of fetal parts in extra-uterin and intra-abdominal place after a late abortion. The patient was succesfully operated by celioscopy.

Abdominal intrauterine vacuum aspiration

Evaluating and "cleaning" of the uterine cavity is probably the most performed operation in women. It is done for several reasons: abortion, evaluation of irregular bleeding in premenopausal period, and postmenopausal bleeding. Abortion is undoubtedly the number one procedure with more than 44 million pregnancies terminated every year. This procedure should not be underestimated and a careful preoperative evaluation is needed. Ideally a sensitive pregnancy test should be done together with an ultrasound in order to confirm a uterine pregnancy, excluding extra-uterine pregnancy, and to detect genital and/or uterine malformations. Three out of four abortions are performed by surgical methods. Surgical methods include a sharp, blunt, and suction curettage. Suction curettage or vacuum aspiration is the preferred method. Despite the fact that it is a relative safe procedure with major complications in less than one percent of cases, it is still responsible for 13% of all maternal deaths. All the figures have not declined in the last decade. Trauma, perforation, and bleeding are a danger triage. When there is a perforation, a laparoscopy should be performed immediately, in order to detect intra-abdominal lacerations and bleeding. The bleeding should be stopped as soon as possible in order to not destabilize the patient. When there is a perforation in the uterus, this "entrance" can be used to perform the curettage. This is particularly useful if there is trauma of the isthmus and uterine wall, and it is difficult to identify the uterine canal. A curettage is a frequent performed procedure, which should not be underestimated. If there is a perforation in the uterus, then this opening can safely be used for vacuum aspiration.

Migration of Bakri balloon through an unsuspected uterine perforation during the treatment of secondary postpartum hemorrhage

The current case describes an unreported complication of Bakri balloon placement: the migration of the Bakri balloon to the broad ligament through an unsuspected uterine rupture. Finally, a hysterectomy had been required. The Bakri balloon may be involuntary introduced in an unexpected uterine rupture, even if the balloon is placed with ultrasound guidance.

[Diagnosis and management of uterine perforations after intrauterine device insertion: a report of 11 cases]

OBJECTIVE

Intrauterine device insertion is common. It is however not harmless and uterine perforation can be serious.

PATIENTS AND METHODS

Eleven cases of uterine perforation after intrauterine device insertion were listed at Tourcoing hospital between 2005 and 2009. They were analyzed to identify risk factors of uterine perforation and specify management.

RESULTS

The main symptom was pelvic pain (4 cases), pregnancy occurrence (3 cases) or inability to remove the IUD (2 cases). The intrauterine device was set during the first 9 months of post-partum in 7 cases, 2 patients were still breastfeeding. Seven patients underwent laparoscopy, 2 needed switch for laparotomy, one was treated by laparotomy only and one was lost of follow-up.

DISCUSSION AND CONCLUSION

Incidence of uterine perforation after IUD insertion ranges from 0,1 to 3/1000. Pelvic pain is the most revealing symptom. Fifteen percent of perforations complicate with adjacent organ lesion. Perforation incidence seems greater if the intrauterine device is set during the 6 first weeks of post-partum and breastfeeding, but non influenced by operator practical experience. Ultrasound follow-up of patients carrying intrauterine device is controversial. Facing a suspicion of ectopic intrauterine device, pelvic ultrasound examination is the first step imaging modality and using 3D could be useful. If it fails to localize the intrauterine device, an abdominal X-ray must be performed. Ectopic intrauterine device removal is recommended.

Ultrasound is the optimal choice for guidance in difficult hysteroscopy

OBJECTIVES

To compare costs and complications associated with ultrasound-guided hysteroscopy vs laparoscopy-guided hysteroscopy vs hysteroscopy alone for the surgical repair of intrauterine septa and synechiae.

METHODS

This was a retrospective cohort study. Charts of all patients undergoing reparative surgery for intrauterine synechiae or uterine septa at our academic institution between 2000 and 2008 were reviewed. A total of 159 procedures were included in the study, categorized into concurrent laparoscopic guidance (n = 69), ultrasound guidance (n = 52) or no guidance (n = 38). Data regarding billing, surgical case logs and complications were collected for these procedures. Using these data, complication rates and inflation-adjusted charges were compared between the groups. Statistical analysis was performed using Fisher's exact test and Student's t-test, as appropriate.

RESULTS

A uterine perforation rate of 8.7% was observed with laparoscopic guidance vs 1.9% with ultrasound guidance (P = 0.12) and 5.3% with no guidance (P = 0.41). Analysis of billing data showed that average total costs were significantly less for ultrasound guidance than for laparoscopic guidance ($9124 vs $11 895, P < 0.001). Ultrasound guidance did not increase costs over hysteroscopy alone ($9124 vs $8242, P = 0.54).

CONCLUSION

Real-time transabdominal ultrasound guidance during the resection of intrauterine synechiae or septa resulted in a trend towards reduced uterine perforation. Moreover, ultrasound guidance is less costly than laparoscopic guidance and adds no additional cost over hysteroscopy alone. Taken together, transabdominal ultrasound guidance is the optimal means of intraoperative guidance for the resection of uterine synechiae and septa.

[Intrauterine contraceptive device in an appendix--a case report]

The application of an intrauterine contraceptive device can perforate the uterus and migrate to adjacent organs such as the bladder or small bowel. The main symptoms are painful insertion of the intrauterine contraceptive device and missing IUD strings. The diagnosis of perforation and transuterine migration of the IUD is made on the basis of an ultrasound examination and an abdominal X-ray. The proper management is such case is immediate removal of the IUD. The aim of this paper was to present a case of a 34-year-old woman with a copper IUD found during a caesarean section.

Osseous metaplasia of the cervix and endometrium: a case of secondary infertility

OBJECTIVE

To report a case of osseous metaplasia of the cervix and endometrium as a cause of secondary infertility.

DESIGN

Case report.

SETTING

Istanbul Bakirkoy Women and Children Teaching and Research Hospital.

PATIENT(S)

A 31-year-old patient with secondary infertility owing to osseous metaplasia of the endometrium and cervix in whom uterine perforation occurred during the removal of bone fragments.

INTERVENTION(S)

Diagnostic and operative hysteroscopy and laparotomy.

MAIN OUTCOME MEASURE(S)

Visualization of the disappearance of the osseous metaplasia region with transvaginal ultrasound examination after the hysteroscopy intervention.

RESULT(S)

Osseous metaplasia lesions are removed by operative hysteroscopy. During this operation, laparotomy was done because of perforation of the uterine wall, and the perforated area was repaired. Two weeks after surgery, the patient underwent a transvaginal ultrasound examination, and the abnormal ultrasound appearance had resolved.

CONCLUSION(S)

As a rare cause of infertility, osseous metaplasia can be seen in the cervix and the endometrium. If osseous metaplasia is deep enough during operative hysteroscopy, uterine perforation may occur. Clinicians must be careful for this reason, especially in cases of deep osseous metaplasia.

[Insertion of IUD after extrauterine mislocation of the previous one]

We present a case report of a 37-year-old woman with accidental finding of two IUDs--one inserted correctly and the other one located in the abdomen.

Spontaneous uterine perforation of choriocarcinoma with negative beta-human chorionic gonadotropin after chemotherapy

OBJECTIVE

To report an extremely rare case of spontaneous uterine perforation of choriocarcinoma with negative beta-human chorionic gonadotropin (β-hCG) post-chemotherapy.

CLINICAL PRESENTATION AND INTERVENTION

We present a 35-year-old choriocarcinoma patient whose serial serum β-hCG levels following a fifth course of chemotherapy had been within the normal range, but who developed spontaneous uterine perforation with intra-abdominal hemorrhage after eight courses of combined chemotherapy. The patient then underwent an emergency hysterectomy and survived.

CONCLUSION

Patients with persistent focus of disease in the uterus might experience uterine perforation even after adequate chemotherapy, and therefore, the follow-up for patients after chemotherapy is very important.

[Extrauterine mislocated IUD]

Intrauterine contraceptive device (IUD) is a safe and effective method of contraception, widely used all over the world. The most common IUD complications include heavy bleeding, painful cramps, expulsion, complete or partial uterine perforation, infertility caused by pelvic inflammatory disease (PID), and an increased risk for septic and spontaneous abortion in cases of pregnancy with an IUD in situ. A potentially serious complication is the perforation of the uterus, with reported incidence of 0.5-1/1000 insertions. After perforation, devices have been found in various locations in the pelvis and abdomen. Between 2000 and 2008 there were five cases with mislocated intrauterine devices in our clinic. All patients were operated by laparoscopy and there was one conversion into laparotomy. Three patients were breast-feeding at the time. An average time between insertion and recognizing expulsion was 19.2 months. Missing strings during gynaecologic examination are the first sign of an expulsion. Transvaginal sonography combined with abdominal X-ray, is necessary to reach a definitive diagnosis. Laparoscopic treatment may be appropriate in most cases. IUD is a safe and effective method of contraceptive but its insertion may be connected with serious complications.

Early sonographic diagnosis of intrauterine device migration to the adnexa

Uterine perforation is an uncommon complication of intrauterine devices (IUDs). Perforating IUDs can migrate to various locations but paradoxically are rarely found in ovaries or broad ligament. We describe an unusual case of a 23-year-old woman 1-month postpartum with an IUD translocation to the right adnexa. The IUD was inserted only 1 week prior to presentation, and she experienced pain on insertion. After visualization by ultrasound, the IUD was laparoscopically removed. We suggest early use of ultrasound in cases of potential IUD migration, particularly in high-risk patients and when IUD insertion causes pain.

Laparoscopic management of uterine perforation: report of three cases

We present three cases of uterine perforation which were managed laparoscopically at the Aga Khan University Hospital Nairobi, between January and December 2008. Our objective was to determine the outcomes of uterine perforations and to create awareness on the availability of the laparoscopic management at such complications and to recommend the procedure as a suitable option to laparotomy.

Laparoscopic retrieval of perforated intrauterine device

We present a case of successful laparoscopic retrieval of a perforated intrauterine device (Lippes loop). The Lippes loop was inserted after manual intrauterine adhesiolysis as a treatment of uterine synaechia presenting as secondary amenorrhoea of 20 months duration. The uterine perforation in this patient did not occur at the time of insertion but possibly during the attempt at transcervical removal of the missing IUD by manipulation with the retrieval hook. Double puncture laparoscopic technique under ketamine general anaesthesia was performed to remove the IUD without complication and patient went home the same day.

Spontaneous uterine perforation due to pyometra presenting as acute abdomen

Spontaneous perforation of the uterus is rare, its incidence being about 0.01% − 0.05%. We report a rare case of diffuse peritonitis caused by spontaneously perforated pyometra. A 63-year-old woman with severe abdominal pain was admitted to our hospital. Laparotomy was performed because of the suspicion of gastrointestinal perforation with generalized peritonitis. At laparotomy, about 900 mL of pus was found in the peritoneal cavity. There were no abnormal findings in the alimentary tract, liver, or gallbladder. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Pathological investigation of the surgical specimen revealed endometritis and myometritis of the uterus; but there was no evidence of malignancy, and the cervical canal was patent. Although spontaneously perforated pyometra is rare, a perforated pyometra should therefore also be considered when elderly women present with acute abdominal pain.

[Intravesical migration of intrauterine device resulting in stone formation]

The migration into the bladder of an intrauterine contraceptive device (IUCD) by uterine perforation is a rare complication. We report two cases of IUCD which migrated into the bladder and subsequently became calcified. The two patients having had their IUCD respectively for 3 and 13 years. Revealing signs were related to bladder irritation for the first patient and hematuria for the second. The diagnosis was suggested on the plain abdominal X-ray and on ultrasound and was confirmed by cystoscopy. Ballistic lithotripsy of the bladder stone with endoscopic extraction of the IUCD was then performed. Performing a transvaginal sonographic examination of the pelvic organs, especially of the uterine anatomy is interesting before insertion of an intrauterine contraceptive device (IUCD), and repeat transvaginal sonographic examinations immediately after the insertion and 4-12 weeks later are advisable. This approach would permit early detection of any complications related to insertion of the IUCD.

Uterine perforation and small bowel incarceration: sonographic and surgical findings

Uterine perforation rarely complicates a first trimester surgical abortion, but perforation resulting in vascular or intraabdominal organ damage may require surgical intervention. The index of suspicion for uterine perforation needs to remain high when a patient presents with abdominal/pelvic pain after an abortion, as the sonographic appearance of the uterus can be variable over time.

[Uterine and jejunum perforation due to intrauterine device. A report of a case and literature review]

The application of a copper IUD can perforate completely the uterus and involve adjacent organs such as the bladder, small bowel, colon, rectum or appendix. Once the diagnosis is established, complete extraction must follow. We present a case report of a 33 year-old patient in which a copper IUD was placed in a medical office, three months after a third cesarean, without history of sepsis. Ninety days after placement, the patient complained of menstrual irregularities (opsomenhorrea) without any other symptoms. On physical examination with speculum, the IUD's guide strings were not visible; a transvaginal USG was performed without visualization of the IUD in the uterine cavity. An abdominal CAT scan showed the presence of the IUD outside the uterus. Hysteroscopy-laparoscopy was performed with transoperatory fluoroscopy, which revealed the copper IUD inside the yeyunum, a complete extraction followed with entero-entero anastomosis. This case will show that IUD placement is not innocuous and that adjacent organ damage must always be considered and resolved immediately.

Successful pregnancy after localized resection of perforated uterus in choriocarcinoma and a literature review

Choriocarcinoma is an aggressive neoplasm arising in the body of the uterus. Rapid growth and myometrial invasion may be followed by uterine perforation. In this study, we present the cases of two young patients (18 and 19 years of age) with acute abdominal pain and shock, while they were under chemotherapy due to persistent trophoblastic disease. During emergent exploratory laparotomy, localized resection of uterus was performed. They had their first successful term pregnancy 5 and 4 years after surgery, respectively. Uterine perforation following choriocarcinoma is a rare event. Hysterectomy is recommended in emergency conditions, but localized resection of uterus should be considered in women who are desirous of future fertility.

Central nervous system involvement from malignant mixed Müllerian tumor (MMMT) of the uterus

The central nervous system is traditionally considered as an uncommon site for metastatic disease from the female genital tract, and cerebral metastasis as the primary manifestation of an occult gynecological malignancy is even more rare. Here, we report the case of a 61-year-old female who presented with neurological symptoms of confusion, headache, cerebellar ataxia and right-sided weakness. Magnetic resonance imaging of the brain revealed two solid lesions in the frontal lobe and the left cerebellar hemisphere. Endometrial biopsy of a uterine mass detected during search for the primary lesion showed malignant mixed Müllerian tumor (MMMT). The patient refused surgery. Cranial radiotherapy for progressive cerebral disease led to resolution of her neurological symptoms. Two months after the diagnosis of MMMT the patient died from local complications of advanced pelvic disease. At autopsy, only the epithelial component of the tumor had metastasized to the brain. Attention should be paid to possibility of unusual distant metastases associated to MMMT in order to avoid delay in diagnosis and treatment of these patients.

[Spontaneous uterine perforation secondary to pyometra: a report of three cases]

We performed a retrospective observational review-based study of the medical records of consecutive women with diagnosis of spontaneous uterine perforation, between 1995 and 2003. During this period 3 patients with an average age of 76.2 years and with acute abdominal pain attended to the emergency department. Physical examination revealed signs of peritoneal irritation, as a result emergency laparotomy was performed, where uterine perforation was not found in the preoperative diagnosis. All patients had purulent fluid in the abdominal cavity and uterine perforation. A total abdominal hysterectomy with bilateral salpingooophorectomy was carried out under the diagnosis of generalized peritonitis caused by spontaneous perforation of pyometra. They also required cavity lavage, drainages placement, and antibiotics. Histological examination revealed uterine perforation and pyometra without evidence of malignancy. Prognosis was good and they were discharged on postoperative day 8.5 without complications. Spontaneous uterine perforation, secondary to pyometra, should be considered in the differential diagnosis of acute abdomen in postmenopausal patients, still without gynecological signs.

Trophoblastic tissue spread to the sigmoid colon after uterine perforation

BACKGROUND

Trophoblastic tissue spread following uterine perforation during dilation and curettage is rare. We present a case of trophoblastic spread to the sigmoid colon following uterine perforation, which was treated by surgical removal of the implants and intramuscular administration of methotrexate.

CASE

A woman presented 3 weeks after curettage for a blighted ovum. Laparotomy performed for suspected intra-abdominal bleeding revealed bleeding trophoblastic implants in a perforation tract and the anterior uterine wall and on the appendix epiploica of the sigmoid colon. The implants were surgically removed and methotrexate was administered for persistently high beta-hCG levels. The patient fully recovered.

CONCLUSION

Extrauterine trophoblastic implants should be considered in women evaluated for abdominal pain whose pregnancy test is positive after uterine perforation. Conservative treatment with methotrexate in nonacute patients may be considered.

Major gynaecological surgery in the Ghanaian adolescent

OBJECTIVE

To determine the indications for, findings, procedures performed and outcomes in major gynaecological operations performed on patients nineteen years old or younger.

DESIGN

Retrospective observational study.

SETTING

Korle Bu Teaching Hospital, Accra, Ghana.

SUBJECTS

Cases of major gynaecological surgery in patients aged 19 years or younger in a six-year period.

RESULTS

There were 245 patients, whose mean age was 17.3(SD 1.7) years. Sixty eight (27.8%) were less than seventeen years old and 177(72.2%) were 17-19 years old. Ruptured ectopic pregnancy, ovarian tumour, pelvic abscess and perforated uterus constituted 91% of indications. Ruptured ectopic pregnancy was confirmed in 106(43.3 %), most of whom had salpingectomy performed. Five (13.9%) of 36 ovarian tumours were malignant, all in advanced stages of disease. Thirty six had pelvic abscesses; another 29 had uterine perforations, twelve of whom had hysterectomy performed. Five patients had congenital developmental anomalies of the genital or urinary tract. Non concordance between pre- and post-operative diagnoses occurred in 29(11.8%). Mean duration of post-operative hospital stay was 13.0(SD 8.9) days and the mortality rate was 3.8%. One hundred and eighty four (75.1%) of post-operative diagnoses were related to sexual activity or pregnancy.

CONCLUSION

Most of the gynaecological problems requiring major surgery in the Ghanaian adolescent may be prevented by adequately addressing issues regarding adolescent sexuality. Sex education, as part of family life education, should be incorporated into the school curriculum. This should aim at providing appropriate level of knowledge and promoting the development of attitudes and skills that will lead to the adoption of desired behaviours.

Migration of an intrauterine contraceptive device to the sigmoid colon: a case report

BACKGROUND

Copper T intrauterine devices (IUDs) remain the mainstay of family planning measures in developing countries, but have been associated with serious complications such as bleeding, perforation and migration to adjacent organs or omentum. Although perforation of the uterus by an IUD is not uncommon, migration to the sigmoid colon is extremely rare. Here, we report a case of migration of an IUD to the sigmoid colon.

CASE REPORT

A 40-year-old woman who had an IUD (Copper T), inserted 1 month after delivery, presented, 7 months later, with secondary amenorrhea and transient pelvic cramps. Clinical findings and ultrasonographic examinations of the patient revealed an 8-week pregnancy, while laboratory tests were normal. Transvaginal ultrasonography also visualized the IUD located outside the uterus, near the sigmoid colon, as if it were attached to the bowel. The pregnancy was terminated at the patient's wish; a diagnostic laparoscopy was performed concomitantly, which showed bowel perforation owing to the migration of the IUD. The device, which was partially embedded in the sigmoid colon, was removed via laparoscopy; however, because of bowel perforation, laparotomy was performed to open colostomy.

CONCLUSIONS

This case report highlights the continuing need for intra- and postinsertion vigilance, since even recent advances in IUD technique and technology do not guarantee risk-free insertion.

Extrauterine translocated contraceptive device: a presentation of five cases and revisit of the enigmatic issues of iatrogenic perforation and migration

Translocation of an intrauterine contraceptive device to an extrauterine site in the peritoneal cavity is an uncommon complication. In cases reported in literature, the timing of extrauterine presentation and the distant sites of translocation often raise the issue of whether iatrogenic uterine perforation or migration of the device was responsible. We present and discuss five referred cases of the extrauterine device inserted in centres outside the University of Port Harcourt Teaching Hospital. The indication for insertion of the intrauterine contraceptive device in the patients (mean age 25.6 years) was contraception in four patients and adhesiolysis for Asherman's syndrome in the fifth. The most common presenting symptom was inability to feel the device's string (in three patients). Four of the patients presented within one month of the insertion. Three of the five translocated intraperitoneal devices were recovered by laparotomy and the forth by laparoscopy. The fifth patient, pregnant, defaulted with the device still retained. We are of the opinion that primary iatrogenic uterine perforation occurs occasionally. Other possible translocatory mechanisms include spontaneous uterine contractions, urinary bladder contractions, gut peristalsis and movement of peritoneal fluid.