Introduction
Intrauterine device (IUD) is one of the most frequent methods of modern contraception [
1,
2] due to its cost effectiveness and low complication rate [
2]. About 0.5% of women in Uganda are using this contraception method [
3]. Uterine perforation is among the most serious complication associated with IUD insertion. The incidence of perforation is between 1.3 and 1.6 per 1000 insertions [
1,
4] although some studies report higher rates of up to 13 per 1000 insertions [
5,
6]. Perforation can either be iatrogenic (primary) during the insertion by applied mechanical force or secondary which occurs spontaneously [
4] probably because of uterine spasm [
5,
6]. Risks of perforating the uterus depend on the position of the uterus, insertion technique and the experience of the operator inserting IUD [
1]. Up to 15% of the perforation involves adjacent organs notably the bladder, small and large intestines [
5].
Treatment of uterine peroration by IUD is surgical removal either laparoscopicaly or by a laparotomy [
8,
9]. In developed world, laparoscopy is the preferred method of removal and indication for laparotomy includes IUD embedded in the colon, small intestine or when laparoscopic procedure failed [
1,
10]. In our setting here in Uganda, the only method available is laparotomy although endoscopic method could be attempted for luminal IUD. Careful patient selection and insertion by trained clinician is very important to reduce the risk of perforation [
5].
Case Report
A 32 year old para 4 presented to Gulu Regional Referral Hospital, Gynecology Outpatient Department with history of lower abdominal pain, increased frequency of passing urine with dysuria and deep dyspareunia. She had a TCu 380A IUD inserted from a private health unit one month ago. She reported to have felt a sharp lower abdominal pain more on the right side during insertion in which she reported to the operator. Three days later, she developed mucoid blood stain per vaginal discharge on addition to lower abdominal pain which persisted and could not feel the ‘thread’ in the vagina. She reported these complain to the operator and was prescribed analgesic without pelvic examination.
Examination showed her in fair general condition. Genito-urinary systems examination revealed no thread in the vagina, marked cervical motion tenderness and right iliac fossa tenderness. Other systems were unremarkable. Pelvic ultrasound revealed no IUD in the uterine cavity but was seen in the right adnexial region [Fig.1]. Elective exploratory laparotomy was done, found an IUD perforated the uterus and embedded into the myometrium but just visible in the vesico-uterine peritoneum reflection [Fig.2]. The ‘T’ bar of the TCu 380A IUD was held by artery forceps and was extracted [Fig.2].
The side of the perforation was further assessed for bleeding, and bladder was examined to exclude vesical perforation. Patient had uneventful recovery and was discharge on the second post-operative day.
Discussion
Uterine perforation is among the most serious complication associated with IUD insertion. The incidence of perforation is between 1.3 to 1.6 per 1000 insertion [
1,
4] as it tends to occur in the immediate post insertion period (primary perforation) [
11]. Although symptoms of perforation may be nonspecific, suspicion of perforation should arise if the patient had a sharp pain during the insertion. This patient had a sharp pain during the time of insertion and the pain persisted for the rest of the one month post insertion period. She also had mucoid bloody per vaginal discharge. This blood could have arisen from the perforated site. The urinary frequency could be because of the bladder irritation by the TCu 380A IUD just embedded behind the bladder [Fig.2]. Lower urinary tract symptoms are common features of uterine perforation and bladder involvement [
12,
13] and patients who present with this should be investigated for possible migration or perforation [
14,
15]. History of “No Thread” in the vagina should not be assumed to be ‘fallen’ IUD but should be investigated for possible uterine perforation and/or migration. Ultrasound scan is the simplest, rapid and non-invasive imaging modalities use to assess the position of IUD [
5]. CT scan would reveal the exact location of the IUD and the associated complication [
6].
Simple plain abdominal radiography may help to detect abdominal TCu 380A IUD. Ultrasound and computed tomography scanning may help to precisely localize migrated IUD devices [
16]. This patient underwent abdominal ultrasound scan as it is the simplest, rapid and non-invasive imaging modalities use to assess the position of IUD [
5].
Conclusion
Careful patient selection and pelvic assessment before insertion of an IUD may help to minimize this potentially dangerous complication. Health care training in the insertion technique is very important in Ugandan setting as a single complication could turn off thousands of women who might need this method of contraception worsening the contraceptives unmet need.
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