Abstract
Introduction
Intrauterine contraceptive device (IUCD) is a safe and effective method of contraception. It is however rarely associated with complications. Migration of this device to the rectum is very rare. We report a case of IUCD migrating to the rectum with the history of missing IUCD strings.
Presentation of case
A 32-year-old multipara presented 8 weeks following IUCD insertion with missing thread, ultrasound scan done showed a viable pregnancy with IUCD in-situ. Following vaginal examination, IUCD could not be retrieved. Pregnancy was allowed to continue for IUCD to be retrieved at delivery. She presented again about 6 weeks later with IUCD strings protruding through the rectum and was subsequently removed.
Discussion
Uterine perforation and migration of IUCD into the pelvic organs is an uncommon but major complication following insertion of the device. The risk of perforation appears to depend on type of device, skill of the operator and position of the uterus. Postpartum insertion, lactation and atrophic uterus also increase risk of perforation.
Conclusion
perforation and migration of IUCD to the rectum is a rare but possible complication of following insertion of the device. Family planning providers should continue to undergo training and retraining to minimize complications associated with the use of IUCD.
Keywords: Intrauterine contraceptive device, Rectum, Uterine perforation, IUCD strings
Highlights
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IUCD migration is an uncommon complication following insertion.
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Migration of this device to the rectum is rarely found in clinical practice.
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Pregnancy and breastfeeding may be risk factors for IUCD migration.
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This case shows migration of IUCD to the rectum which was also retrieved through the rectum.
1. Introduction
Intrauterine contraceptive device is one of the most prescribed methods of birth control as it is safe, convenient, easily available and painless [1]. They are effective and long lasting. Complications following use of IUCD include displacement, embedment, expulsion and perforation [2]. These are often associated with malpositioning of the IUCD during insertion [2]. The estimated rate of uterine perforation following IUCD insertion is 1 per 10,000 insertions [3]. Following uterine perforation, it can migrate to adjacent organs including the rectum though this is very rare [3,4]. We report our experience of IUCD migrating into the rectum with a view to minimizing complications associated with use of the device. This case has been reported in line with the SCARE criteria [5].
2. Case presentation
A 32-year-old multipara presented for family planning 6 months following delivery. She was still breastfeeding at presentation. Following counseling on the various methods of contraception, she preferred cupper IUCD. She was unsure of her last normal menstrual period. Pregnancy test done was negative. The insertion was conducted by one of our experienced family planning staff. Following this procedure, there was no associated abdominal pain or vaginal bleeding. After the procedure, she was counseled on how to feel for the IUCD strings and when to report back to the hospital. Six weeks after insertion, she presented for follow up and IUCD thread remained visible. After another four weeks, she reported back with a positive pregnancy test and inability to feel the IUCD strings. She had no other symptom suggestive of bowel perforation. She had attempted medical termination of pregnancy which was unsuccessful. An ultrasound scan was done which showed an intrauterine pregnancy at 8 weeks gestation with IUCD in the uterus (Fig. 1). She was stable with vital signs within normal limits. Following vaginal examination, IUCD could not be retrieved as the strings were not visible. Patient was therefore counseled on the possible pregnancy outcomes with IUCD in-situ. She accepted to keep the pregnancy and to retrieve the IUCD at delivery. About 6 weeks later, she presented back with IUCD strings protruding through the rectum (Fig. 2). She had no other symptoms suggestive of bowel irritation. An ultrasound scan was done and IUCD was no more in the uterus. She had no features suggestive of acute abdomen and her vital signs were all stable. A rectal examination was performed which showed IUCD that was lodged in the rectum and was easily palpated. She was counseled, IUCD (lodged in the rectum) was retrieved with minimal pulling (Fig. 3). Following observation, she had no other complaint and pregnancy was allowed to continue. She has not presented back for follow up.
Fig. 1.
Ultrasound scan showing viable pregnancy with coexisting IUCD.
Fig. 2.
IUCD thread protruding via the rectum.
Fig. 3.
IUCD after retrieval from the rectum.
3. Discussion
Uterine perforation and migration of IUCD into the pelvic organs is an uncommon but major complication following insertion of the device. Though most patients will be asymptomatic, some will present with symptoms. Migration of the device into the gastrointestinal tract will present with features such as lower abdominal pain, fever and diarrhea [3]. In cases of perforation, the device is located freely in the peritoneal cavity in up to 80 % of cases [4]. Following uterine perforation, the device can also migrate to the omentum, rectum, sigmoid colon, appendix, small bowel and urinary bladder [1]. It is very rare to find perforation of the rectum with IUCD thread protruding through the anus [4,6]. This very unusual presentation was found in the index patient. Uterine perforation following IUCD insertion can be prevented by using plastic uterine sound, suitable tenaculum, appropriate traction, pull back release mechanism and supervision of application by skilled and experienced clinicians [1].
The exact mechanism leading to perforation is not well understood. However, the risk of perforation appears to depend on type of device, skill of the operator and position of the uterus [1]. Other risk factors for perforation include insertion less than 6 months postpartum, lactation and atrophic uterus [6]. Perforation and misplacement may occur at the time of insertion. This presents as acute pelvic pain, bleeding and inability to feel the IUCD thread [1]. Another possible mechanism involves slow migration over a long period of time especially in women with above risk factors [1]. Oestrogen levels are low during lactation, resulting in small uterus and this increases the risk for uterine perforation [7]. Our patient was 6 months postpartum and was breastfeeding. Migration of IUCD to the rectum may be aided by inflammation and visceral contractions [6,8,9]. Pregnancy as shown in this case report seems to be a trigger factor for bowel perforation following IUCD insertion [8]. Symptoms may be non-specific in some patients following IUCD migration. Pelvic discomfort may be the only presenting symptom. However, there may be other life threatening features such as peritonitis, infection, bowel perforation, bowel obstruction, fistula and abscess formation [6]. Pregnant women with retained IUCD are at risk of adverse outcomes such as spontaneous miscarriage, preterm delivery, septic abortion and chorioamniotitis hence early removal will reduce these risks [10].
Generally, it is recommended that all IUCDs that have perforated the uterine wall should be removed [1,11]. The methods of IUCD retrieval include endoscopy, laparoscopy and laparotomy [6]. These depend on location of the device, degree of embedment within the rectal wall, involvement of other organs and associated complications [6]. Rectal retrieval as seen in this case may be attempted where feasible.
In conclusion, rectal migration of IUCD is very rare. Family planning providers should continue to undergo training and re-training so as to minimize complications associated with use of device. Regular self-examination for the IUCD thread is important in early detection of migration.
Consent
Written informed permission was obtained from the patient for publication and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Ethical approval
Institution Ethical approval is not required by our institution for case report. Patient is required to give written informed consent. In this case, written informed consent was obtained from the patient and same will be made available when requested by the journal editor.
Funding
Payment of this publication was made by Centre of Excellence in Reproductive Health Innovation, University of Benin.
Author contribution
Conceptualization: Maradona Isikhuemen
Data collection, Writing: All authors
All authors read and approved the final version of this manuscript
Guarantor
Maradona Isikhuemen.
Conflict of interest statement
The authors declare that they have no conflict of interest regarding this case report.
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