Case Report
Translocated Intrauterine Contraceptive Device: Management Dilema
Doris Onwuzurike*
Department of Obstetrics and Gynaecology, South Warwickshire NHS Foundation Trust, UK
*Corresponding author: Doris Onwuzurike, Department of Obstetrics andGynecology, South Warwickshire NHS Foundation Trust, Lakin Road, Warwick, CV34 5BW,UK
Published: 10 Feb, 2018
Cite this article as: Onwuzurike D. Translocated
Intrauterine Contraceptive Device:
Management Dilema. Ann Clin Case
Rep. 2018; 3: 1502.
Abstract
We report a case of uterine perforation at the time of insertion of a Levonogestrel Intrauterine
System(LNG-IUS).A chest/abdominal X-Rays were requested some weeks later and the IUCD
was identified in the right upper quadrant of the abdomen.The dilemma was then what was the
appropriate management of this translocated LNG-IUS as the patient was asymptomatic and she had
become amenorrhoeic which was one of the original reasons why she chose this method.
Keywords:Translocated intrauterine contraceptive device; Levonogestrel intrauterine system
Introduction
Intra-Uterine Contraceptive Devices (IUCDs) are a common choice for long term reversible contraception among womenin the developed, as well as the developing world [1-3].The high acceptability of IUCD is due to its affordability, safety profile, convenience, ease of reversibility and minimal systemic side effects [3].There are only a few adverse events associated with the use of IUCD however these factors can greatly affect its acceptability [3]. One of such factors is uterine perforation at the time of insertion, this has been reported to occur in less than 1 per 1,000 IUCD insertions[3,4].A Levonogestrel Intrauterine System (LNG-IUS) is a type of IUCD, which releases progestogen directly into the uterine cavity and then into the systemic circulation.It has a very low failure rate from a contraceptive viewpoint with figures ranging from 0.1% over a 1 yr periodto 0.5% over a 5 yr timescale [5,6], but its main use is for reducing heavy periods in patients with dysfunctional uterine bleeding and making them amenorrhoeic in over 40% of cases in some studies [7].
Case Report
A 38 year old who had 3 children vaginally, was referred to the gynaecology outpatient clinic
two months after she had a LevonogestrelIntra-Uterine System (LNG-IUS) fitted at a family
planning clinic.She previously had a copper Intrauterine Contraceptive Device (IUCD) fitted in the
past with no problems, but decided to change to a LNG-IUS in view of her heavy periods.She did
find the procedure “slightly uncomfortable” and initially had right upper quadrant pain. Two days
after the procedure, she could not feel the IUCD tag and this prompted her to seek medical advice.
By the time she had the gynaecology appointment, the abdominal pain had settled and she did
not complain of any bleeding or vaginal discharge. Her past medical history revealed conservative
treatment for cervical intraepithelial neoplasia, grade 1, and she had had a normal cervical smear
two years previously.She was married, did not drink alcohol or smoke and had no significant family
history of note.
On examination, her abdomen was soft and mildly tender in the right upper quadrant. The
uterus was noted to be retroverted, non-bulky and mobile with no adnexal masses palpable. On
speculum examination, cervix appeared normal but the LNG-IUS threads could not be seen.
An initial transvaginal and transabdominal ultrasound (USS) Scan confirmed that there was no
evidence of the LNG-IUS within the uterus. Subsequently, an abdominal X-Ray was requested and
showed the LNG-IUS to be in the right upper quadrant of the abdomen (Figure 1).
The risks and benefits of a laparoscopic diagnosis and attempt laparoscopic removal were
discussed with the patient.Concerns were raised about the possibility of a laparotomy being
required if the laparoscopy was unsuccessful in finding, and removingthe displaced LNG-IUS. She
was reluctant to go ahead with this procedure and was subsequently discharged from the clinic with
the advice to contact the unit if she developed any acute symptoms or if she wished to re-discuss the management options again.
Figure 1
Figure 1
X-Ray was requested and showed the LNG-IUS to be in the right
upper quadrant of the abdomen.
Discussion
Uterine perforation is a recognised, but uncommon complication
of IUCD insertions [4]. It is usually relatively asymptomatic but may
present as sharp pain at the time of insertion, disappearance of IUCD
threads, post procedure bleeding, local signs and symptoms based on
eventual location. In rare occurrences when this occurs, a few case
reports have identified the IUCD in the urinary bladder, rectum,
colon, peritoneum, ovary, appendix and wall of iliac veins [8-13].
Several risk factors such as retroverted uterus, insertion during the
early post-partum period, unskilled or inexperienced provider have
all been associated with an increased risk of uterine perforation[13].
The Faculty of Sexual and Reproductive Healthcare (FRSH)
recommends USS and a plain abdominal X-Ray as first line
investigation for misplaced IUCD [14]. In this case this was proven
to be successful in the identification of the IUCD in the right upper
quadrant of the abdomen. Other investigations such as CT of the
abdomen have been described to be needed when initial investigations
have been inconclusive of the exact location of the IUCD[10].The
management of intra-abdominal migration of IUCD is surgical;
Laparoscopy or laparotomy or eventually both if the laparoscopy fails
to retrieve the IUCD. Although, removal is recommended even in
asymptomatic patients as there is a risk of more severe complications
due to perforation of intra-abdominal organs and vessels, the
management option is still currently decided on a case by case basis
and eventual decision is left to the patient after discussions of known
pros and cons of each procedure.If a laparotomy is required, serious
consideration must be given to the morbidity and mortality of such
a procedure and the autonomy of the patient must be taken into
account.It should also be remembered, what other devices surgeons
leave in the abdomen to clip/clamp structures (e.g. filshe clips at
sterilizations or surgical staples etc) and the fact that sometimes these
can become detached at a later stage, without any long term effects.
In this case, despite discussions on the possible complications
of conservative management, the patient decided the risk of surgery
outweighed the potential risk of further intra-abdominal migration
of the IUCD and decided to opt out of this treatment.Even at
laparotomy, it can sometimes be like “hunting for a needle in a
haystack” and sometimes intra-operative radiological imaging may
be useful in helping to identify the exact location of the IUCD and
may reduce morbidity associated with the procedure.
Conclusion
The patient exercised her autonomy in the decision making with regards to the management of her case and this also highlights the importance of “informed consent” when deciding which route to go down.The primary purpose of the Levonogestrel - IUCD was not as a method of contraception, but for the treatment of menorrhagia, and hence the woman was satisfied with being amenorrhoeic. It has now been 5 years down the line and the woman has still remained well with no other symptoms of note.
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