Misplaced IUCD -A Case Study

Misplaced IUCD -A Case Study

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MIGRANT IUCD

ABSTRACT
In a developing country like India where population census is crossing the limits,
contraceptive methods are the necessary measures for the population control.
Intrauterine Contraceptive devices (IUCDs) are the second most commonly used method
of contraception after sterilization. Misplaced IUCDs usually present with the missing
thread and remain asymptomatic in most of the cases.
INTRODUCTION
Intrauterine devices (IUCDs) are a commonly used form of contraception
worldwide. However, migration of the IUCD from its normal position in the
uterine fundus is a frequently encountered complication, varying from uterine
expulsion to displacement into the endometrial canal to uterine perforation.
Different sites of IUCD translocation vary in terms of their clinical significance
and subsequent management, and the urgency of communicating IUCD migration
to the clinician is likewise variable. Expulsion or intrauterine displacement of the
IUCD leads to decreased contraceptive efficacy and should be clearly
communicated, since it warrants IUCD replacement to prevent unplanned
pregnancy. Embedment of the IUCD into the myometrium can usually be
managed in the outpatient clinical setting but occasionally requires hysteroscopic
removal. Complete uterine perforation, in which the IUCD is partially or
completely within the peritoneal cavity, requires surgical management, and timely
and direct communication with the clinician is essential in such cases. Careful
evaluation for intra abdominal complications is also important, since they may
warrant urgent or emergent surgical intervention. The radiologist plays an
important role in the diagnosis of IUCD migration and should be familiar with its
appearance at multiple imaging modalities.
CASE REPORT
CASE 1
A case of P2L2, last child birth 9years back. IUCD inserted in postpartum period.
Now patient came for IUCD removal and sterilisation. Patient is asymptomatic. Referred as
a case of misplaced IUCD to our department. We done a X ray abdomen in our department
which shows radioopaque IUCD in higher abnormal position and orientation within the
pelvis(Fig.1). Following that, Ultra sonogram was performed showing vertical limb of
IUCD piercing the uterus at the fundal region and horizontal limb lies over the outer
surface of uterus(Fig.2 & 3) . Similar findings confirmed by CT(Fig.4). Peroperatively
identification of horizontal limb outside the uterus which was held by artery forceps and
IUCD removed successfully by laparatomy(Fig.5)

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FIG.2-4: VERTICAL LIMB OF IUCD PIERCING THE UTERUS AT THE FUNDAL REGION AND
HORIZONTAL LIMB LIES OVER THE OUTER SURFACE OF UTERUS
FIG.1: RADIOOPAQUE IUCD
NOTED HIGH IN THE PELVIS
SHOWING ABNORMAL POSITION
AND ORIENTATION

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FIG.5: PEROPERATIVELY IDENTIFICATION OF HORIZONTAL LIMB OUTSIDE THE UTERUS WHICH WAS HELD
BY ARTERY FORCEPS AND IUCD REMOVED SUCCESSFULLY BY LAPARATOMY

CASE 2
A case of P1L1 , Last child birth 8 years back by LSCS. IUCD inserted in immediate
post-operative period. Patient complains of lower abdominal pain for 1 month. Referred as a
case of misplaced IUCD to our department. X ray with uterine sound shows radio opaque
IUCD noted in pelvis in upside down orientation and far away from uterine sound(Fig.6).
USG was done subsequently. Uterine cavity is free, IUCD is seen outside the uterine cavity,
vertical limb is seen in superior aspect of fundus, horizontal limb is seen piercing the adjacent
bladder wall(Fig.7 & 8). Planned for cystoscopy and IUCD removal done successfully(Fig.9
& 10).

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FIG.7 & 8: IUCD IS SEEN OUTSIDE THE UTERINE CAVITY, VERTICAL LIMB IS SEEN IN SUPERIOR ASPECT
OF FUNDUS, HORIZONTAL LIMB IS SEEN PIERCING THE ADJACENT BLADDER WALL

Fig.9 & 10: CYSTOSCOPIC VISUALISATION OF Cu-T INSIDE THE URINARY BLADDER.

FIG.6: IUCD NOTED IN PELVIS IN
UPSIDE DOWN ORIENTATION
AND FAR AWAY FROM UTERINE
SOUND

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CASE 3
21 year female,P1L1, last child birth 3 years back by LSCS. IUCD inserted in immediate
postpartum period. Now came for IUCD removal and had minimal lower abdominal pain.
Referred as misplaced IUCD to our department. Xray with uterine sound shows radio opaque
IUCD noted in pelvis which was in close approximation to upper end uterine sound(Fig.11). Usg
abdomen & pelvis shows IUCD which is not within endometrial cavity and it is seen piercing the
myometrium(Fig.12 & 13). Subsequently CT performed and confirmed the findings(Fig.14-16).
Then patient planned for Hysteroscopic examination and removal of IUCD done at same sitting
without major adverse effects.



Fig.12 & 13: AXIAL AND SAGITAL SECTIONS OF UTERUS SHOWS IUCD BURIED IN MYOMETRIUM WITH
EMPTY ENDOMETRIAL CAVITY.
FIG.11: IUCD NOTED IN PELVIS
WHICH WAS IN CLOSE
APPROXIMATION TO UPPER END
UTERINE SOUND

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Fig.14 & 15: CT IMAGING - AXIAL AND SAGITAL SECTIONS OF UTERUS SHOWS IUCD BURIED IN
MYOMETRIUM WITH EMPTY ENDOMETRIAL CAVITY.



CASE 4
29 year female,P2L2, LSCS done 5 months back, IUCD inserted in postpartum period.
Patient complains of pain during menstruation and menorrhagia . Xray shows IUCD within
pelvis close to uterine sound with abnormal angulation(Fig.17). Subsequently USG
performed, endometrial cavity appears empty, vertical limb of IUCD embedded within the
FIG.16: 3D –VOLUME RENDERING TECHNIQUE SHOWS
RELATIVE POSITION OF Cu-T IN PELVIS

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myometrium(Fig.18 & 19). Then hysteroscopic removal of IUCD done in a single sitting
without major adverse effects.




FIG.18 & 19: SHOWS USG APPEARANCE OF EMBEDDED Cu-T IN MYOMETRIUM.

DISCUSSION
IUCDs are the most acceptable, safe, efficacious, reversible and widely used
contraceptive method but it may be associated with menorrhagia, irregular bleeding, pelvic
inflammatory diseases, ectopic pregnancy and silent uterine perforation. The reported
incidence of the transmigration of the IUCD from the uterus to the neighbouring organs is 1-
3/1000 IUCD insertions.

The incidence of transmigration is affected by the several factors which includes
parity, timing of IUCD insertion, uterine position, past history of abortions, type of IUCD and
the operator experience. Out of these risk factors, chance of uterine perforation is maximum
at the time of IUCD insertion. Moreover the incorrect positioning of the IUCD is the result of
faulty technique and insertion by insufficiently trained staff. Review of the literature
FIG.17: SHOWS IUCD WITHIN PELVIS
CLOSE TO UTERINE SOUND WITH
ABNORMAL ANGULATION

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suggested various mechanisms for the migration of IUCDs which includes the faulty insertion
technique or the chronic inflammatory process due to the copper content of the IUCDs which
leads to the erosion of the uterine wall. Copper-containing devices are known to cause
massive tissue response and thus leading to complications once lying in the peritoneal cavity.
The complete extrusion of the IUCD through myometrium is facilitated by the uterine
contractions and the pressure difference between the uterine (high) and the peritoneal cavity
(low).The movement and the migration in the peritoneal cavity is facilitated by the
contractions of the abdominal organs i.e. urinary bladder, intestine as well as movement of
the peritoneal fluid.

Patient with the misplaced IUCD remain asymptomatic in 85% of cases and there is
no effect on the adjacent organs. But in 15% of the cases it may present with unwanted
pregnancy, irregular vaginal bleeding and abdominal pain. Dangerous complications
associated with the misplaced IUCD include bowel perforation, rectovaginal fistula, rectal
strictures, bladder perforation, bowel obstruction, appendiceal perforation and mesenteric
perforation.

Removal of misplaced IUCD is desirable even if the patient is asymptomatic so that
the future complications like perforation of the adjacent organs or any fistula development
can be avoided. WHO also advocates the removal of the misplaced or malpositioned IUCD
because of the risk of injury to the adjoining organs and medicolegal issues
Various imaging modalities are used in the evaluation of IUCDs. US is
appropriate for initial evaluation; it is widely available and inexpensive and does not
involve radiation. Furthermore, US can often provide answers to clinical questions
related to the IUCD. It easily helps determine whether an IUCD is correctly
positioned and can often help identify IUCD -related complications. IUCD
displacement and myometrial perforation can be fully evaluated by performing US
alone. Three-dimensional (3D) US is often helpful for further characterizing these
findings, and its use is becoming standard practice in the routine evaluation of
IUCDs.
Abdominal radiography can be helpful in demonstrating an extrauterine IUCD
and is required for the diagnosis of IUCD expulsion. Conventional radiography
exposes the patient to only minimal radiation, and the radiopaque IUCD is easily
identified if it has not been expelled. Occasionally, computed tomography (CT) is
used for the assessment of IUCD positioning; more often, however, IUCDs are
incidentally visualized at CT studies that were ordered for different indications . CT
is the best modality for the evaluation of complications associated with intra
abdominal IUCDs, such as visceral perforation, abscess formation, and bowel
obstruction. However, CT does expose the patient to significantly more radiation.
Magnetic resonance (MR) imaging is not typically used specifically for the
evaluation of intrauterine contraception, but modern IUCDs are safely imaged with
both 1.5-T and 3.0-T magnets and appear as signal voids.
Endoscopic procedures have emerged as a preferred modality for the removal of all
types of misplaced or malpositioned IUCDs. Devices in the uterine cavity or partially
embedded in the myometrium can be easily dealt with the hysteroscopy. Misplaced IUCDs
anywhere in the abdomen can be managed with the laparoscopy and in very few cases of
misplaced IUCD's laparotomy is required.

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FLOW CHART ILLUSTRATES AN OVERVIEW OF IMAGING-BASED MANAGEMENT OF
TRANSLOCATED IUDS.


CONCLUSIONS
IUCDs are a widely used method of contraception with inherent risks that the
radiologist should understand both radiologically and clinically. Multiple imaging
modalities can be used to evaluate an IUCD, but US is appropriate for initial
evalua- tion. Conventional radiography of the abdomen is used to assess the
location of an IUCD when it is not clearly visualized at US. CT is the most use- ful
modality for identifying complications of an intra abdominal IUCD.
The radiologist should make sure to communicate any findings of IUCD
malpositioning to the clinician. Detection of expulsion or displacement should be
immediately communicated to the patient and her healthcare provider, since they can
lead to decreased contraceptive efficacy and may require further management.
Embedment of an IUCD in the myometrium may necessitate intervention in the
outpatient clinical setting and warrants communication of this finding to the referring
clinician, as well as clear documentation in the radiology report. Timely and direct
communication with the clinician is most urgent for those patients with complete
uterine perforation and partial or complete protrusion of the IUCD into the
peritoneal cavity. Patients with an uncomplicated perforation will likely undergo

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laparoscopic removal of the IUCD. Early surgical intervention appears to decrease
the likelihood of adhesion formation, thereby making laparoscopic removal easier.
Emergent surgical intervention should be guided by the patient’s clinical
presentation, supplemented by findings at crosssectional imaging performed to
detect serious intra abdominal complications.
It is also important to understand the complications associated with pregnancy
in females with an IUCD. Such pregnancies are associated with multiple adverse
outcomes for the mother and fetus. Understanding these complications will allow a
more thorough assessment of the study and may provide impetus for expedited
clinical communication of pertinent findings.

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