Supriya Poonia*, Vibha More**, Shruti Panchbuddhe**, M. N. Satia ***
(*Third Year Resident, ** Assistant Professor, *** Professor. Department of Obstetrics and Gynecology, Seth GS Medical College and
Hospital, .) Mumbai, India
Intrauterine devices (IUD) are amongst the most commonly used methods of contraception. Perforation of the uterus and migration into the peritoneal cavity is one of its rare but serious complication. Here is a case with IUD migration into recto-sigmoid mesentery with removal by laparotomy.
IUD has been in vogue since 1965 for contraception. Its increase in use is due to their efficacy, easy reversibility, patient satisfaction and minimal systemic side effects.[2, 3] Perforation occurs rarely with migration into the organs intimately related to the uterus such as urinary bladder, rectum, colon, peritoneum, ovary, appendix and wall of iliac veins. IUD is often the method for lactating mothers as it does not affect the quality and composition of milk. Removal of IUD may be done by hysteroscopy, laparoscopy or laparotomy.
A 26-year-old Para 2 Live issue 2 with previous cesarean section, six months postpartum was brought to emergency department from peripheral maternity hospital with ultrasonography showing a misplaced copper –T in intraperitoneal cavity on the right side. Patient had copper T (Cu- T 380-A) inserted at peripheral hospital by an auxiliary nurse midwife on day-5 of menses during lactation period. She complained of agonizing abdominal pain. The threads were not felt the next day. Uterine perforation was suspected and hence patient was referred to tertiary care center. Clinical examination revealed stable vital parameters and a soft abdomen. Bowel sounds were present. On speculum examination copper –T threads could not be seen. No tenderness was elicited on vaginal examination. Radiography with intrauterine sound showed IUD towards right side in the uterine cavity. Ultrasonography of the abdomen and pelvis showed Copper-T in the right adnexa, close to the right ovary. In view of discrepancy between X-Ray( lateral film was not available) and ultrasonography a computed tomography (CT) scan of the abdomen and pelvis was done. It revealed the copper-T lying partially outside the uterus in pouch of
Douglas and one arm appeared embedded in the
uterine wall, abutting the
rectosigmoid colon. No air or free fluid was seen in the peritoneal cavity. A
hysteroscopy was performed, which did not any copper-T, but it was felt in the left uterine wall.
However, it could not be removed. In view of
suspected adhesions and bowel involvement exploratory laparotomy was done. Copper-T
was seen in pouch of Douglas on left
side embedded in mesentery of rectosigmoid colon It was removed and a small mesentery tear was sutured with polyglactin 910 no
2-0. Bowel was inspected. No
bowel injury was seen. A
small sealed 2 mm uterine perforation was seen on the fundus of uterus near
right cornua which was left untouched. Post procedure period was uneventful.
Patient was discharged
on the 7th postoperative day.
Figure 1. Anteroposterior radiograph of abdomen and pelvis with uterine sound in situ. IUD is seen towards right side, probably in the uterine cavity.
Figure 2. CT scan abdomen and pelvis showing IUD (arrows) between uterus and rectosigmoid colon.
Figure 3. Copper-T (arrow) is seen lying in the recto sigmoid mesentery on laparotomy.
Since the introduction in 1965, IUD is commonly used as effective, safe and economic method of contraception. Incidence of migrated IUD is 0.5-1%/1000 IUD insertions.  Incidence of misplaced IUD is influenced by several factors such as parity, insertion time, previous abortions, type and method(push out insertion technique) of insertion technique, operator experience and position of uterus. IUD can be used in lactating mothers as they do not effect milk composition. Thinning of uterine wall due to hypoestrogenic state could be the cause of perforation as seen in the lactation period. Sharp pain at the time of insertion, disappearance of IUD thread and post procedure bleeding are suggestive of perforation
Perforation may be complete where IUD migrate into peritoneal cavity or embed in nearby structures or partial where part of it is retained in uterine cavity or wall. Perforation mostly occurs during insertion especially owing to wrong push out insertion technique. Less commonly perforation is due to chronic inflammatory reaction caused by cytokines release, degradation of extracellular matrix by matrix metalloproteinase resulting in gradual erosion of the uterine wall. Translocated IUD induces a dense fibro elastic reaction necessitating a laparotomy for its removal due to suspected adhesions.
Uterine perforation by IUD may remain asymptomatic in 85% cases. It may present as sharp pain at insertion time, disappearance of IUD at the time of insertion, post coital bleeding. Misplaced IUD may invade its neighboring organs such as the adnexa, broad ligament, pouch of Douglas, intestine(obstruction, stricture, adhesions), urinary bladder(vesical calculi), peritoneum(omental mass or intraperitoneal bleed or abscess), appendix ( perforation mimicking appendicitis) rectum or recto-sigmoid mesentery as in our case.[2,3,4,5,6,7] Often these complications are due to faulty technique of IUD insertion which is push out technique.
A plain radiograph of the abdomen was previously the initial investigation of choice, for verifying the presence of an IUD in the pelvis but now a days often forgotten due to easy availability of imaging modalities like ultrasound and CT scan. In our case only anteroposterior X-Ray image was available and the lateral image was misplaced. So an ultrasound examination was done. It shows the location of the IUD in relation to the uterus without the need for an intrauterine sound which is used to identify the uterine cavity in a radiograph.. CT Scan is indicated when when there is discrepancy between ultrasound and radiograph or when bowel involvement is suspected. In our case anteroposterior radiograph was not sufficient to comment on IUD location and ultrasonography showed it to be lying outside the uterus hence the need of the CT scan. Although X-Ray and ultrasonography done revealed the copper-T on the right side; CT images and direct visualization intraoperatively showed the IUD location on the left side. This can be due to intraperitoneal migration of IUD which though rare is not uncommon. The treatment of the misplaced IUCD is surgical, laparoscopy or laparotomy. In view of suspected adhesions laparoscopic removal was not attempted and IUD was removed by laparotomy. Withdrawal of the migrated IUD is advisable even if its migration is asymptomatic, so that further complications like a bowel and bladder perforation or a fistula formation may be prevented.
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Poonia S, More V, Panchbuddhe S,
IUD In Rectosigmoid Mesentery. JPGO
2014 Volume 1 Number 6 Available from: http://www.jpgo.org/2014/06/misplaced-iud-in-rectosigmoid-mesentery.html Satia MN