Abstract
Introduction:
Intrauterine devices (IUDs) are the most widely used reversible contraceptive method worldwide. Uterine perforation and extrauterine migration are two complications associated with their use. We report one such case in this article.
Case presentation:
A 28-year-old female patient was admitted with a periumbilical abdominal swelling on the left side, causing minimal pain, likely parietal, that had been developing for about 1 year. Ultrasound revealed a fibrous capsule organized around an unidentified foreign body within the anterior abdominal wall. The fibrous capsule was removed via laparotomy, revealing a TCu 380 IUD inside and a scar from a uterine perforation on the uterine dome. The postoperative course was uneventful.
Clinical discussion:
The IUD is a long-acting, non-permanent form of female contraception. Its insertion into the uterus is a simple, routine procedure, but its side effects, complications, and contraindications must be understood to optimize its effectiveness. Perforation followed by migration is a rare but serious complication. The causes are varied, ranging from uterine morphology and texture to local factors related to the IUD and the healthcare provider’s inexperience. Diagnosis is often delayed, with signs related to the organ hosting the IUD confirmed by imaging. Endoscopy plays a crucial role in treatment.
Conclusion:
Proper insertion technique and regular monitoring are essential to prevent uterine perforation and IUD migration. The IUD must be removed immediately upon diagnosis.
Keywords: case report, intrauterine device, migration, uterine perforation
Introduction
Intrauterine devices (IUDs) are the most widely used reversible contraceptive method worldwide, used by 15.5% of women aged 15–49[1]. Insertion is a simple local procedure, but it can lead to complications such as infection, expulsion, perforation, and migration, mainly when the rules for use are not followed correctly[2]. Extrauterine migration is a complication of IUDs and often follows uterine perforation during insertion[3]. Uterine perforation is an exceptional complication (1.3–1.6 per 1000 insertions)[1]. We report the case of a patient who presented with migration of an IUD into the anterior abdominal wall. This work has been reported in line with the SCARE checklist[4].
HIGHLIGHTS
Uterine perforation and extrauterine migration of an intrauterine device are rare complications.
It can lead to other serious complications, including infection and lithiasis.
Diagnosis is based on clinical findings and medical imaging.
Endoscopy remains the technique of choice for removal.
Proper insertion technique, monitoring, and follow-up using medical imaging could prevent these complications.
Clinical observation
A 28-year-old female patient, who had a full-term pregnancy and gave birth vaginally 6 years ago, with no particular medical or surgical history, presented with no drug history, no allergies, no family history, and no social history. The patient did not mention inserting an IUD after delivery during the interview. She presented with an abdominal swelling that was not particularly painful, roughly rounded, located in the periumbilical region on the left side, hard, fixed to the superficial plane, and mobile relative to the deep plane, which had been developing for about 1 year. It measured approximately 6 cm in length, with healthy skin above it. There were no bowel problems, menstrual problems, or other associated symptoms. She was in good general health and showed no signs of clinical infection.
Preoperative laboratory tests were normal, and an abdominal ultrasound revealed a remodeled hyperechoic formation in the abdominal wall, containing a hyperechoic structure with a posterior shadow cone.
Based on the above findings, the lack of laparoscopy in the region necessitated surgical removal via an indicated laparotomy. The next day, under general anesthesia and in the supine position, a fibrolipomatous formation with an irregular, thickened wall was found invading the peritoneum, muscles, and aponeurosis of the rectus abdominis, organized around a TCu 380A IUD (Fig. 1). A punctiform scar was noted on the uterine dome, likely representing healing of the uterine perforation caused by the IUD (Fig. 2). No adhesions were noted. We performed complete cyst removal, removing the entire capsule, and washed the area and abdominal cavity with saline solution before closing layer by layer. The operation was performed by a general surgeon at a local hospital in a rural area. The patient reported after the procedure that, 1 month later, following her delivery, she had had an IUD fitted after giving her informed consent at the family planning clinic. Pathological examination of the specimen revealed fibrolipomatous hyperplasia with no signs of malignancy.
Figure 1.
Fibrolipomatous capsule containing the IUD: (A) upon opening, (B) after removal.
Figure 2.
The scar from the perforation of the uterine dome (indicated by the blue arrow).
Postoperatively, she received analgesics, antibiotic coverage, and anticoagulant prophylaxis. The postoperative course was uneventful, and the patient was discharged from the hospital on postoperative day 1. The patient attended a follow-up appointment 1 month after the operation. She had no specific complaints, and the surgical wound had healed well.
Comments
The IUD is a preferred method of non-permanent contraception. It is widely used in developing countries, particularly in rural areas[1]. Several types of IUDs are currently available, with bioactive IUDs being the most commonly used due to their greater tolerability[5]. Insertion is straightforward in routine practice, but side effects, complications, and contraindications must be understood to optimize effectiveness[6,7]. Perforation is a rare but serious complication that can cause the IUD to migrate into neighboring organs. Migration has been reported in the Douglas cul-de-sac, omentum, mesentery, colon, and bladder, leading to urinary lithiasis in this case[7]. The incidence of uterine perforation is rare, not exceeding 1.3 per 1000 insertions, according to large clinical trials[1,8,9]. It precedes migration and often occurs at the time of insertion but may go unnoticed and be discovered later[1,10]. These perforations may be partial, when only part of the IUD pierces the wall of the uterus or cervix, or complete, when the IUD passes through the wall of the uterus and enters the abdominal cavity[8,11]. They may occur immediately during IUD insertion or be delayed by progressive erosion of the uterine wall, linked to the inflammatory process associated with the IUD[8], especially with copper IUDs, as in our case. Insertion after abortion, as well as in the early postpartum period, is one of the factors that promote migration, as are multiparity, a scarred uterus, uterine malposition, uterine tuberculosis, and the operator’s inexperience or clumsiness[12]. This leads to migration into neighboring structures. Initially intramyometrial, due to incarceration of an IUD branch in the myometrium, migration continues intraperitoneally, facilitated by local inflammatory phenomena and uterine contractions[7,13].
Clinically, symptoms vary with the migration site and IUD type. In our case, the IUD embedded in the anterior abdominal wall caused a local inflammatory reaction but remained asymptomatic for 6 years, consistent with the literature, which reports that 85% of perforation cases are asymptomatic until diagnosis[8]. The interval between IUD insertion and the onset of clinical signs can be several years (up to 36 years)[14].
The diagnosis can be made early if pain occurs immediately after IUD insertion, indicating iatrogenic perforation[15]. Perforation may be completely asymptomatic and may occur some time after IUD insertion, possibly after it has been fitted[14]. The diagnosis of migration can also be made when the threads disappear, which is normally noticed by the patient herself in 11% of cases. In other cases, the diagnosis is made during medical monitoring or during pregnancy (25%)[13]. Finally, chronic abdominal pain may be indicative in 30% of cases[15], as in our clinical case. A positive diagnosis of perforation and migration is based on imaging. Ultrasound should be performed immediately after IUD insertion to confirm that the insertion technique was correct[7,13–15]. It also allows migration to be confirmed during monitoring when perforation is suspected, based on the disappearance of the threads at the exocervix[13]. Endovaginal ultrasound is more effective for examining the uterus and determining the precise location of the IUD[15,16]. An abdominal X-ray performed without preparation, outside pregnancy, shows a metallic structure and helps determine its area of projection[3]. However, it lacks topographical precision regarding the uterine wall[15]. Computed tomography (CT) may be necessary in some cases, particularly when complications arise, such as acute sub-occlusion with a pelvic abscess. CT enables a positive topographical diagnosis, facilitated by reconstructions, and provides assessment of lesions associated with IUD migration[15,16]. Pelvic magnetic resonance imaging, although more effective, should be reserved for specific cases, particularly in pregnancy, where CT is contraindicated. In cases of diagnostic difficulty, laparoscopy is required to locate an IUD that has not been expelled and cannot be found in situ[13]. Table 1 provides a chronological summary of events from delivery through the postoperative period after surgical removal of the IUD.
Table 1.
Timeline summarizing events from childbirth to follow-up after the surgical IUD removal.
| Date | Time | Events |
|---|---|---|
| 22/04/2016 | 1H25 | Vaginal delivery |
| 26/05/2016 | 8H30 | Insertion of an intrauterine device |
| 21/07/2022 | 10H50 | General surgery consultation |
| 21/07/2022 | 14H30 | Performing an abdominal ultrasound scan |
| 22/07/2022 | 9H30 | Surgical removal of an abdominal mass |
| 22/07/2022 | 11H | End of procedure |
| 22/07/2022 | 19H | Discharge from the recovery room |
| 23/07/2022 | 10H30 | Discharge from the hospital |
| 25/08/2022 | 14H25 | Follow-up appointment, 4 weeks postoperative |
Once migration has been diagnosed, removal is necessary[13]. Within the viscera, removal is performed endoscopically[12,15,16]. If endoscopic removal fails or digestive or vesico-uterine complications arise, laparotomy is indicated[12,15]. In our case, the migration was anterior abdominal parietal, following migration from the uterine dome. Given the available technical facilities, a laparotomy was performed.
Conclusion
Unrecognized IUD migration is relatively rare. It can lead to significant complications and must be prevented through proper insertion techniques and regular monitoring. Diagnosis is straightforward, using clinical examination, imaging, and laparoscopy. Once the diagnosis is made, endoscopy is the gold standard for removing an IUD that has migrated into the viscera. Laparotomy remains, however, an option in regions where endoscopy is still scarce or inaccessible.
Strengths and weaknesses of the study
The strengths of our study lie in the relative rarity of this complication related to IUDs and in the educational aspect of prevention. However, the limitations include the unclear identification of risk factors and the lack of imaging.
Acknowledgements
Not applicable.
Footnotes
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Contributor Information
Edem Kossi Gueouguede, Email: edemgueougueded@mail.com.
Gnozi Emmanuel Kanaza, Email: manuelkanaza@gmail.com.
Efoe-Ga Amouzou, Email: eamouzou@univ-lome.tg.
Kokou Kouliwa Kanassoua, Email: kanassouakokou@gmail.com.
Iroukoura Kassegne, Email: kassegneiroukora@gmail.com.
Ethical approval
Ethical approval for this study was obtained from the hospital’s ethics committee. A copy of the ethical approval is available for review by the Editor-in-Chief of this journal upon request.
Consent
Written informed consent was obtained from the patients to publish this case report and the accompanying images. A copy of the ethical approval is available for review by the Editor-in-Chief of this journal upon request.
Sources of funding
The authors received no funding.
Author contributions
All other authors contributed to data collection. All authors read and approved the final manuscript.
Conflicts of interest disclosure
The authors declare that they have no competing interests.
Research registration unique identifying number (UIN)
Not applicable.
Guarantor
P’wèréw Rodolphe plante.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Data availability statement
Data sharing does not apply to this article, as no datasets were generated or analyzed during the current study.
Patient perspective
The patient reports being satisfied with the hospital care, given the speed of treatment and the outcome achieved.
AI declaration
The DeepL and Grammarly apps were used to translate this into English. No other AI was used.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data sharing does not apply to this article, as no datasets were generated or analyzed during the current study.