Normally placed hormonal IUCD (Mirena)

Case contributed by Dr Sahil Loomba

Presentation

G2P2L2A0D0 patient presented with a history of IUCD insertion 5 years back. Presently comes in for a regular check up.

Patient Data

Age: 30 years
Gender: Female

Pelvis

Ultrasound

Normally placed IUCD with 'laminated appearance of stems' and 'non-laminated appearance of strings'

Case Discussion

IUCD is a widely used, widely available form of long term contraception that is 'reversible'.
"Mirena" is a 2levonorgestrel-releasing intrauterine contraceptive device. 
These are mostly placed electively and are contraindicated in emergency situations. 

The device has two stems - one horizontal (shaft) and another vertical stem (arms) which are considered normally placed with the following criteria:

  1. the device has a "laminated" appearance of uniformly echogenic lines on sonography, both for the horizontal and vertical stems on 2D/3D scans
    1. arms - placed along the long axis of the fundal uterine endometrium.
    2. shaft - placed between the two uterine cornua with the ends facing either side.
  2. strings of the device appear echogenic with a "Non-laminated" irregular echogenic appearance within the cervix
  3. stems are differentiated from strings based upon their appearances
  4. each stem will cast a posterior acoustic shadow which may obscure the structures posteriorly and also cause spurious endometrial measurements
  5. sometimes immediate post insertional air may create an echogenic artefact that is considered normal. 

Misplaced IUCD
Long-term placed devices may get embedded into the endometrium when they are directed in a non-cranio-caudad fashion.  These may be considered abnormal if clinically there are menstrual troubles when these may be labeled ineffective and removal is advised. 

Misplaced IUCD may be also seen lower in the cervix, in adnexae or lost into the abdomen. Expulsion of IUCD is also commonly seen.

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