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Migration of an Intrauterine Contraceptive Device during the Course of Pregnancy: A Case Report
Case Report
Migration of an Intrauterine Contraceptive Device during the Course of Pregnancy: A Case Report Tracy Glass, DO, MS*, Teresa Baker, MD, and Robert P. Kauffman, MD From the Texas Tech University Health Sciences Center at Amarillo, Texas (all authors).
ABSTRACT Uterine perforation by a contraceptive intrauterine device (IUD) is a relatively rare event. These events may result secondary to mechanical force applied during placement (primary perforation) or migration by uterine contractions or surgical manipulation after placement (secondary perforation). A 33-year-old woman with an IUD placed 9 years before admission visited the emergency department with an early pregnancy and a 3-day history of vaginal bleeding. Vaginal examination revealed IUD strings visible at the cervical os, and transvaginal ultrasound confirmed the presence of an IUD in the lower uterine segment and upper cervix. The IUD migrated spontaneously to the fundal myometrium at 15 weeks’ gestation. Premature rupture of membranes ensued at 20 weeks’ gestation, and, at delivery, the IUD could not be retrieved. Subsequent computed tomography confirmed that the IUD was incompletely embedded in the fundal myometrium and partially extending into the peritoneal cavity. At laparoscopic sterilization 6 weeks later, the IUD had perforated the small bowel, and the device was removed with concomitant bowel repair. This case documents spontaneous migration of a copper IUD from the lower uterine segment through the fundus during early pregnancy and supports removal of asymptomatic ectopic IUDs whenever possible. Journal of Minimally Invasive Gynecology (2009) 16, 81–83 Ó 2009 AAGL. All rights reserved. Keywords:
Intrauterine contraception device; Laparoscopy; Perforation; Pregnancy
The contraceptive intrauterine device (IUD) is the most widely used form of reversible contraception worldwide [1]. Despite a well-established safety record, uterine perforation is a recognized, albeit uncommon, complication of IUD use [1–3]. Although perforation may occur at insertion, later migration into the peritoneal cavity has been reported [2–4]. In the case herein, a copper IUD migrated from the lower uterine segment into the fundal myometrium with partial extension into the peritoneal cavity lumen during the course of an unsuccessful 20-week pregnancy. Case Report A 33-year-old woman, G8 P4214, visited the emergency department with an early pregnancy and a 3-day history of vaginal bleeding. By history, a TCu 380A IUD was inserted 9 years before admission. At examination, IUD strings were visible at the external cervical os without evidence of IUD The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Tracy Glass, DO, MS, 1400 Coulter Road, Amarillo, TX 79106. E-mail: [email protected] Submitted July 22, 2008. Accepted for publication September 6, 2008. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2009 AAGL. All rights reserved. doi:10.1016/j.jmig.2008.09.579
extrusion. Transvaginal ultrasonography confirmed the presence of a 6-week intrauterine gestation (gestational sac) with the IUD visualized in the lower uterine segment and upper cervix (Fig. 1). The patient consented to IUD removal but the strings avulsed from the device during the attempt. At 15 gestational weeks, the patient had pelvic cramping, and a transabdominal ultrasound revealed the IUD now located in the fundal myometrium with a viable singleton pregnancy (Fig. 2). At 19 weeks’ gestational age, transabdominal ultrasound showed no fetal abnormalities but oligohydramnios was detected (amniotic fluid index 5.1 cm). The IUD locale was unchanged from the earlier ultrasound examination at 15 weeks. Speculum examination revealed blood-tinged amniotic fluid emanating from the cervical os, but the cervix was closed and not effaced. The patient opted for expectant treatment despite the poor prognosis for a viable pregnancy. Two days later, the patient had vaginal bleeding and painful uterine contractions. The patient denied fever or chills and she remained afebrile. She subsequently delivered a nonviable 20-week male infant. A portion of the placenta delivered spontaneously without the IUD, and ultrasound-guided postpartum curettage was performed approximately 2 hours later to remove the remaining placental fragments. The IUD appeared embedded in the posterior fundal myometrium.
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Journal of Minimally Invasive Gynecology, Vol 16, No 1, January/February 2009
Fig. 1. Transvaginal ultrasonography confirming location of intrauterine device (IUD) in lower uterine segment at 6 weeks’ intrauterine gestational age.
An attempt to remove the IUD under ultrasonographic guidance using ring forceps was unsuccessful giving rise to the question of whether the IUD had incompletely perforated through the uterus and into the peritoneal cavity. Postoperative pelvic computed tomography confirmed the stem portion of the IUD remained embedded within the myometrial wall while the distal portion was outside the uterus adjacent to the fundus (Fig. 3). In accordance with her desire for permanent sterilization, the patient underwent laparoscopic bilateral tubal ligation 6 weeks later. At laparoscopy, the IUD was protruding from the posterior wall of the uterus and into the lumen of a loop of small bowel (Figs. 4 and 5). The IUD was removed intact, and the small bowel injury was successfully repaired laparoscopically. The patient tolerated the procedure well and underwent an unremarkable recovery. Discussion The IUD is an effective and safe form of contraception, yet potentially serious complications may occur including uterine perforation and migration to extrauterine sites including the bowel and bladder [2,5,6]. In a review of the medical literature, the incidence of uterine perforation with the IUD is reported at 0.87/1000 insertions [2] but another study suggested that the incidence in
Fig. 2. Transabominal ultrasound performed at 15 weeks’ gestational age revealed intrauterine device (IUD) in fundal portion of uterus.
Fig. 3. Computed tomography with sagittal reconstructed views revealing intrauterine device (IUD) incompletely perforating myometrium with distal portion outside uterus adjacent to fundus, while stem portion remained embedded within myometrial wall.
real-life practice may be higher [3]. The accepted mechanisms by which perforations occur are 2-fold. Primary perforations occurring at the time of insertion result from direct mechanical force. Physician experience, interval from last delivery, cervical stenosis, nulliparity, and uterine anatomic variations are established risk factors for primary perforation [4]. Secondary perforations occurring at some point after insertion appear to result from pressure necrosis leading to erosion of the uterine wall [4], uterine contractions elicited in response to a foreign body [7], or a combination of the two. In this case report, a TCu 380A IUD located in the lower uterine segment and upper cervix in early pregnancy subsequently migrated into the fundal uterine wall during the latter part of the first or second trimester. Subsequently, the IUD partially eroded into the peritoneal cavity and small bowel
Fig. 4. Location of intrauterine device through posterior wall of uterus and into small bowel as visualized during laparoscopic evaluation.
Glass et al.
Migration of an IUD During Pregnancy
83
can document migration from the lower uterine segment into the fundal myometrium between gestational weeks 6 and 15 (well before uterine manipulation with a endometrial curette). Although questions remain regarding the absolute necessity of removing an ectopic IUD in an asymptomatic patient [2], this report supports existing recommendations to pursue removal of ectopic IUDs whenever possible [6]. This patient was indeed fortunate that the intraluminal perforation did not create an enteroperitoneal fistula or other potentially lifethreatening sequelae.
Conclusions The IUD remains a safe and popular contraceptive choice. Despite an impressive record of safety and effectiveness, perforation remains an uncommon but potentially serious risk. Perforation may occur at the time of insertion or sometimes well after placement. This case report documents an unusual retrograde migration of a copper IUD during early pregnancy. In addition, it supports routine removal of ectopic IUDs when possible to minimize the risk of serious sequelae.
References Fig. 5. Retrieval of intrauterine device (IUD) laparoscopically after bilateral tubal ligation. (A) Grasping of IUD with Maryland forceps. (B) Gentle traction easily dislodged IUD from both uterus and small bowel.
lumen at an undetermined time. It is notable that the patient reported frequent uterine cramping and irritability during the entirety of her 20-week pregnancy, which would support uterine contractions as an important mechanism leading to secondary uterine perforation (via mechanical force). In nonpregnant individuals, periovulatory myometrial rhythmic contractions propel spermatozoa from the cervix toward the tubal ostia, an activity that appears to be suppressed or even reversed by the copper IUD [8,9]. Peristaltic activity at other times of the menstrual cycle and during pregnancy starts in the upper uterus and progresses in a wavelike manner toward the cervix [10]. In this case, the documented migration of the IUD from the upper cervix to the fundal myometrium is countercurrent to direction of uterine contractions observed during pregnancy. Although the IUD migration pattern is difficult to explain in this case, it is clear that the copper IUD did not inhibit uterine contractile activity during the first and second trimesters. Previous case reports cite IUD migration before or during pregnancy [5,6,11] with most perforations noted in early pregnancy. In this case, secondary perforation occurred presumably as a result of uterine contractions. We cannot eliminate the possibility that postpartum curettage did not exacerbate the degree of IUD perforation, but clearly, we
1. ESHRE Capri Workshop Group. Intrauterine devices and intrauterine systems. Hum Reprod Update. 2008;14:197–208. 2. Markovitch O, Klein Z, Gidoni Y, Holzinger M, Beyth Y. Extrauterine mislocated IUD: is surgical removal mandatory? Contraception. 2002; 66:105–108. 3. Harrison-Woolrych M, Ashton J, Coulter D. Uterine perforation on intrauterine device insertion: is the incidence higher than previously reported? Contraception. 2003;67:53–56. 4. Zakin D, Stern WZ, Rosenblatt R. Complete and partial uterine perforation and embedding following insertion of intrauterine devices, I: classification, complications, mechanism, incidence, and missing string. Obstet Gynecol Surv. 1981;36:335–353. 5. Inceboz U, Ozcakir H, Uyar Y. Migration of an intrauterine contraceptive device to the sigmoid colon: a case report. Eur J Contracept Reprod Health Care. 2003;8:229–232. 6. Tuncay YA, Tuncay E, Guzin K, Ozturk D, Omurcan C, Yucel N. Transuterine migration as a complication of intrauterine contraceptive devices: six case reports. Eur J Contracept Reprod Health Care. 2004;9: 194–200. 7. Tatum HJ. Clinical aspects of intrauterine contraception: circumspection 1976. Fertil Steril. 1977;28:3–28. 8. Salamanca A, Carrillo MP, Beltran E, Clavero PA. Transvaginal sonographic evaluation of subendometrial-myometrial contractility in women using a copper-releasing intrauterine device. Contraception. 2008;77:444–446. 9. Kido A, Togashi K, Kataoka ML, Nakai A, Koyama T, Fujii S. Intrauterine devices and uterine peristalsis: evaluation with MRI. Magn Reson Imaging. 2008;26:54–58. 10. Ijland M, Evers J, Dunselman G, Van Katwijk L, Hoogland H. Endometrial wavelike movements during the menstrual cycle. Fertil Steril. 1996; 65:746–749. 11. Dunn JS Jr, Zerbe MJ, Bloomquist JL, Ellerkman RM, Bent AE. Ectopic IUD complicating pregnancy: a case report. J Reprod Med. 2002;47: 57–59.
Migration of an Intrauterine Contraceptive Device during the Course of Pregnancy: A Case Report Tracy Glass, DO, MS*, Teresa Baker, MD, and Robert P. Kauffman, MD From the Texas Tech University Health Sciences Center at Amarillo, Texas (all authors).
ABSTRACT Uterine perforation by a contraceptive intrauterine device (IUD) is a relatively rare event. These events may result secondary to mechanical force applied during placement (primary perforation) or migration by uterine contractions or surgical manipulation after placement (secondary perforation). A 33-year-old woman with an IUD placed 9 years before admission visited the emergency department with an early pregnancy and a 3-day history of vaginal bleeding. Vaginal examination revealed IUD strings visible at the cervical os, and transvaginal ultrasound confirmed the presence of an IUD in the lower uterine segment and upper cervix. The IUD migrated spontaneously to the fundal myometrium at 15 weeks’ gestation. Premature rupture of membranes ensued at 20 weeks’ gestation, and, at delivery, the IUD could not be retrieved. Subsequent computed tomography confirmed that the IUD was incompletely embedded in the fundal myometrium and partially extending into the peritoneal cavity. At laparoscopic sterilization 6 weeks later, the IUD had perforated the small bowel, and the device was removed with concomitant bowel repair. This case documents spontaneous migration of a copper IUD from the lower uterine segment through the fundus during early pregnancy and supports removal of asymptomatic ectopic IUDs whenever possible. Journal of Minimally Invasive Gynecology (2009) 16, 81–83 Ó 2009 AAGL. All rights reserved. Keywords:
Intrauterine contraception device; Laparoscopy; Perforation; Pregnancy
The contraceptive intrauterine device (IUD) is the most widely used form of reversible contraception worldwide [1]. Despite a well-established safety record, uterine perforation is a recognized, albeit uncommon, complication of IUD use [1–3]. Although perforation may occur at insertion, later migration into the peritoneal cavity has been reported [2–4]. In the case herein, a copper IUD migrated from the lower uterine segment into the fundal myometrium with partial extension into the peritoneal cavity lumen during the course of an unsuccessful 20-week pregnancy. Case Report A 33-year-old woman, G8 P4214, visited the emergency department with an early pregnancy and a 3-day history of vaginal bleeding. By history, a TCu 380A IUD was inserted 9 years before admission. At examination, IUD strings were visible at the external cervical os without evidence of IUD The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Tracy Glass, DO, MS, 1400 Coulter Road, Amarillo, TX 79106. E-mail: [email protected] Submitted July 22, 2008. Accepted for publication September 6, 2008. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2009 AAGL. All rights reserved. doi:10.1016/j.jmig.2008.09.579
extrusion. Transvaginal ultrasonography confirmed the presence of a 6-week intrauterine gestation (gestational sac) with the IUD visualized in the lower uterine segment and upper cervix (Fig. 1). The patient consented to IUD removal but the strings avulsed from the device during the attempt. At 15 gestational weeks, the patient had pelvic cramping, and a transabdominal ultrasound revealed the IUD now located in the fundal myometrium with a viable singleton pregnancy (Fig. 2). At 19 weeks’ gestational age, transabdominal ultrasound showed no fetal abnormalities but oligohydramnios was detected (amniotic fluid index 5.1 cm). The IUD locale was unchanged from the earlier ultrasound examination at 15 weeks. Speculum examination revealed blood-tinged amniotic fluid emanating from the cervical os, but the cervix was closed and not effaced. The patient opted for expectant treatment despite the poor prognosis for a viable pregnancy. Two days later, the patient had vaginal bleeding and painful uterine contractions. The patient denied fever or chills and she remained afebrile. She subsequently delivered a nonviable 20-week male infant. A portion of the placenta delivered spontaneously without the IUD, and ultrasound-guided postpartum curettage was performed approximately 2 hours later to remove the remaining placental fragments. The IUD appeared embedded in the posterior fundal myometrium.
82
Journal of Minimally Invasive Gynecology, Vol 16, No 1, January/February 2009
Fig. 1. Transvaginal ultrasonography confirming location of intrauterine device (IUD) in lower uterine segment at 6 weeks’ intrauterine gestational age.
An attempt to remove the IUD under ultrasonographic guidance using ring forceps was unsuccessful giving rise to the question of whether the IUD had incompletely perforated through the uterus and into the peritoneal cavity. Postoperative pelvic computed tomography confirmed the stem portion of the IUD remained embedded within the myometrial wall while the distal portion was outside the uterus adjacent to the fundus (Fig. 3). In accordance with her desire for permanent sterilization, the patient underwent laparoscopic bilateral tubal ligation 6 weeks later. At laparoscopy, the IUD was protruding from the posterior wall of the uterus and into the lumen of a loop of small bowel (Figs. 4 and 5). The IUD was removed intact, and the small bowel injury was successfully repaired laparoscopically. The patient tolerated the procedure well and underwent an unremarkable recovery. Discussion The IUD is an effective and safe form of contraception, yet potentially serious complications may occur including uterine perforation and migration to extrauterine sites including the bowel and bladder [2,5,6]. In a review of the medical literature, the incidence of uterine perforation with the IUD is reported at 0.87/1000 insertions [2] but another study suggested that the incidence in
Fig. 2. Transabominal ultrasound performed at 15 weeks’ gestational age revealed intrauterine device (IUD) in fundal portion of uterus.
Fig. 3. Computed tomography with sagittal reconstructed views revealing intrauterine device (IUD) incompletely perforating myometrium with distal portion outside uterus adjacent to fundus, while stem portion remained embedded within myometrial wall.
real-life practice may be higher [3]. The accepted mechanisms by which perforations occur are 2-fold. Primary perforations occurring at the time of insertion result from direct mechanical force. Physician experience, interval from last delivery, cervical stenosis, nulliparity, and uterine anatomic variations are established risk factors for primary perforation [4]. Secondary perforations occurring at some point after insertion appear to result from pressure necrosis leading to erosion of the uterine wall [4], uterine contractions elicited in response to a foreign body [7], or a combination of the two. In this case report, a TCu 380A IUD located in the lower uterine segment and upper cervix in early pregnancy subsequently migrated into the fundal uterine wall during the latter part of the first or second trimester. Subsequently, the IUD partially eroded into the peritoneal cavity and small bowel
Fig. 4. Location of intrauterine device through posterior wall of uterus and into small bowel as visualized during laparoscopic evaluation.
Glass et al.
Migration of an IUD During Pregnancy
83
can document migration from the lower uterine segment into the fundal myometrium between gestational weeks 6 and 15 (well before uterine manipulation with a endometrial curette). Although questions remain regarding the absolute necessity of removing an ectopic IUD in an asymptomatic patient [2], this report supports existing recommendations to pursue removal of ectopic IUDs whenever possible [6]. This patient was indeed fortunate that the intraluminal perforation did not create an enteroperitoneal fistula or other potentially lifethreatening sequelae.
Conclusions The IUD remains a safe and popular contraceptive choice. Despite an impressive record of safety and effectiveness, perforation remains an uncommon but potentially serious risk. Perforation may occur at the time of insertion or sometimes well after placement. This case report documents an unusual retrograde migration of a copper IUD during early pregnancy. In addition, it supports routine removal of ectopic IUDs when possible to minimize the risk of serious sequelae.
References Fig. 5. Retrieval of intrauterine device (IUD) laparoscopically after bilateral tubal ligation. (A) Grasping of IUD with Maryland forceps. (B) Gentle traction easily dislodged IUD from both uterus and small bowel.
lumen at an undetermined time. It is notable that the patient reported frequent uterine cramping and irritability during the entirety of her 20-week pregnancy, which would support uterine contractions as an important mechanism leading to secondary uterine perforation (via mechanical force). In nonpregnant individuals, periovulatory myometrial rhythmic contractions propel spermatozoa from the cervix toward the tubal ostia, an activity that appears to be suppressed or even reversed by the copper IUD [8,9]. Peristaltic activity at other times of the menstrual cycle and during pregnancy starts in the upper uterus and progresses in a wavelike manner toward the cervix [10]. In this case, the documented migration of the IUD from the upper cervix to the fundal myometrium is countercurrent to direction of uterine contractions observed during pregnancy. Although the IUD migration pattern is difficult to explain in this case, it is clear that the copper IUD did not inhibit uterine contractile activity during the first and second trimesters. Previous case reports cite IUD migration before or during pregnancy [5,6,11] with most perforations noted in early pregnancy. In this case, secondary perforation occurred presumably as a result of uterine contractions. We cannot eliminate the possibility that postpartum curettage did not exacerbate the degree of IUD perforation, but clearly, we
1. ESHRE Capri Workshop Group. Intrauterine devices and intrauterine systems. Hum Reprod Update. 2008;14:197–208. 2. Markovitch O, Klein Z, Gidoni Y, Holzinger M, Beyth Y. Extrauterine mislocated IUD: is surgical removal mandatory? Contraception. 2002; 66:105–108. 3. Harrison-Woolrych M, Ashton J, Coulter D. Uterine perforation on intrauterine device insertion: is the incidence higher than previously reported? Contraception. 2003;67:53–56. 4. Zakin D, Stern WZ, Rosenblatt R. Complete and partial uterine perforation and embedding following insertion of intrauterine devices, I: classification, complications, mechanism, incidence, and missing string. Obstet Gynecol Surv. 1981;36:335–353. 5. Inceboz U, Ozcakir H, Uyar Y. Migration of an intrauterine contraceptive device to the sigmoid colon: a case report. Eur J Contracept Reprod Health Care. 2003;8:229–232. 6. Tuncay YA, Tuncay E, Guzin K, Ozturk D, Omurcan C, Yucel N. Transuterine migration as a complication of intrauterine contraceptive devices: six case reports. Eur J Contracept Reprod Health Care. 2004;9: 194–200. 7. Tatum HJ. Clinical aspects of intrauterine contraception: circumspection 1976. Fertil Steril. 1977;28:3–28. 8. Salamanca A, Carrillo MP, Beltran E, Clavero PA. Transvaginal sonographic evaluation of subendometrial-myometrial contractility in women using a copper-releasing intrauterine device. Contraception. 2008;77:444–446. 9. Kido A, Togashi K, Kataoka ML, Nakai A, Koyama T, Fujii S. Intrauterine devices and uterine peristalsis: evaluation with MRI. Magn Reson Imaging. 2008;26:54–58. 10. Ijland M, Evers J, Dunselman G, Van Katwijk L, Hoogland H. Endometrial wavelike movements during the menstrual cycle. Fertil Steril. 1996; 65:746–749. 11. Dunn JS Jr, Zerbe MJ, Bloomquist JL, Ellerkman RM, Bent AE. Ectopic IUD complicating pregnancy: a case report. J Reprod Med. 2002;47: 57–59.