Postplacental intra-abdominal placement of levonorgestrel 52 mg intrauterine system: A case report

Journal Pre-proofs Case Report Postplacental intra-abdominal placement of levonorgestrel 52mg intrauterine system: a case report Sarah F. Peterson, Andrea Henkel, Amitha Ganti, Paul D. Blumenthal PII: DOI: Reference:

S0010-7824(20)30049-4 https://doi.org/10.1016/j.contraception.2020.01.015 CON 9392

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Contraception

Received Date: Revised Date: Accepted Date:

30 September 2019 28 January 2020 29 January 2020

Please cite this article as: S.F. Peterson, A. Henkel, A. Ganti, P.D. Blumenthal, Postplacental intra-abdominal placement of levonorgestrel 52mg intrauterine system: a case report, Contraception (2020), doi: https://doi.org/ 10.1016/j.contraception.2020.01.015

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Peterson 1

Postplacental intra-abdominal placement of levonorgestrel 52mg intrauterine system: a

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case report

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Sarah F. Peterson MD1, Andrea Henkel MD1, Amitha Ganti MD1, Paul D. Blumenthal MD,

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MPH1

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Stanford University School of Medicine, Department of Obstetrics and Gynecology, Division of

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Family Planning Services and Research, Stanford, California

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Corresponding Author:

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Sarah F. Peterson, MD Stanford University School of Medicine Department of Obstetrics and Gynecology 300 Pasteur Drive Room HG332 Stanford, CA 94305-5317 616-340-5821 [email protected]

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Acknowledgement of funding: This research did not receive any specific grant from funding

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agencies in the public, commercial, or not-for-profit sectors.

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Declarations of interest: None

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Permission from the patient: The authors have obtained written consent from the patient on

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whom the report is based.

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Word Counts: Abstract 49, Manuscript text 1243

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Abstract:

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manual postplacental placement demonstrates the importance of proper insertion technique and

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ascertainment of fundal placement. Ultrasound guidance can be considered if fundal placement is

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uncertain. Short interval follow up should be recommended to confirm proper placement.

This case of an intra-abdominal levonorgestrel 52mg intrauterine system found three weeks after

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Keywords: postplacental, postpartum, intrauterine contraceptive device, intraabdominal LNG-

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IUS, missing LNG-IUS, perforation

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Introduction

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The unmet need for contraception remains highest in the postpartum period [1].

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Recommendations from U.S. and international organizations support offering postpartum

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intrauterine device (IUD) services for all women [1]. Postplacental IUD insertion is safe without

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increased risk of perforation or infection compared to interval insertion, though most studies do

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find higher expulsion rates [2, 7]. Placement of long-acting, reversible contraception (LARC) in

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the immediate postpartum period is an important opportunity to engage women in family

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planning decisions as they are already actively interfacing with the healthcare system.

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Perforation risk is rare with postplacental insertion of a copper-containing IUD and there are no

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documented reported cases involving postplacental levonorgestrel intrauterine system (LNG-

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IUS) insertion. We present a case of a LNG-IUS found to be intra-abdominal three weeks after

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postplacental insertion.

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Case Report

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A 32-year old, G4P3 at 39 weeks 0 days of gestation underwent labor induction for gestational

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diabetes and poorly controlled epilepsy. After contraceptive counseling during prenatal visits,

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she requested postplacental LNG 52mg IUS placement. Her labor course was uncomplicated

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with epidural anesthesia, a normal vaginal delivery, and an estimated blood loss of 100 ml.

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Within a few minutes of placenta delivery, the resident obstetrician (postgraduate year 3)

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removed a LNG 52mg IUS (Liletta, Allergan and Meds360, Irvine, CA) from its applicator,

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placed the IUS between the index and middle fingers and guided the device into the uterus. The

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other hand was simultaneously placed on the abdomen to stabilize the uterus externally. Once the

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resident felt the IUS was correctly positioned, the resident slightly rotated the internal hand away

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from the IUS to avoid dislodging it from its fundal position and then removed the hand. The

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resident trimmed the strings at the level of the cervix. Ultrasound was not used during or

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immediately after IUD placement. The patient was discharged on postpartum day two.

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At three weeks postpartum, the patient presented to an urgent care for increased vaginal

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bleeding and persistent abdominal pain. An abdominal radiograph was performed due to the

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patient’s history of constipation. Imaging showed an IUD positioned over the right lateral

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superior iliac wing, suggesting extrauterine location of the IUD device. She was then sent to our

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emergency room for further evaluation. The clinician visualized a normal cervix and no IUD

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strings during speculum examination and could not feel IUD strings with bimanual examination.

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An abdominal ultrasound examination of the pelvis showed no IUD in the endometrial cavity but

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a 2.4 cm echogenic linear object in the cervix [Fig. 1]. A repeat abdominal radiograph again

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demonstrated an IUD over the right lower quadrant, likely outside the uterus [Fig. 2]. Due to

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suggestion of the IUD within the cervix on ultrasound and knowing perforation with

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postplacental IUD insertion is extremely rare, an attempt was made to remove the IUD in clinic

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under ultrasound guidance but the patient was unable to tolerate the procedure. We suggested

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proceeding to the operating room for examination under anesthesia, hysteroscopy and possible

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diagnostic laparoscopy.

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Diagnostic hysteroscopy revealed no IUD within the uterine cavity. Prior to converting to

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laparoscopy, an intraoperative abdominal radiograph was repeated to confirm presence of the

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IUD in the abdomen. Upon laparoscopic entry, the IUD was found along the right pelvic side

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wall in the right paracolic gutter, near the level of the cecum [Fig. 3]. The IUD strings were

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grasped and the IUD was removed intact. The uterus appeared normal with no evidence of a

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healing defect from prior perforation [Fig. 3]. Her postoperative recovery was unremarkable.

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Comment

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Uterine perforation represents a rare complication of postplacental IUD placement. Our

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case is the only report of which we are aware with a postplacentally inserted LNG-IUS found to

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be intra-abdominal. Although rare, it is important to know that uterine perforation can occur with

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postplacental IUD placement and that providers training in postplacental IUD placement can

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correctly ascertain fundal placement.

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The most common risk with postplacental IUD insertion is the risk of expulsion. In a

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systematic review, postplacental IUD insertion consistently resulted in higher rates of expulsion

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(10-20%) than interval insertion (1-3%) [3]. No difference in expulsion rates was reported

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between devices placed manually or with forceps (13.3 and 12.7 per 100 women, respectively)

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[4]. There does appear to be a decreased risk of expulsion with copper IUDs (20%) compared to

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LNG devices (38%) [5]. Immediate ultrasound to assess fundal placement has not been shown to

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have predictive utility in anticipating expulsions [5], but could be a useful tool if placement is

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uncertain or is being performed with trainees. Overall, the issue of expulsion, is, more than

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anything else, a counseling point that should be discussed with potential acceptors.

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Uterine perforation is a rare but potentially serious risk of IUD insertion. A large

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population-based study reports the overall incidence of perforation with IUD insertion as 0 to

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1.2/1000 [6]. Of the 370 identified perforations over a 13-year period, more than half of all the

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patients had given birth within the previous six months and at least one-third were breastfeeding

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and amenorrhoeic at the time of insertion. A large prospective follow-up study demonstrated an

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incidence of uterine perforation during the first 12 months postpartum of 2.2/1000. This risk was

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not increased with immediate postplacental insertion or insertion after 6 months postpartum, but

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did progressively increase in the 0-3 month and 3-6 month postpartum groups [7]. The majority

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of perforations occurred during insertions by inexperienced providers. Notably, the authors

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report the only documented case we could find of uterine perforation after postplacental IUD

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insertion [7]. In that case, a copper T-380A IUD inserted via a ring forceps was noted to be

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extrauterine at the 12-month follow up visit. Given there was no short-term follow-up in this

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study, it is difficult to estimate the relative likelihood of IUD migration out of the uterine cavity

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over time as opposed to perforation at the time of insertion. The same could be a possibility in

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our case of an extra-uterine LNG-IUS, though with a much shorter time frame of possibility.

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Our case serves as a reminder that, although rare, uterine perforation at the time of

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postplacental IUD placement can occur with either a copper IUD or LNG-IUS. Although the exact

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mechanism for extrauterine location of this IUD cannot be definitely determined, it was likely a

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result of iatrogenic trauma to the posterior or fundal aspect of the uterus by the physician’s hand

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during placement, resulting in the IUD being placed intra-abdominally. An alternative mechanism

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could be partial perforation of the uterus and subsequent migration of the IUD through the area of

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trauma to result in extrauterine location. Ultrasound guidance confirmation can be considered if

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fundal IUD placement is uncertain, particularly if the instrument (whether hand, forceps or

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dedicated inserter) cannot be palpated by the abdominal hand at the time of insertion, as

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recommended by numerous guidelines [8]. Ultrasound use as a guidance tool should be at the

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provider’s discretion either as simultaneous transabdominal ultrasound, or as confirmation post-

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placement to ensure fundal, intrauterine placement. Additionally, shorter interval follow-up in the

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postpartum period (within 2-3 weeks) for patients who receive a postplacental IUD could allow

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earlier confirmation that their IUD is in the appropriate position or prompt an earlier evaluation if

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there is concern for misplacement. While perforation is rare, expulsion is a more likely adverse

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event that earlier follow-up could potentially help decrease by decreasing risk of tension on the

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strings causing a partial expulsion and ultimately, the risk of unintended pregnancy as a result of

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unrecognized expulsion and initiation of sexual activity without reliable contraception.

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References

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[1]. American College of Obstetricians and Gynecologists' Committee on Obstetric Practice.

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Committee Opinion No. 670: Immediate Postpartum Long-Acting Reversible Contraception.

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Obstet Gynecol. 2016;128(2):e32-7.

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[2]. Whitaker AK, Chen BA. Society of Family Planning Guidelines: Postplacental insertion of

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intrauterine devices. Contraception 2018;97:2-13.

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[3]. Kapp N, Curtis KM. Intrauterine device insertion during the postpartum period: a systematic

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review. Contraception. 2009;80(4):327-36.

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[4]. Xu JX, Rivera R, Dunson TR, Zhuang LQ, Yang XL, Ma GT, et al. A comparative study of

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two techniques used in immediate postplacental insertion (IPPI) of the Copper T-380A IUD in

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Shanghai, People's Republic of China. Contraception. 1996;54(1):33-8.

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[5]. Goldthwaite LM, Sheeder J, Hyer J, Tocce K, Teal SB. Postplacental intrauterine device

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expulsion by 12 weeks: a prospective cohort study. Am J Obstet Gynecol. 2017;217(6):674 e1-

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e8.

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[6]. Kaislasuo J, Suhonen S, Gissler M, Lahteenmaki P, Heikinheimo O. Intrauterine

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contraception: incidence and factors associated with uterine perforation--a population-based

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study. Hum Reprod. 2012;27(9):2658-63.

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[7]. Caliskan E, Ozturk N, Dilbaz BO, Dilbaz S. Analysis of risk factors associated with uterine

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perforation by intrauterine devices. Eur J Contracept Reprod Health Care. 2003;8(3):150-5.

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[8]. Whitaker AK, Chen BA. Society of Family Planning Guidelines: Postplacental insertion of

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intrauterine devices. Contraception. 2018;97(1):2-13.

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Figure Legends

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Figure 1 (A,B). Transabdominal ultrasonographic images of the pelvis with longitudinal and

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transverse views of the cervix. A white arrow highlighting echogenic object in cervix was

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interpreted by the radiologist as “may reflect a portion of the IUD”.

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Figure 2. Single radiographic view of the abdomen showing IUD projecting over the right lower

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quadrant (white arrow).

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Figure 3 (A-C). Intraoperative photographs of the intrauterine device located along the right

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pelvic side wall (Figure3A and 3B). Figure 3A with white circle highlighting the location of IUD

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in the right paracolic gutter. Figure3C showing the posterior aspect of the uterus with no

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evidence of perforation site.

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