Removal of intra-abdominal intrauterine contraceptive devices

Elective surgical removal of migrated intrauterine contraceptive devices from within the peritoneal cavity: a comparison between open and laparoscopic removal

BACKGROUND

Intrauterine contraceptive devices (IUCDs) comprise the most popular form of reversible contraception. Uterine perforation is a rare but potentially serious complication associated with their use. We examined all reported cases of elective surgical removal of peritoneally migrated IUCDs, to compare laparoscopic and open approaches, and to identify beneficial surgical techniques.

DATABASE

MEDLINE and Embase were searched using the following medical subject heading terms: (IUCD or IUD or IUS or intrauterine device or intrauterine devices, copper or intrauterine devices, medicated) AND (migrated or displaced or foreign-body migration or intrauterine device migration) AND (peritoneal or peritoneal cavity). The Cochrane Library was searched using the terms IUCD, IUD, IUS, and intrauterine device. Additional studies were identified by manually searching the reference lists of the studies found through database search. Studies were included irrespective of language or publication type.

DISCUSSION

We identified 129 cases, reported in 30 studies. In the majority of cases (93.0% [120/129]), surgery was attempted laparoscopically; however 22.5% (27/120) of surgeries were converted to open operations, giving an overall rate of open surgery of 27.9% (36/129). This systematic review supports the use of laparoscopic surgery for elective removal of migrated IUCDs from the peritoneal cavity. With complications rarely reported, it is also likely the procedure could be undertaken in an outpatient setting. The use of intraoperative adjuncts (ie, cystoscopy) and the rate of conversion to open surgery are influenced by the site of the IUCD. Therefore, accurate preoperative localization of the device is advised.

Intrauterine contraceptive device migration presenting as abdominal wall swelling: a case report

A number of complications are reported with the use of intrauterine contraceptive devices. These may pursue asymptomatic course or present as an acute abdomen after migration into peritoneal cavity. The authors here are reporting an abdominal wall swelling caused by transuterine migration of a copper intrauterine contraceptive device in a 28-year-old female. An open approach was used, and impacted foreign body was retrieved.

Gynaefix frameless IUD: Cause of bowel resection

A case of a lost GyneFix intrauterine contraceptive device (IUD) is described, in which laparoscopy failed to identify the device and laparotomy had to be carried out to remove the IUD, which was embedded in the small bowel necessitating bowel resection. Awareness of this complication is necessary, and advanced training is required in order to minimize risks. A description of the GyneFix device, the possible adverse effects and incidence of complications, the importance of post-insertion follow-up, and the need for awareness of the possibility of migration through the bowel are discussed.

[A surprising reason for consulting: wires projecting from the anus, a rare complication of intra uterine device insertion]

Rectal perforation by migration of an intrauterine device is a rare complication which gynecologists must be aware of. Treatment can associate endoscopic examinations and a surgical procedure.

Medicolegal aspects of an unusual uterine perforation with multiload-Cu 375R

Perforation of the uterus is one of the most serious complications associated with insertion of intrauterine contraceptive devices (IUD). According to recent studies, this lesion occurs in 0.87 per 1000 cases, but statistics generally fluctuate between 0.05 and 13 per 1000 insertions. "Primary" perforations occur at the time of IUD insertion, and "secondary," or delayed, perforations are usually assumed to be caused by reactive uterine contractions. We report an unusual case of uterine perforation, which occurred 9 days after the insertion of a Multiload-Cu 375 IUD. The criteria for differential diagnosis between primary and secondary complications are discussed, particularly from the perspective of medical malpractice cases.

Uterine perforation by GyneFix frameless IUD: two case reports

Two cases of uterine perforation are described, occurring 11 days and 4 months, respectively, after the insertion of GyneFix, a frameless intra-uterine contraceptive device (IUD). In both the cases initial ultrasound scan showed the intra-uterine position of the device. Removal of the IUD, either by laparoscopy or laparotomy, had to be carried out. Awareness of this complication, insertion of GyneFix by a trained operator, appropriateness of ultrasound scan monitoring and possible underreporting of this complication are discussed.

Uterine perforation with Lippes loop intrauterine device-associated actinomycosis: a case report and review of the literature

A case of a 67-year-old postmenopausal woman, gravida 2, para 2, with an uterine perforation from actinomycotic infection with Lippes loop IUD is reported. She had the Lippes loop IUD inserted for 35 years, and had never had any pelvic examination nor Papanicolaou smear. She presented with acute abdominal pain. The clinical picture mimicked peptic ulcer perforation. The woman underwent laparotomy and exudative fluid was discovered in the abdominal cavity with the tip of the Lippes loop IUD at one of the two small holes of the uterine fundus. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. The postoperative microscopic pathological report demonstrated characteristics of actinomycosis. She was treated with parenteral high-dose penicillin for 4 weeks followed by oral penicillin for 6 months. The woman had an uneventful recovery. To our knowledge, this is the first case report of uterine perforation due to Lippes loop IUD-associated actinomycotic infection.

Ileal penetration by a Multiload-Cu 375 intrauterine contraceptive device. A case report with review of the literature

A case of a 28-year-old gravida 3 para 2 woman with an ileal penetration by an intrauterine device (IUD) is reported. Four weeks following insertion of a Multiload-Cu 375, the woman underwent laparotomy due to persistent vague abdominal pain and translocation of the IUD. The device had perforated the fundal uterine wall and the two flexible side arms and the copper-bearing rod had completely eroded into the wall of the ileum with only the strings protruding outside the small bowel mesentery. Resection of an ileal segment with end-to-end anastomosis was performed. The woman made an uneventful recovery. It appears that a translocated Multiload-Cu 375 IUD body can penetrate and be entirely embedded within the bowel wall as early as 4 weeks following translocation. This report documents the shortest interval between insertion and proven bowel injury by an IUD.

Role of endoscopy in retrieval of misplaced intrauterine device

We report a series of 45 patients with misplaced intrauterine devices (30 extrauterine and 15 intrauterine). Only those patients with intrauterine misplacements in whom conventional blind removal was not possible were included in the study. All of the 15 misplaced intrauterine devices could be removed hysteroscopically; 22 of the 30 extrauterine misplaced devices (73%) could be removed laparoscopically. One patient required both laparoscopy and hysteroscopy. Only 7 (15.5%) of 45 patients required laparotomy for safe removal of misplaced devices. Considerable comfort and minimal hospital stay associated with endoscopic procedures should offer these as the first line attempt to remove a misplaced intrauterine or extrauterine translocated device.

The pathology of intra-uterine contraceptive devices

The IUCD is a simple and effective way of producing contraception without the need for patient compliance. It is not rendered ineffective by other drugs, as may be steroid contraceptives, and its side-effects, for carefully selected patients, are considered by most practitioners to be acceptably low (Van Kets et al. 1989).

Laparoscopic removal of translocated intrauterine contraceptive devices

Data is presented regarding 20 translocated intrauterine contraceptive devices (IUCD). Successful laparoscopic removal was made in 13 (65%) cases though all these devices were Copper 'T' 200 model which tend to produce dense adhesions. Only when the IUCD was suspected to be partially or fully in the gut lumen or thick adhesions were present, or the device was not visualised, was laparotomy performed. Hence it is advocated that laparoscopy should be performed as a routine in patients with suspected translocated IUCD, as it obviates the need for laparotomy and thus decreases the duration of the hospital stay as well as preventing morbidity associated with laparotomy.

Management of translocated and incarcerated intrauterine contraceptive devices

Thirty-seven consecutive patients who reported with absent or snapped strings and failed attempts at removal of intrauterine contraceptive devices (IUCD) by hooks or curette were posted for hysteroscopy/laparotomy following a plain X-ray of the pelvis to exclude unrecognized spontaneous expulsion. Direct visualization of the endometrial cavity was invaluable in locating and removing IUCDs, particularly the embedded and fragmented ones. Translocated medicated devices were associated with dense adhesions, suggesting the need for their prompt removal. There appears to be an increased risk of translocation in lactating women.

Uterine perforation by copper intrauterine device

Sixteen cases with uterine perforation by a copper intrauterine device (IUD) are presented. In 13 cases the IUD had been inserted within 5 months following delivery, and in 6 cases the insertion had been painful. Missing string was the first sign in most cases. Laparatomy was performed in all cases to remove the IUD. The IUD was adherent to omentum or sigmoid in 10 cases. There is an increased risk of uterine perforation if the IUD is inserted postpartum during lactation and involution of the uterus. Therefore a painful IUD insertion and a missing string demand investigation of a partial or complete perforation.

The peritoneal reaction to the translocated copper intrauterine device in women and female rats

The observation of a very severe peritoneal reaction to translocated copper-bearing devices in five women necessitated operative removal. Three Copper-T (Ortho Gyne-T, Ortho, Saunderton, High Wycombe, England) and two Copper-7 (Gravigard, Searle, High Wycombe, England) devices were involved. Similarly severe peritoneal reactions were noted in 90% of female rats who had small-sized modified copper devices inserted into their peritoneal cavities. In a control group of rats with the same device but without a copper wire, mild adhesions were observed in the majority (85%), and none had a severe peritoneal reaction. It seems evident that the severe peritoneal reaction is induced by the copper wire in both women and female rats.

Laparoscopic removal of translocated intrauterine contraceptives devices

Over a 6 year period, 67 women had a translocated intrauterine contraceptive device (IUCD) removed from the peritoneal cavity or uterovesical fold under general anaesthesia. In 40 patients removal of the IUCD at laparoscopy succeeded, whereas in 24 laparotomy proved necessary and three IUCD were removed per vaginam. Compared with the inert plastic device a larger proportion of copper-containing IUCD in the peritoneal cavity required laparotomy for removal, however, 44% could be removed by laparoscopy, the less traumatic procedure.