Agrawal A*, Samant PY**, Swathi HV***
(* Fourth Year Resident, ** Additional Professor, *** Second Year Resident, Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai, India.)
Finding of intrauterine contraceptive device (IUCD) incidentally during abdominal and pelvic surgery from colon, peritoneal cavity, pouch of Douglas and bladder have been reported in many cases. Usually this is the sequel of uterine perforation and IUCD being displaced. In some cases, IUCD can be detected incidentally during investigation and in some cases directly during surgery. Here we report a case of an incidentally detected IUCD in the pouch of Douglas during vaginal hysterectomy.
IUCD is commonly used for birth spacing and longer acting contraceptive methods. In spite of all the advantages it also has some complications which need to be explained to the clients before insertion. Complications include infection, irregular bleeding, chronic pelvic pain, infertility and ectopic pregnancy. There may be some serious complications like perforation of the uterus and translocation into adjacent structures. Though rare; they may be life threatening leading to perforation of the colon and even fistula formation, but in certain cases translocation may be asymptomatic.
A 44 year old woman presented to gynecology outpatient department with irregular menstrual cycles and heavy bleeding for 6 months. She bled every 15-20 days and the bleeding lasted for 7-8 days with passage of clots but no pain. She was P4 L4 with all normal deliveries. Her last child birth was 12 years ago. She didn’t give any history of contraception use or sterilization operation. She didn’t have any significant medical or surgical illness. On examination, her vital parameters were stable, there was no thyroid swelling, systemic examination was normal. Abdomen was soft with no tenderness or mass. On pelvic examination uterus was 10-12 weeks in size with multiple small fibroids. Ultrasonography revealed bulky uterus with multiple fibroids in the anterior wall and on the fundus. Cervical and endometrial aspiration cytology were normal. She was advised vaginal hysterectomy. Hysterectomy was uneventful but there was a foreign body located in the peritoneal cavity which was retrieved. It was found to be an IUCD (Cu 7) without strings and was nude without any copper wire wound to it. There was no visible scar on the uterine walls. On recovery, the she was asked about IUCD insertion; she was not aware of this IUCD insertion and had not experienced any remarkable pelvic pain or gastrointestinal symptoms in the past. IUCD was removed and her post-operative period was uneventful.
Figure 1. Uterus with Copper 7.
Risk of IUCD perforation may vary from 1.3-1.8/ 1000.[1,2] IUCD should be placed with proper skill and caution to prevent this complication. IUCD can be placed post abortion, post placental, post partum, interval after 6 weeks of delivery or at any time between the 7th to 10th day of the menstrual cycle. Risk of perforation and displacement is slightly higher when it is placed immediately after delivery, as the uterus is soft, involuting and has thinning of the uterine wall during the postpartum period. Early presentation is usually symptomatic with pain in abdomen while late presentation is asymptomatic and they present with missing thread or pregnancy.[4,5]
According to Balci et al diagnosis of missing IUCD can be made with pelvic ultrasonography (USG) as the first diagnostic modality. Pelvic radiography (X Ray lateral view with uterine sound) can also be done when diagnosis can’t be made by USG.
Tarus and Kaufman in their study found that abdominal sonography and computerized tomography (CT) scan were helpful in locating IUCD. X-ray and USG may be helpful but CT scan provides clear information regarding IUCD location in relation to other viscera.
Management of translocated IUCD will depend on clinical judgment and symptoms of the patient. Usually endoscopic management is preferred. Mosley et al in 2012 in their review regarding removal of missing IUCD stated that majority of the displaced IUCD were copper IUCD or Lippes loop. Out of 129 cases of displaced IUCD in 120 cases laparoscopic removal was done and in 20 of 120 cases laparoscopy had to be converted to open method. The approach may be decided depending upon the pre- operative evaluation and location of IUCD prior to surgery.[4,6] In cases with dense adhesion of bowel and urogenital organs to IUCD laparotomy is preferred. Laparoscopy is now been the preferred mode as it is associated with less tissue handling, lesser adhesion formation, shorter hospital stays and rapid recovery.[1,2] In our case probably adhesions did not form as the Cu 7 was nude and there was no infection.
Cases have been reported with IUD displaced into the bladder, colon, peritoneum, appendix, omentum, adnexa leading to many complications like peritonitis, fistula formation, obstruction, and tubo-ovarian abscess. Cystoscopy, sigmoidoscopy and colonoscopy may be of help in retrieving IUCD in cases with IUCD in bladder or colon respectively.
Timing and technique of IUCD placement is important in preventing complication. IUCD should be placed after proper counseling and awareness so that if the thread is missing, she can come for follow up. Translocation into abdominal cavity though very rare, is still a life threatening complication.
- Mosley FR, Shahi N, Kurer MA. Elective Surgical Removal of Migrated Intrauterine Contraceptive Devices From Within the Peritoneal Cavity: A Comparison Between Open and Laparoscopic Removal. JSLS 2012;16:236–41.
- Arslan A, Kanat-Pektas M, Yesilyurt H, Bilge U. Colon penetration by a copper intrauterine device: a case report with literature review. Arch Gynecol Obstet. 2009;279(3):395-7.
- Katara AN, Chandiramani VA, Pandya SM, Nair NS. Migra-tion of intrauterine contraceptive device into the appendix. Indian J Surg. 2004;66:179–180.
- Weerasekera A, Wijesinghe P, Nugaduwa N. Sigmoid colocolic fistula caused by intrauterine device migration: a case report. Journal of Medical Case Reports.2014;8:81.
- Balci O, Mahmoud AS, Capar M, Colakoglu MC. Diagnosis and management of intra-abdominal, mislocated intrauterine devices. Arch Gynecol Obstet. 2010;281(6):1019 –1022.
- Taras AR, Kaufman JA. Laparoscopic retrieval of intrauterine device perforating the sigmoid colon. JSLS. 2010; 14(3): 453–455.
- 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):e60-2.
- Medina TM, Hill DA, DeJesus S, Hoover F. IUD removal with colonoscopy: a case report. J Reprod Med. 2005;50(7):547-9.
Agrawal A, Samant PY, Swathi HV. Translocated IUCD In Peritoneal Cavity. JPGO 2017. Volume 4 No.8. Available from: http://www.jpgo.org/2017/08/translocated-iucd-in-peritoneal-cavity.html