Migrated intrauterine device: Case series report

Abstract

Introduction and importance

Implantation of an intrauterine device (IUD) is a common method of contraception in Saudi Arabia. Although rare, IUD migration and colon perforation have been reported. The current report presented three cases of IUD migration into the colon and recto-uterine pouch.

Methods and outcomes

The study included a series of three cases of migrated IUDs. The first case was a 25-year-old female, Gravida 2, Para 2 + 0, at 28 week-gestation, who presented with abdominal pain with a history of IUD placement that had not been removed or imaged before. The patient submitted to the caesarian section (CS), where IUD was found in the sigmoid colon. Elective laparoscopic removal of IUD with resection and primary repair of sigmoid colon was done later. The second case was a 37-year-old female, Gravida 1, Para 1 + 0, non-pregnant hypothyroidism, and a history of IUD placement. The patient got pregnant and gave birth through CS. She was then presented with abdominal pain and requested the removal of the IUD. On colonoscopy, IUD was seen in the pouch of Douglas with no evidence of a fistulous tract. IUD was removed through laparoscopy. The third case was a 47-year-old female, Gravida 14, Para 14 + 0, with a history of previous CS presented with a missing IUD that had been inserted 20 years ago after she had five pregnancies and subsequent deliveries. On colonoscopy, IUD was embedded on the wall of the transverse colon, and through abdominal surgery, IUD was removed by cutting through the colon and primary repair was done.

Clinical discussion

the presentation of IUD migration cases was foundto vary according to the site of migration and type of IUD.however the cases are usually present with abdominal pain. An abdominal pelvic imaging with CT in these patients are essential in diagnosis.

Retrival of migrating IUDs may be done through colonoscopy, laparoscopy, and in some cases with adhesion laparotomy is the solution.

Conclusion

Abdominal and pelvic CT scan are very important in the diagnosis and the localization of IUD. Elective colonoscopy and laparoscopy are successful management approaches for these cases.

Highlights

• •Intrauterine device (IUD) is a common and safe long-term contraception method. Uterine perforation and IUD migration are not very common.
• •Common migration sites of IUD are the colon and the pouch of Douglas, with abdominal pain as the main clinical presentation.
• •Laparoscopy and/or colonoscopy are the best approaches for the management of these cases.

1. Introduction

Intrauterine devices (IUDs) are a widely used and safe method of long-term contraception, and their use by women ranges from 14 to 27 % worldwide [1]. Copper- or levonorgestrel-based IUDs are the most effective, with less than a 1 % failure rate in the first year of use [2]. Knowing the benefits and harms of IUD insertion is necessary to inform decision-making and dispel misconceptions about its use [3].

The available literature suggests that pregnancy rates, adverse events, and discontinuation because of side effects during the first two years of prolonged IUD use are low and may not be clinically significant [[2], [3], [4]]. However, some other studies showed a positive association between lactation and perforation of the uterine wall, but a causal relationship has not been established [4]. Although uterine perforation is one of the most serious complications of IUD use, it is not very common, and it can often be asymptomatic [5]. After perforation, the IUD can be localized in various neighboring organs, with ectopic localization in the omentum, mesentery, pouch of Douglas, colon, and bladder have been reported [[6], [7], [8]]. The present case series report describes 3 cases of IUD migration into the colon (2 cases) and the pouch of Douglas (one case).

2. Methods and results

A case series study included three cases of migrating IUDs are described. Their mean age was 36.3 ± 11.0 years. The cases were retrospective and nonconsecutive, and all were presented in a single center. The data was obtained from the registration database of our hospital after approval from the ethical committee of the studied hospital. and the informed written consent from the studied patients. Data privacy and security were taken into consideration during the study.

This case series has been reported in line with the PROCESS 2020 Guideline [9].

2.1. Case 1

A 25-year-old female, Gravida 2, Para 2 + 0, at 28 week-gestation, female with a history of IUD placement for one year (including her pregnancy and two months after she delivered her baby) that had not been removed or imaged before. The patient reported abdominal pain for two days, then relieved, and became intermittent and localized in the lower abdomen. The patient was otherwise healthy. There were no signs of nausea, vomiting, constipation, dysuria, fever, or bleeding in the vagina or rectum.

An abdominal-pelvic ultrasound was done that showed an IUD migration. The patient submitted to CS, and during the operation, the gynecologist found the IUD in the wall of the sigmoid colon. The gynecologist consulted a surgeon who fixed it to the anterior abdominal wall. The patient was discharged and given a date for elective surgery.

On the second hospital admission, her abdomen was soft and lax but with a tender lower abdomen. A plain X-ray showed that the IUD was on the left side of her lower abdomen (Fig. 1). Laboratory findings were normal. (See Table 1.)

Fig. 1.

Plain x-ray abdomen of the first case.

Plain X ray showed the IUD is on left side of lower abdomen. Arrow pointing at the migrating IUD.

Table 1.

Characteristics of the studied three cases.

Characteristics	Case 1	Case 2	Case 3
Age	25 years	37 years	47 years
Gravida	2	1	14
Parity	2	1	14
Abortion	0	0	0
Intrapartum complications	Nil	Nil	Nil
IUD type	Hormonal	Copper	Copper
Investigation	CT scan	Abdominal and pelvic CT scan	Abdominal Trans-axial CT scan
Findings	IUD in the left anterior peritoneal cavity, just anterior to sigmoid colon	IUD in the recto-uterine pouch	IUD in the upper abdomen just posterior to transverse colon
Management	Laparoscopy	Laparoscopy	Abdominal surgery

CT scan showed the IUD in the left anterior peritoneal cavity, just anterior to the sigmoid colon, with focal wall thickening of the sigmoid, in keeping with previous uterine perforation (Fig. 2). Laparoscopy was done where IUD was removed with resection, and primary repair of the sigmoid colon was done (Fig. 3). The patient was discharged and was followed in the outpatient clinic for two months after removal of the IUD with good clinical improvement.

Fig. 2.

Coronal and axial contrast-enhanced computed tomography (CT) scan of the abdomen of the first case.

Coronal and axial contrast-enhanced computed tomography (CT) scan of the abdomen showing the IUD in the left anterior peritoneal cavity, just anterior to sigmoid colon, with focal wall thickening of sigmoid. Arrow pointing the site of IUD.

Fig. 3.

Laparoscopy of the first case.

Laparoscopy showing the extraction of a migrated IUD with resection and primary repair of sigmoid colon

2.2. Case 2

A 37-year-old female, Gravida 1, Para 1 + 0, non-pregnant hypothyroid on levo50 mcg/day with a history of IUD placement two years ago, then the patient got pregnant and gave birth through CS. The patient came to our hospital with abdominal pain. The pain was in the lower abdomen and associated with on-and-off constipation and dysuria. There was no fever, no vaginal or rectal bleeding. Abdominal examination showed a soft lax abdomen but a tender lower abdomen. Laboratory findings were normal. Colonoscopy showed a scope passed up to 60 cm, no areas of strictures, and no definite pathology. However, an internal hemorrhoid on retroflexion was seen.

An abdominal and pelvic CT scan showed an IUD in the recto-uterine pouch (the pouch of Douglas) with minimal fat standing, but no fistulous tract, no contrast extravasations, nor free fluid or collection were seen (Fig. 4). The migrated IUD was then retrieved via laparoscopy (Fig. 5), and the patient was discharged on the first postoperative day with follow-up in the outpatient clinic.

Fig. 4.

Computed tomography (CT) scan of the abdomen and pelvis of the second case.

An abdominal and pelvic CT scan showing the IUD in the recto-uterine pouch with minimal fat standing but no fistulous tract, no contrast extravasations, nor free fluid or collection were seen where arrow pointing to the migrating IUD.

Fig. 5.

The IUD after its retrieval via laparoscopy of the second case.

The retrieved IUD was put in a bottle after its retrieval via laparoscopy.

2.3. Case 3

A 47-year-old female, Gravida 14, Para 14 + 0, with a history of previous CS presenting with a missed IUD that was inserted 20 years ago after she had five pregnancies and deliveries.

The patient's condition deteriorated ten years ago when she started to have on-and-off abdominal pain. She visited a private clinic where she was diagnosed with irritable bowel syndrome. She was treated with Zantac and analgesics. Three months ago, the pain became continuous and was not relieved with the mentioned medication anymore. She sought medical advice at a private clinic where an abdominal x-ray revealed migrated IUD.

On admission to our hospital, her abdomen was soft and lax on examination, and her laboratory findings were normal. An abdominal Trans-axial CT scan without contrast was done and showed the IUD in the upper abdomen just posterior to the transverse colon at the level of L2-L3. There was no free air or free fluid in the abdomen or pelvis, and no significant lymph nodes were noted in the abdomen or pelvis (Fig. 6). (See Fig. 7.)

Fig. 6.

Abdominal Trans-axial CT scan without contrast of the third case.

Abdominal Trans-axial CT scan without contrast showing the IUD in the upper abdomen just posterior to transverse colon at the level of L2-L3. There were no free air or free fluid in the abdomen or pelvis, and no significant lymph nodes noted. Arrow pointing at the migrating IUD.

Fig. 7.

Abdominal Trans-axial CT scan without contrast of the third case.

A colonoscopy examination showed the IUD embedded in the wall of the transverse colon. Through abdominal surgery, IUD was removed by cutting through the transverse colon, where non-significant little adhesions were found, and the surgery was completed successfully with primary repair of the colon. The patient was discharged home in stable condition on the 5th postoperative day.

3. Discussion

The IUD is a form of safe and long-term contraception option used by women worldwide. In most women, however, the IUD is placed during lactation after delivery while the uterus is soft, and it was likely that a rare complication of placing an IUD occurred.

One of the most serious complications is uterine perforation and penetration into the intestinal cavity resulting in sterile perforation [10]. In our cases, the placement of an IUD was done just after birth in cases 2 and 3. Early puerperal insertion of the IUD was found to be a risk factor for bowel injury [11], and the device was partially or completely embedded in the bowel wall [12]. The commonest sites of ectopic localization of the IUD after its migration were the omentum, mesentery, pouch of Douglas, colon, and bladder have been reported [[6], [7], [8]]. In our case series, the IUD was found embedded in the wall of the sigmoid colon (1st case)and the transverse colon (3rd case). In the second case of this series, however, the IUD was found in the pouch of Douglas. About 80 % of IUDs are found in the peritoneal cavity after perforation [13], including the pouch of Douglas.

The presentation of IUD migration varies depending on the site of migration and type of IUD. All the studied patients in this series were presented with abdominal pain, and they were healthy otherwise. Abdominal pain may signify bowel perforation; however, bowel perforation may be asymptomatic. In asymptomatic patients, migrating IUDs may remain undetected for years [12]. In the literature, most reported cases of bowel and urinary bladder perforation were asymptomatic at the time of diagnosis [14]. However, in some cases, the diagnosis of perforation may be made by the appearance of clinical signs such as fever, diarrhea, or urinary tract infection, or even serious complications such as peritonitis, subacute intestinal obstruction, or as strings at the anus [15].

As routine follow-up for patients with IUD placement is not done, migration may be suspected only when patients develop abdominal pain, the appearance of clinical signs, or a subsequent pregnancy. In our second case, the patient got pregnant and gave birth after the IUD placement. The diagnosis of IUD migration during pregnancy, however, may be difficult due to radiation risk limiting the use of X-rays and computed tomography. In asymptomatic patients, diagnosis and retrieval may be safely delayed until delivery. An abdominal and pelvic imaging with CT or magnetic resonance imaging (MRI) in these patients is valuable to evaluate for the involvement of neighbored organs, and if there is high suspicion for colonic involvement, a colonoscopy could be considered [16].

Retrieval of migrating IUDs may be done through colonoscopy and laparoscopy [11,12]. Colonoscopy is useful in cases where the device is within the bowel lumen or in the inner lining of its wall. The laparoscopic retrieval is considered the best approach for intraperitoneal migration, also in cases where IUD is embedded in the colon wall. In our case series study, the retrieval of IUD, in the first and second cases, was done using laparoscopy. In the 3rd case, however, laparotomy was performed because of adhesion. For all intra-abdominal devices, the laparotomy rate following diagnostic laparoscopy was high (34 %), especially it very high for devices embedded in the bowel, i.e., 68 % [17]. Generally, even in asymptomatic patients, the World Health Organization recommends immediate surgical removal of the migrated IUDs. Minimally invasive methods such as colonoscopy, cystoscopy, or laparoscopy are tried at first, depending on the site of migrated IUDs. However, if IUD is embedded in an organ such as a colon or bladder, exploratory laparotomy is recommended rather than other invasive procedures [3]. This was the management in our third case where laparotomy was done.

Finally, regular IUD counseling and follow-up may be of great value in the early discovery of IUD migration in such cases by enhancing the comprehensiveness and patient-centeredness about potential changes in their bleeding patterns and other adverse effects and complications of IUD migration.

The strengths of this study include that it is the first to study cases of migrating IUD from Riyadh and to add the Saudi literature to this topic. It also contributes to the accumulating literature about the importance of CT in diagnosis and colonoscopy and laparoscopy in management. However, this case series was a single-center study, and like other similar retrospective studies, the potential risk of missing data could not be prevented. In the studied cases, different procedures were performed for retrieval of migrated IUDs, and accordingly, they were done by different surgeons.

4. Conclusion

The present case series suggests abdominal pain as one of the main presenting symptoms in patients with IUD migration. The patients should be educated to check for the IUD, and this should be an important part of the IUD insertion clinics. Abdominal and pelvic CT scan is very important in the diagnosis and the localization of IUD. Colonoscopic and laparoscopic techniques are the best approaches used for the retrieval of migrating IUDs. Laparotomy is indicated when intra-abdominal adhesions and/or the IUD are deeply embedded in the bowel wall.

Funding

None.

Consent

Ethical approval was obtained from the ethical committee of our hospital at the start of the study. A copy of the approval is available for review by the Editor-in-Chief of this journal on request.

Credit authorship contribution statement

Alaa Aljohani (first author; Writing – Original draft; Writing - Review & editing), Abdullah Zarea (collect data), Reem Alnafea (collect data), Khaled Jadaani (collect data), Rami Sairafi (Review & editing), Ali Alzahrani (Supervise, Review & editing).

Ethical approval

Ethical approval for this study was provided by The r e s e a r c h committee in Security Forces Hospital, the committee is constituted and functions in accordance with the National Committee of Bio Ethics (NCBE) in Saudi Arabia, Accreditation number (H-01-R- 069).

Research Number in Security Forces Hospital Program: 23–671-35 IRB Registration Number with KACST, KSA: H-01-R-069.

Date: 22 June 2023.

Registration of research studies

We don't need to register this work.

Guarantor

The Guarantor is DR.ALAA ALJOHANI.

Declaration of competing interest

The author declares that there is no conflict of interest.