Uterine Perforation by Two Intrauterine Contraceptive Devices ( IUCD)

Abstract:
Perforation of uterus by intrauterine contraceptive device (IUCD) is a known complication. However, to our knowledge, to have two IUCD perforating the uterus has never been reported. We present here this case which we believe is the first reported in literature, and discus the importance of careful evaluation prior to insertion of contraceptive loop and the management implemented.
 
Case report:
A 37 years old  had become pregnant on a top of an IUCD, which was placed after her last delivery. She is para 7+0 all were normal vaginal deliveries. She was known for having mitral valve prolapse and on long acting penicillin prophylaxis on monthly base. The IUCD placed at a private clinic.

On antenatal follow up, the IUCD thread was not visualized outside the cervix at the 2nd trimester visit. Care was continued and was uneventful. She reached full term and delivered vaginally. Regrettably,  no attendant looked for the device and the woman went home thinking the device was expelled with the placenta. 6 weeks later she went again to a private clinic and the specialist put an IUCD, taking the patient story of IUCD expulsion with the placenta. A couple of weeks later she went for a follow up.  She was seen by her doctor who could not see the device thread. An ultrasound scan (USS) and  x-ray (figure1) which showed two IUCD's. The patient was referred to our hospital and ultrasound showed no device within the uterine cavity. A pelvic C.T. (figure 2) was performed to localize the devices. A laparotmy was then decided on after patient counseling and discussion with the cardiologist/anesthetist.

On laporotomy, an IUCD thread covered with omentum at the left corner of the uterine cornu was visible. Easy excision of this omentum was performed. With removal of this omentum mass the 2nd device become visible, just coming at the site of left tube insertion (figure 3). This tube was twisted and adherent with the uterus and the left ovary. No apparent previous scar was seen anywhere else in the uterus. No active bleeding was seen. As she requested, a bilateral tubal ligation was performed. She was covered with antibiotics, anticoagulant and went home well on 5th day.
 
Discussion
Perforation of the uterus by IUCD occurs in 1/5000 (1) and commonly at time of insertion with a rate of about 1/1150 at postpartum period.  Probably this rate is related to individual experience and timing of insertion possibly the softening of myometrium in immediate post abortal and post partum  period and related to individual experience (1)(2). This  case, we believe unique having perforation by 2 IUCD probably through same site. The substandard care is a lesson  in this case. Starting whether the IUCD is good option for a patient of mitral valve prolapse, we believe not , as this may resulted in endocarditis and it is known as a relative contraindication (3). The care during and after delivery should have include meticulous looking for the device, and an ultrasound should have been done if the IUCD was not identified with the placenta. No doubt putting a second IUCD by same doctor, based only on  patient story without confirming expulsion of the 1st one,  does not reflect an a appropriate care.  This could have been avoided by an ultrasound which is available in all centers and clinics caring for women, and x ray could have also helped. This also raise the question whether USS should be done in every women visit and  replaces the digital examination in gynaecological cases as many believes.   We opted for laporotomy rather laparoscopy after discussing the case with the cardiologist and anesthetist regarding the CO2 insufflation with possible risk to the patient and after adequate counseling. Finally we believe standard care at different stages would have guard against this extra morbidity, the women has unnecessarily exposed to.

Figure 1:  X-ray of two intrauterine contraceptive devices

Figure 2: Pelvic CT of two intrauterine contraceptive devices

Figure 3: Omentum mass with the 2nd device become visible & the first IUCD

References:

References:

1 - J.George Moore, Alan. H. De cherney. contraception and sterilization. In: Haker and Moore(eds). Essentials of Obstetrics and gynaecology. 3rd edition. Harcout Brace &company 1998 :517

2 - O’Hanlenk, Hule D.L. postpartum intrauterine perforation 1992. contraception. 45(40):351-61

3 - Louise Kenny. Contraception, sterilization and termination of pregnancy. In: David M. Luesley, Philip N. Baker.(eds). Obstetrics and gynaecology an evidence based text for MRCOG.U.K Arnold press.2004.520.

Correspondence to:

Dr. Salah baloul

Consultant obstetrician & gynaecologist

King abdul Aziz Specialist Hospital

Taif, K.SA

E mail baloul_sa@yahoo.com

Tele 00966504706717