We aim to present a rare case of a missing intrauterine contraceptive device (IUCD) that was found in the terminal ileum by laparoscopy and was first managed by laparoscopy and then underwent laparotomy.
A 29-year-old woman who had a copper IUD inserted by a senior gynecologist presented to the clinic with pelvic pain and discomfort. She underwent laparoscopy for IUD removal. Intraoperatively, the IUD was found to be embedded in the terminal ileum and therefore the laparoscopy was converted to an open laparotomy. The patient was readmitted several times due to abnormal fluid accumulation in the pelvic region, which was finally resolved by the insertion of a pigtail.
This case highlights the possibility of complications occurring in the medical field even if the practitioner is a senior gynecologist. Additionally, missed IUDs require extensive investigation and imaging to develop an appropriate management plan to avoid serious complications.
Introduction
Inserting an intrauterine contraceptive device (IUCD) is one of the most effective methods of contraception, with a pregnancy prevention rate of up to 99% [1,2]. Uterine perforation is the most serious complication associated with IUDs, but patients may be completely asymptomatic [2-4]. There are few articles describing IUD transmigration and bowel perforation [4]. In this article, we present a rare case of missing IUD found in the terminal ileum by laparoscopy; initially the case was managed laparoscopically, but it was converted to laparotomy.
Presentation of the case
A 29-year-old woman, gravida 2, para 2+0, presented to the obstetrics walk-in outpatient clinic complaining of pelvic pain and discomfort that had lasted for one month. She had regular periods and denied any symptoms of abnormal uterine bleeding or vaginal discharge, changes in bowel habits, rectal bleeding, melena, dyspareunia, dysuria or haematuria. A senior gynecologist inserted her copper IUD a year ago; no difficulties arose during insertion. Her previous pregnancies were spontaneous vaginal births. Otherwise, the patient had no significant medical, family, or social history.
On physical examination, the patient was conscious, alert, and oriented with stable vital signs. His body mass index was 20.2 and his systemic examination was normal. The IUD string was not visible on vaginal examination.
All laboratory test results were normal and pregnancy was ruled out. A pelvic transvaginal ultrasound revealed an IUD that had migrated to the right adnexa adjacent to the right ovary. An x-ray showed the IUD in the lower right pelvic region (Figure 1).
Subsequently, the patient was informed of the migration of the IUD and the risk of a right salpingo-oophorectomy in the event of bleeding; she was reserved for exploratory laparoscopy and IUD removal after obtaining consent.
In the operating room (OR), a panoramic view through the laparoscope indicated a normal uterus and left adnexa, while the right adnexa showed moderate adhesions to the intestine and omentum. The IUD was fully integrated into the terminal ileum. The general surgical team was involved and removed the IUD from the bowel by making an initial cautery incision followed by retraction of the IUD. Due to the limited expertise of the general surgeon on call, the operation was converted to an open laparotomy for ileocecal resection and anastomosis without intraoperative spillage of bowel contents. A new copper IUD was inserted intrauterinely under direct visualization. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
The patient’s surgical and postoperative results were normal and she was discharged without complications on the second postoperative day. The removed IUD showed no bacterial growth. However, the resected bowel showed ulceration with focal transmural inflammation (acute and chronic) and prominent Peyer’s patches (reactive lymphoid hyperplasia). The patient was readmitted to the emergency room (ER) for the first time five days after the operation, complaining of a fever (38.2°C) and right lower quadrant (RLQ) abdominal pain that had lasted for two days. The patient underwent enhanced multiaxial computed tomography (CT) to examine the anastomotic site. There was no evidence of oral contrast leakage from the anastomosis. However, a small area of loculated fluid measuring 1.4 x 0.8 cm was observed on the right side of the pelvis around the surgical sutures. The patient was put on empiric antibiotic therapy for a total of 10 days (metronidazole 500 mg and cefuroxime 500 mg) if early abscess formation was suspected, and the CT scan was repeated after five days. CT scan results demonstrated the development of a large collection of pelvic fluid slightly enhancing the periphery measuring 11.7 × 6.7 × 11.1 cm at intervals (Figure 2).
The patient was transferred to the operating theater as a level 2 emergency case for laparoscopic evacuation of the hematoma. She was discharged with antibiotics (metronidazole 500 mg and cefuroxime 500 mg) on the fourth day after evacuation. Six days after discharge, the patient was readmitted to the emergency department complaining of fever and colicky abdominal pain RLQ, aggravated by movement and not relieved by medication. Another CT scan was performed, showing a slight decrease in size of the previous fluid collection; it now measured 9.1 × 5.8 × 8.8 cm. Additionally, the left ovary was included in the fluid collection. The interventional radiology team planned the evacuation of the fluid collection by inserting a pigtail catheter. Six days after insertion of the pigtail catheter, a CT scan demonstrated a marked decrease in the size of the collection (Figure 3).
The next day, the pigtail drain was removed and the patient was discharged after completing her course of antibiotics (metronidazole 500 mg and cefepime 1000 mg).
Discussion
IUD insertion procedures are the most common causes of uterine perforation [2]. Recent studies have indicated that nearly half of cases were not recognized until more than a year after insertion [2]. There are two basic forms of IUDs: IUDs containing copper and IUDs containing levonorgestrel (Mirena) [5]. Copper-containing IUDs act primarily as spermicidal agents; this mode of action is mediated by local inflammatory responses of the uterus to the IUD as a foreign body [6]. Uterine perforation occurs with a frequency rate between 0.4 and 1.6 per 1000 insertions [4]. Postulated mechanism of uterine perforation could be due to either primary penetration or subsequent inflammation [4,7]. Although copper-containing IUDs work by inducing inflammation, a large cohort study showed that there were no significant differences in uterine perforation rates of copper and levonorgestrel IUDs. [8]. Identified risk factors for uterine perforation were breastfeeding, postpartum IUD insertion, uterine malformation, and IUD insertion by less experienced clinicians; however, the precise cause of uterine perforation has not yet been established [4,8].
Symptoms of uterine perforation vary depending on the location of the IUD [3]. Perforation of the IUD in the intestinal structures can cause a triad of abdominal pain, fever and diarrhea [4]. However, 85% of cases reported in the literature were asymptomatic [3].
The sign leading to suspect the absence of an IUD is the absence of IUD threads [4]. This justifies the need for further investigation to locate the IUD, and initial localization by ultrasound is preferred [4]. Ectopic localized IUDs require additional types of imaging for detection [4,9]. In addition, since the IUD is radiopaque, the abdominopelvic X-ray can locate the extra-uterine IUDs and diagnose the expulsion of the IUD. [9]. The most accurate methods of IUD localization are computed tomography and magnetic resonance imaging (MRI), as they also assess the presence of intra-abdominal complications, such as visceral perforation, abscess formation, and occlusion intestinal. [9].
Minimally invasive methods are recommended to remove migrated IUDs depending on their location [3]. For intra-abdominal IUDs, the preferred treatment is laparoscopic removal; however, in some cases, especially when an IUD has perforated the bowel, an open laparotomy is indicated [8,10]. A review by Gill et al. [10] showed that in the event of perforation of the small intestine or the large intestine, 13 cases out of 19 (68%) were treated by immediate passage to laparotomy; adhesions were the main reasons for laparotomies. In 2014, Rahnemai-Azar et al. [11] reported the successful retrieval of an IUD from the small intestine by laparoscopy. They attributed their success to the ability of the surgeon and the wound shield retraction device, which provided good visualization.
In this case, pregnancy was initially ruled out and imaging led to the diagnosis of IUD migration. However, CT and MRI were not performed due to a lack of concerning symptoms. The operation was started laparoscopically, but the IUD was not located. Following the thread, the IUD was found embedded in the terminal ileum. Therefore, the operation was converted to an open laparotomy for bowel resection and anastomosis.
conclusion
After only a year had passed since the IUD was inserted without complications by a senior gynecologist, it was found embedded in the terminal ileum, despite a pelvic transvaginal ultrasound showing its location in the right appendix. . In addition, the inexperience of the on-call surgeon led the surgery from laparoscopy to laparotomy with bowel resection and anastomosis. In addition, the patient was readmitted several times because of this event. This case highlights the possibility of complications whether a physician is a senior gynecologist or a junior resident. It also emphasizes the importance of a thorough investigation of a missing IUD to avoid more serious complications. Finally, migration of the IUD and perforation of adjacent structures should always be mentioned when counseling the patient.
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