IUCD (intrauterine contraceptive device) related uterine perforations are one of the causes of uterine perforation. It is a rare, but serious complication of an intrauterine contraceptive device, and is often clinically silent.
The incidence rate is reported at ~2 in 1000 2.
- atrophic / postpartum uterus
- uterine structural abnormalities 5
- large fibroids 5
Perforation of the uterus at the time of insertion may be clinically silent or cause significant pelvic pain. A late perforation may be asymptomatic, or present with non-specific lower abdominal pain. In all cases, the visible 'strings' will be missing at direct inspection. Peritoneal sepsis is a rare presentation.
IUCD-related uterine perforation ranges from embedment in the myometrium to complete transuterine perforation with a migration of the intrauterine contraceptive device into the peritoneal cavity 6.
Embedment refers to the penetration of an intrauterine contraceptive device into the endometrium or myometrium without extending through the serosa.
Intra-abdominal migration occurs when the intrauterine contraceptive device is freely floating in the abdomen or pelvis encased in adhesions or adherent to bowel or the omentum. Adhesions can lead to infertility, chronic pain, and intestinal obstruction 6.
Ultrasound is the recommended first-line investigation 3 in all women in whom the ‘strings’ cannot be visualized. Orthogonal radiographs are often the second line. CT can be used in complex cases where visceral involvement or surgical difficulty is suspected.
- an intrauterine contraceptive device lying lateral to midline may suggest the diagnosis
- may have a normal endometrial cavity on ultrasound
- hyperechoic linear structure lying outside the uterus
Treatment and prognosis
Treatment depends on the degree of perforation and whether there are any complications (such as peritoneal sepsis or intestinal obstruction).
- 1. Heinberg EM, McCoy TW, Pasic R. The perforated intrauterine device: endoscopic retrieval. JSLS. 2008;12 (1): 97-100. Free text at pubmed - Pubmed citation
- 2. Harrison-Woolrych M, Ashton J, Coulter D. Uterine perforation on intrauterine device insertion: is the incidence higher than previously reported?. Contraception. 2003;67 (1): 53-6. Pubmed citation
- 3. Caliskan E, Oztürk N, Dilbaz BO et-al. Analysis of risk factors associated with uterine perforation by intrauterine devices. Eur J Contracept Reprod Health Care. 2004;8 (3): 150-5. Pubmed citation
- 4. Zakin D, Stern WZ, Rosenblatt R. Complete and partial uterine perforation and embedding following insertion of intrauterine devices. I. Classification, complications, mechanism, incidence, and missing string. Obstet Gynecol Surv. 1981;36 (7): 335-53. - Pubmed citation
- 5. Amirbekian S, Hooley RJ. Ultrasound Evaluation of Pelvic Pain. Radiol. Clin. North Am. 2014;52 (6): 1215-1235. doi:10.1016/j.rcl.2014.07.008 - Pubmed citation
- 6. Boortz HE, Margolis DJ, Ragavendra N et-al. Migration of intrauterine devices: radiologic findings and implications for patient care. Radiographics. 2012;32 (2): 335-52. doi:10.1148/rg.322115068 - Pubmed citation
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