Difficult Iud Insertion Odds of It Happening Again

• Journal Listing
• Open up Access J Contracept
• v.7; 2016
• PMC5683155

Open Access J Contracept. 2016; 7: 19–32.

Intrauterine devices and risk of uterine perforation: electric current perspectives

Sam Rowlands

^oneMiddle of Postgraduate Medical Enquiry and Education, Faculty of Health and Social Sciences, Bournemouth University, Dorset, UK

Emeka Oloto

²Staffordshire and Stoke on Trent Partnership NHS Trust, Leicester, UK

David H Horwell

³Spire Harpenden Hospital, Harpenden, UK

Abstract

Uterine perforation is an uncommon complication of intrauterine device insertion, with an incidence of one in 1,000 insertions. Perforation may exist complete, with the device totally in the abdominal cavity, or partial, with the device to varying degrees inside the uterine wall. Some studies evidence a positive association between lactation and perforation, only a causal relationship has not been established. Very rarely, a device may perforate into bowel or the urinary tract. Perforated intrauterine devices tin generally be removed successfully at laparoscopy.

Keywords: uterine perforation, intrauterine device, intrauterine system

Introduction

The aim of this review is to heighten sensation of the circumstances in which perforation of the uterus past intrauterine devices (IUDs) can occur, the consequences of such perforations, and approaches to the management of suspected or actual perforation.

IUDs for contraception were offset introduced by Richter¹ in 1909 and were farther developed and deployed past Gräfenberg² from 1929; there was then a resurgence with the modern era beginning in 1959 when flexible plastic IUDs were introduced.³ Over the years, there accept been many blueprint modifications to improve effectiveness, acceptability, and safety.^three IUDs are a highly effective grade of long-acting reversible contraception.

Employ of intrauterine contraception worldwide is extensive: 13.nine% of the world's 1.16 billion women aged 15–49, married or in a wedlock, are using this method.^iv Uptake of intrauterine contraception in Red china is even college at 40.6% of their 269 one thousand thousand women anile 15–49.

Perforation of the uterus with IUDs was get-go described in the 1930s.^{5 , vi} Initially, there was denial that this could happen at the time of insertion, and information technology was postulated that devices were e'er forced through the uterine wall by uterine contractions.^vii Consensus opinion is now that the most mutual mechanism is that the device is forced into or through the uterine wall at the time of insertion. Other terms such every bit "the wandering IUD", the misplaced/displaced or missing IUD, ectopic IUD, migration, mislocation, transmigration, or translocation are therefore somewhat misleading. Less ordinarily, an IUD may penetrate into just remain within the myometrium; this is termed partial perforation.⁸ It appears that uterine contractions tin can sometimes force such a device through the uterine wall.

Although uterine perforation is a potentially serious complication of intra-uterine contraceptive utilize, it is uncommon and information technology tin often exist asymptomatic. Some cases are not identified until months or years subsequently insertion.^{9 – xi} In ane series, the longest interval that had elapsed between insertion and diagnosis was 43 years.¹² It is therefore of import to put uterine perforation into context. Information technology very rarely leads to harmful sequelae, and it does not detract from the overall fantabulous safety record of IUDs.³

Literature search

A formal Medline search using the search terms uterine perforation, displac*, migrat*, perforat*, penetrat*, and translocat* together with intrauterine devices or intrauterine devices copper or intrauterine devices medicated gave 629 English linguistic communication results. Of these, 347 were constitute to be relevant. A similar search in EMBASE produced 418 relevant articles out of a total of 914. Farther references were found within these articles.

Methodological considerations

Perforation of the uterus with an IUD is an uncommon phenomenon. Of the perforations that do occur, most do non cause long-term harm, although women are generally advised to go through a surgical removal procedure that has some risks. However, a meaning harm associated with perforation may exist the loss of the IUD'south contraceptive effect, resulting in unplanned, and often unwanted, pregnancy. Sometimes a perforation leads to trauma to internal structures; such cases are idea to exist very rare.

Quantification of the incidence of perforation from large cohort studies has been done and is likely to be precise. How many of these perforations go along to become more complicated is not known at all. Assessing the strength of risk factors for perforation is difficult. For example, the definition of chest-feeding is imprecise, every bit many women reduce the corporeality they feed gradually over time and so it is not an "all or nothing" variable. Although one study with no clan at all was institute, in that location may be other negative studies that editors did not come across fit to publish. At that place may as well be smaller negative studies without the statistical power to give a valid upshot. There is therefore a potential chance of publication bias.

Autonomously from the data on incidence from cohort studies, much of the literature on this subject consists of isolated case reports; at that place are likewise some relatively small case series. This is the lowest quality of show in the hierarchy of evidence autonomously from "expert opinion".¹³ This state of diplomacy means that when presenting the data there will inevitably be selection bias. Clinicians similar to written report unusual cases. In full general, this bias will exaggerate the risks associated with uterine perforation.

The authors have not cited all case reports that were found in the literature. We have selected citations that describe each facet of the subject well, choosing for preference papers that take a case series rather than an individual instance report, and papers that have reasonable literature reviews.

As this review is of necessity based mainly on findings from cohort studies, small serial, and example reports, it cannot by its nature exist a systematic review. However, the authors have attempted to collate current knowledge and opinion on this topic.

Terminology

Initially modern devices were "inert", made entirely of metal or plastic. In the late 1960s, copper was added to plastic devices to increase their efficacy; a "frameless" copper-just device, GyneFix^® (Contrel, Ghent, Belgium), also became available in 1996. Hormone-releasing devices were developed to improve IUD efficacy and to reduce certain complications such as bleeding and hurting. Copper-containing and hormone-releasing types of device are sometimes termed equally "medicated" IUDs.

The abbreviation used for intrauterine devices known equally a whole and for a conventional (nonhormone releasing) intrauterine device is IUD. Many types of IUD have been available over the years, latterly all with added copper. Several types of progestin-releasing IUD are now bachelor; these volition be referred to collectively equally the IUS, the abbreviation for intrauterine organisation. Examples of past and currently bachelor IUDs are shown in Figure 1.

Types of device.

Notes: (A) Ota Ring, (B) Birnberg Bow, (C) Majzlin Spring, (D) Lippes Loop, (E) GyneFix^®, (F) copper-bearing device: CuTT380 slimline, and (Grand) Levonorgestrel intrauterine system: Mirena^®. Types (A–D) all obsolete. Images (A–D) courtesy of the Museum of Contraception and Abortion, Vienna (www.muvs.org). Images (E–Yard) courtesy of Durbin PLC, South Harrow, Middlesex, UK (www.durbin.co.uk).

Mechanism of perforation

Esposito et al¹⁴ postulated that ii mechanisms of uterine perforation exist.

1. Immediate traumatic perforation

2. Later "secondary" perforation caused by gradual erosion through the myometrium

Confirmation of the latter mechanism has been achieved past serial computed tomography (CT) scans performed for nongynecologic purposes.^xv

In the early days of IUDs, insertion instruments were rigid and then perforation was more likely as a consequence.¹⁶ An early version of the Birnberg bow had a perforation charge per unit of one in 200 because of the rigidity of its inserter.^{17 , xviii} With the Progestasert device, there was documented testify of a reduction in perforation rate when the inserter was made more flexible and a uterine audio included in the package.¹⁹ Nowadays, insertion tubes are fabricated so that they are more flexible, only not and then soft that they buckle easily. Other hazard factors are use of a push-out insertion technique, or lack of an insertion tube, equally was the instance with the Dalkon Shield (Dalkon Corporation, Disobedience, OH, U.s.).

Perforation can also happen with a uterine sound. Traditionally, metal sounds were used to measure the uterine crenel length. Plastic sounds are nigh certainly safer as they are less rigid. Perforation of the uterus may occur when the uterus is being sounded, or a simulated track may be created which is then followed by the IUD.

The forces required to insert an IUD increment linearly with increasing inserter tube diameter.^xx The force required to insert an IUD is generally one.5–vi.5 N. The forces generated physiologically within the uterus have been estimated to exist theoretically every bit high as fifty N, sufficient to produce uterine perforation. This would explicate the so-called "secondary" perforation as a event of embedment of a device. Except in cases of lactation or uterine atrophy (eg, due to long-term use of injectable progestins), it is thought that the forces required to crusade perforation are higher than the forces needed to carry out insertion of an IUD.

Classification

Uterine perforation by IUDs was analyzed in detail by Zakin et al⁸ in a now-classic paper. The authors based their assay on the 356 cases that they institute in the literature in 1981. They described consummate perforation, which is the device passing through all uterine layers – endometrium, myometrium, and serosa – to lie freely in the peritoneal cavity or enveloped past omentum or traveling into other rarer locations. In a minority of cases, the IUD penetrates merely into the myometrium, which they termed partial perforation. Zakin et al⁸ fabricated the important points that missing removal threads do non necessarily imply that a device is incorrectly located and conversely that the threads may be visible when a device has perforated.

Three anatomical compartments are considered, disregarding the endometrium and serosa. These are every bit follows:

1. Uterine cavity

2. Myometrium

3. Peritoneal crenel

Fractional perforation

The partially perforated device may be present in one, two, or all iii anatomical compartments (Figure ii). A device with a type A perforation that is mainly situated in the uterine cavity (A1) will exist easier to remove than one in which the IUD is mainly in the myometrium (A2). Indeed, removal of the latter tin can exist difficult or even hazardous. Post-obit a blazon B perforation the IUD lies entirely within the myometrium and so that it cannot exist seen either at hysteroscopy or laparoscopy. In a type C perforation the device has protruded into the peritoneal cavity simply is nonetheless fixed in the myometrium. In a type D perforation, portions of the device are situated in all 3 compartments and a detailed assessment will exist needed to plan the mode of removal; D2 will be more than circuitous to remove laparoscopically than D1.

Classification of partially perforated devices.

Notes: Blazon A: IUD present in uterine cavity and myometrium; Type B: IUD present entirely in myometrium; Type C: IUD present in myometrium and peritoneal cavity; Type D: IUD present in all three compartments. A copper-T device is depicted: any device can perforate the uterus. The size of the IUDs relative to the uterus has been slightly reduced for illustrative purposes.

Abbreviation: IUD, intrauterine device.

A partial perforation may remain equally such or it may convert into a complete perforation inside a matter of days. This latter conversion is nigh certainly due to uterine contractions pushing the device through the myometrium, the strength needed depending on the shape of the device.

In a very unusual instance, an IUD moved during pregnancy from a location in the lower uterine segment at sixteen weeks' gestation to the posterior fundal myometrium at the time of a xx-week miscarriage, to erosion into modest bowel, constitute at laparoscopic sterilization 6 weeks later on.²¹

Consummate perforation

With a complete perforation of the uterus, the device may remain well-nigh the uterus or it may movement within the abdominal cavity. Zakin et al⁸ found that the most common location for a completely perforated IUD is the pouch of Douglas. In nearly half of complete perforations, the device is located in the omentum, either loosely or adherent to information technology; in the latter case it may exist so densely adherent that a portion of omentum needs to exist excised in order to remove the device. The threads of a completely perforated device will generally not be visible at the cervix past the time of follow-up.

Embedment

Hither, a device impinges on the endometrium with a force sufficient to crusade pressure necrosis of underlying tissue and penetration into the superficial layers of the myometrium.²² This phenomenon was seen in the by in women using the Majzlin leap device. When removal of an embedded device is attempted, trauma to tissues may occur. Great care is needed in cases of embedment if marked pain is caused at attempted removal. In one instance, this caused a tear which resulted in a 2-liter hemorrhage.²³

Incidence of perforation

Perforation of the uterus is uncommon: estimates in larger studies range from 0.4 to one.half-dozen per 1,000 insertions.^{9 , 19} A nationwide prospective cohort written report from New Zealand over a x-year period constitute 28 perforations among 17,469 insertions of the Multiload^® Cu375 IUD (Merck and Co., Inc., White-business firm Station, NJ, U.s.a.), giving an incidence of 1.half dozen per 1,000 insertions.⁹ A 3-year report by the same group found three perforations in 3,519 IUS insertions, giving an incidence of 0.ix per 1,000.²⁴ Both these studies represent "existent-life" results, which give a truer picture than clinical trials, especially when IUDs are existence inserted by generalists. A Turkish hospital-based study of the T-380A IUD followed up women at ane twelvemonth and establish an incidence of ii.ii per 1,000 insertions.²⁵ Other studies that could not be so certain of the denominator have found lower rates; for instance a Finnish study calculated an incidence of 0.4 per one,000 sold devices.²⁶ One written report found a college perforation charge per unit in women using an IUD for the kickoff time compared to women who had used the method previously.²⁷

The long-standing argue well-nigh whether or not lactation is a adventure cistron for perforation with IUD insertion is described in the "Effect of insertion after pregnancy or during lactation" section.

Rates of perforation with any IUD may in role exist influenced by the experience or the maintenance of skill of the operator. This was offset mooted in a report from Singapore, in which more perforations were seen in insertions past junior doctors or general practitioners than by experienced gynecologists.⁷ In a large prospective cohort study of a copper IUD, doctors who had inserted fewer than ten IUDs during the 10-twelvemonth study menstruum (73% of the sample) had significantly higher perforation rates than those who had inserted betwixt ten and 99.⁹ The European Agile Surveillance (EURAS) written report showed a college perforation charge per unit in insertions performed by clinicians who inserted fewer than 50 devices per year compared to those inserting 50 or more than per year.²⁷

Although spontaneous reporting to national databases gives no feel for incidence due to the lack of a denominator, it is interesting to notation that since its launch in 1996, in that location have been 114 reports of uterine perforation with the levonorgestrel IUS in the Great britain and 23 reports of such devices becoming embedded in the uterus, neck, or other local tissues.²⁸

Different device types

Perforation occurs with all device types, whether IUDs or IUSs (Figure 1). This includes frameless copper devices such equally the GyneFix^®.^{29 – 31} Perforation with the sharp tip of the GyneFix^® stylet is potentially dangerous. A Cochrane review ended that it is non known if the perforation rate for framed devices differs from frameless devices; one perforation was noted with GyneFix^® in the studies reviewed (approximately 3,000 insertions) compared to none with the TCu380 framed device.³² The possibility has been raised that the GyneFix^® anchoring knot may sometimes exist located on the serosal surface of the uterus at the end of the insertion procedure,³³ either because the thickness of the fundal myometrium may in some cases be less than originally thought when GyneFix^® was designed or because of thinning associated with long-term injectable progestin utilise.^{33 , 34}

The type of framed device does non appear to exist an influencing factor in perforation rates.³² A large European accomplice written report (EURAS) found no clinically important differences in perforation rates between copper IUDs and the Mirena^® IUS (Bayer Schering Pharma, Turku, Republic of finland)²⁷. At that place is no pregnant difference in perforation rates between Levosert^® (Actavis, Hafnarfjörður, Iceland) and Mirena^® IUSs.³⁵ Early experience with newer depression-dose levonorgestrel IUSs in clinical trials has establish a low crude incidence for complete or partial perforation (0%–0.03%).^{36 , 37}

Take a chance factors for uterine perforation

Possible risk factors for perforation are listed below. Even so, the associations are either weak or inconsistent, so causality has not been demonstrated.

• Insertion by less experienced clinicians^{7 , 9 , 27}

• Lactation: come across the "Effect of insertion after pregnancy or during lactation" section

• Postpartum insertion (<6 months since delivery)^{25 , 27}

• Lower parity²⁵

• Higher number of previous abortions²⁵

Historic period of the woman, history of dilation and curettage, and history of cesarean section take been found not to be associated with gamble of uterine perforation.^{25 , 27}

Consequence of insertion after pregnancy or during lactation

The myometrium is softer when in the significant country and for a fourth dimension subsequently, and so is more vulnerable to being torn or punctured during instrumentation. Involution starts immediately after delivery and is rapid during the first week; past 2 weeks postpartum the uterus is contained within the pelvis; past almost 4 weeks it is shut to normal size. During total breast-feeding, estrogen levels are very depression and the uterus is consequently small. Equally noted past Chi et al,³⁸ IUD insertion is less painful in lactating women; this may be due to increased levels of β-endorphins.³⁹ Perforation during insertion at this fourth dimension may be associated with little pain and may therefore be less likely to be noticed at the fourth dimension of its occurrence.

Perforation in the postpartum period is generally rare. A Singaporean written report in the 1960s (in which two,487 of eight,977 insertions were postplacental, ie, inside 48 hours of delivery) recorded 93 perforations with the Lippes loop,^vii where the perforation adventure was maybe loftier due both to its mode of release from its insertion tube and to its linear grade if information technology did non conform to the shape of the uterine cavity. A after Californian written report of insertions between 4 and eight weeks postpartum showed a null perforation rate with copper-7s and copper-Ts.⁴⁰ In a Turkish study of copper T380A insertions, no perforations were observed at up to six weeks postpartum, merely in that location were some when insertions were done after half dozen weeks.⁴¹

The possibility that women who are lactating are more susceptible to perforation of the uterus when an IUD is inserted was beginning raised in 1966.^{16 , 42} This phenomenon was kickoff investigated in a USA example-control written report.⁴³ This report showed a tenfold higher risk of perforation in women who were lactating at the fourth dimension of IUD insertion compared to women with at to the lowest degree i live birth who were not lactating.

However, subsequent studies did non confirm this finding. A multicenter 6-month follow-upwards study of 1,149 women who underwent copper-T 380A IUD insertion found no perforations in any of the women, breast-feeding or not breast-feeding.³⁸

Assay of 50 perforations reported to a Swedish insurance scheme register found that 27 of the women (54%) were breast-feeding at the time of insertion.³⁹ A multicenter pharmacovigilance study institute that 42% of women with IUS perforations were breast-feeding at the time of diagnosis.¹⁰ Too, in the EURAS study, a sixfold increase in adventure of perforation associated with breast-feeding was establish.²⁷

It is therefore not possible to requite a definitive answer as to whether breast-feeding increases the risk of perforation. Current professional guidance gives no restriction on eligibility for IUD insertion afterward 4 weeks from delivery (postpartum), regardless of whether or not a woman is breast-feeding.⁴⁴ For IUD insertion between 48 hours and 4 weeks postpartum, WHOMEC⁴⁵ and UKMEC⁴⁶ assign category 3 (risks generally outweigh advantages), but USMEC⁴⁷ assigns category two (advantages generally outweigh risks). In June 2015, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) reviewed chance factors for perforation in light of the EURAS study results²⁷ and ended that the benefits of intrauterine contraception strongly outweigh the risks, including in those who are lactating or who take recently given birth.⁴⁸

A systematic review of studies of surgical abortion and of miscarriage treated surgically, followed immediately by IUD insertion, showed perforation rates of one per 1,000 and 0.9 per 1,000, respectively.⁴⁹

Perforation sites

Perforation typically occurs into the uterorectal pouch (pouch of Douglas, cul-de-sac) with an anteverted uterus (Figure 3A) or the vesicouterine pouch if information technology is retroverted⁸ (Figure 3B). Flexion of the uterus is too a factor. In one series, ultrasound examination of women with perforated IUDs showed a significant number with an astute bending of flexion of the uterine body in relation to the cervix.¹² Perforation tin can also occur through the fundus, especially if the uterus is in an axial orientation. It has also been reported to occur into the uterosacral ligament,⁵⁰ broad ligament,^{50 – 52} fallopian tube,⁵³ and ovary.⁵⁴ In that location is a report of IUD threads coming through the posterior fornix; after failed localization at laparoscopy, the IUD was removed by colpotomy.⁵⁵ In one case, an IUD was establish within an ovarian carcinoma.⁵⁶ Very rare sites have been described such equally the anterior intestinal wall.^{57 – 59} There is i recorded case of sciatica subsequently a posterior perforation.^sixty

Diagrams showing management of perforation in dissimilar uterine positions.

Notes: (A) Posterior perforation in an anteverted uterus; (B) Inductive perforation in a retroverted uterus.

Most normally the perforated device is found free in the peritoneal cavity. Nevertheless, ultimately, it usually becomes attached to an organ, the bowel, the mesentery, or most ordinarily the omentum.⁶¹ Rarely, adhesion formation stimulated by a perforated device has resulted in intestinal obstruction.⁶²

Perforation of the cervix is very rare and commonly asymptomatic. It is postulated that some degree of malposition of the device subsequently results in force exerted by the vertical stem with irksome, repetitive uterine contractions which gradually propel the device through the cervical tissues.^{8 , 63} Fortunately, removal tin can be relatively easy, usually past freeing the device initially past pushing it up toward the uterine cavity. There are reported cases of cervical perforation by the threads merely,⁶⁴ which were found running in a fistulous tract along the ectocervix. Ane author postulated that this may have been preceded past trauma to the cervix from a tenaculum. However, this phenomenon can occur at sites other than where the tenaculum has been placed.⁶⁵

Perforation into bowel

Perforation of big and small bowel, appendix, and rectum take been described.^{66 – 68} Removal sometimes has to involve resection of a segment of bowel. There are occasional reports of successful removal of an IUD per rectum by proctoscopy or colonoscopy.^{69 , 70} There is 1 instance study of a perforated frameless IUD which apparently disappeared from the body, presumably via the intestine.⁷¹

Perforation with a modern T-shaped IUD has been known to cause partial intestinal obstacle. In a Danish case written report, a perforation next to the sigmoid colon presented v years after insertion with thickening of the bowel wall causing acute abdominal pain.⁷² Zakin et al⁸ described the "stopper effect" whereby a device that had perforated into bowel leaves a defect in the bowel wall on removal through which bowel contents can pass, with resultant peritonitis. An exceedingly rare complication is fistula formation between different sections of bowel.^{73 , 74} A instance of intestinal gangrene has also been reported.⁷⁵

Perforation into the urinary tract

At that place are more than lxx cases of perforation involving the urinary tract reported in the literature.⁷⁶ Perforation through to the bladder or ureter is an uncommon but regularly reported complication of IUD insertion. In some cases, there is urinary calculus formation effectually the device.⁷⁷ In ane instance report, the IUD was mainly situated in the urethra.⁷⁸ In that location is one report of menouria (vesical menses) due to a vesicouterine fistula,⁷⁹ and another report of formation of a colovesical fistula.^fourscore There are three reported cases of retroperitoneal location of a perforated IUD with fibrosis around the right pelvic ureter leading to right hydronephrosis.^{81 , 82} IUDs and associated bladder calculi can exist removed cystoscopically.^{77 , 78}

Localization of devices that have perforated

The first alert sign, and the most common reason for investigation, of possible uterine perforation is the finding of missing or lost IUD/IUS threads. The bedrock of diagnosis of perforation and localization of a perforated device is ultrasound scanning. Localization of devices is more precise using transvaginal scanning than with transabdominal scanning. Ultrasound scanning is a amend modality for identifying devices that are intrauterine rather than extrauterine. IUDs are easier to identify than IUSs on an ultrasound scan (Figure iv) as ultrasound imaging of the original (52 mg) levonorgestrel IUS (Mirena^®) depends principally on the finding of an acoustic "shadow" rather than on visualizing the device itself. The inclusion of a silver ring at the junction between the vertical stalk and side artillery of the smaller dimension xiii.5 mg IUS (Jaydess^® and Skyla^®; Bayer AG, Leverkusen, Frg) permits easier visualization of the device past ultrasound scanning and distinguishes it from Mirena^® on ultrasound scan and from Mirena^® and other devices on X-ray.

Ultrasound scan images of intrauterine IUDs and an IUS.

Notes: (A) Sagittal view of framed IUD, (B) frameless IUD, and (C) sagittal view of IUS showing triangular audio-visual shadow of device. Pictures courtesy of Emeka Oloto.

Abbreviations: IUD, intrauterine device; IUS, intrauterine organisation.

In one serial, ultrasound scanning failed to show the perforated device in more than one-half of cases.¹² In this serial, IUSs were more probable than IUDs to exist missed. A perforated IUS that was ultimately shown on X-ray and CT browse had been missed by ultrasound scan lone.⁸³ In another serial, there was a noticeable discrepancy between the location of IUSs indicated by ultrasound imaging and subsequent actual location at surgery.⁸⁴ Ultrasound can easily miss IUDs located in the upper abdomen.⁸⁴ Both IUDs and IUSs are radiopaque, and then if they are in the abdominal cavity they volition always exist visible on a whole-abdominal and pelvic X-ray view, but the precise location may still be uncertain (Figure 5); a CT scan or magnetic resonance imaging will be able to localize devices of any type more accurately.⁸⁵

X-ray images of extrauterine IUD and IUS.

Notes: (A) Nova-T 380 IUD and (B) Mirena^® IUS. Pictures courtesy of Emeka Oloto.

Abbreviations: IUD, intrauterine device; IUS, intrauterine system.

Clinical features

A scenario that has occurred regularly, particularly in the more distant past, is that a clinician makes a presumption that "lost" threads are due to an IUD having been expelled, leading to long delays in diagnosis if an ultrasound scan, and if necessary an X-ray, is not performed to confirm the absenteeism of the device. Sometimes another device is inserted so that both an intrauterine and an extrauterine device are present. Rarely, a perforation is non detected by ultrasound scanning and a 2nd perforation occurs in the same individual.^{86 , 87}

Assessment of the size and position of the uterus is essential before insertion of an IUD. Utilise of a uterine audio and traction with a tenaculum was suggested in 1966¹⁶ and has get part of routine practice. This is specially important where there is sharp ante- or retroversion of the uterus, astute ante- or retroflexion, or a severe mismatch of flexion and version¹² (Figure 3); if these angulations are not straightened with traction using a tenaculum then perforation is probably more than likely.⁸⁸ Setting the flange on the introducer accurately to the uterine crenel length equally measured with the sound is besides important.

Uterine perforation can occur with the sound, with the device itself, or with both. If the audio or inserter pass further than i would normally expect (over 10–xi cm) and if no resistance is felt, then this should be regarded equally suspicious and the instrument or device immediately withdrawn from the uterus and the process abandoned. If perforation is suspected following insertion of the device, an ultrasound scan may be carried out immediately if the facilities and skills are available, or arranged via an imaging department.

In around 90% of cases, perforation is not recognized at the time of IUD insertion.^{9 , 10} The threads are mostly still emerging from the cervical os at the terminate of the procedure, even with a consummate perforation. Sometimes perforation is suspected betwixt the time of insertion and follow-up, due to persistent symptoms, mainly balmy lower abdominal pain. I of the main purposes of follow-up near 6 weeks after insertion is to exclude expulsion and perforation. In most cases of perforation the threads are non visible at vi weeks. However, not all women attend for this follow-upward examination. In a few cases in which the IUD is located in the pouch of Douglas, the device can be palpated on vaginal or rectal test.⁸

Many instances of perforation are diagnosed later than the follow-up examination, ofttimes because of the occurrence of a pregnancy, which may exist ectopic.⁸⁹ Other indicators of perforation are "lost" threads and persistent lower abdominal pain. In the 10-twelvemonth New Zealand cohort study, over half of perforations were diagnosed more than than 1 yr after insertion.⁹

Information technology should be borne in mind that when a perforated IUS lies shut to the uterus, the woman may nevertheless experience amenorrhea from local progestin release;^xc the IUS may too have an adequate "remote" contraceptive upshot.⁹¹ A perforated IUS has been reported as a rare cause of secondary infertility.^{92 , 93} In 1 case of IUS perforation, plasma levonorgestrel levels were higher from intraperitoneal release than are more often than not found from intrauterine release.⁹⁴ In the Finnish report, women with perforations were less likely to go pregnant if their perforated device was an IUS rather than an IUD.¹¹ However, a example written report described a pregnancy occurring with a perforated IUS well within the expected 5-twelvemonth IUS life span. It was removed from the omentum at cesarean department.⁹⁵

When the bowel is perforated, a triad of symptoms has been described: abdominal pain, fever, and intermittent diarrhea.⁶⁶ Rectal bleeding is likewise possible.⁹⁶ Occasionally, bowel perforation is asymptomatic with discovery equally an incidental finding, for instance at hysterectomy.⁹⁷ When the urinary tract is perforated, symptoms may include dysuria, frequency, suprapubic pain, hematuria, and recurrent urinary tract infections. Once, a perforated device was missed at hysterectomy and constitute afterward in the right lower quadrant, 35 years after insertion and 14 years later on the hysterectomy.⁹⁸ In another instance, an IUS was found in the abdomen despite the patient having had a vaginal hysterectomy and admissions to infirmary on business relationship of abdominal pain.⁸³ In the single reported case of right-sided sciatica, an IUD was resting on the lumbosacral plexus; information technology was postulated that the left side is protected by the sigmoid colon.^sixty

Prevention of uterine perforation

Actions that can aid to reduce the risk of uterine perforation associated with insertion of IUDs include:

• Abstention of insertion or taking extra care (with special consent) from 48 hours to four weeks postpartum, specially if the woman is breast-feeding

• Use of a plastic rather than a metal sound

• Apply of a suitable tenaculum and applying appropriate traction to it

• Provision of less rigid introducers past device manufacturers

• Authentic setting of the flange on the introducer co-ordinate to the sounding distance and the specific instructions for the device

• A pull-back, rather than a push button-out, release mechanism for the device

• Skilled insertion training for clinicians

• Insertion by experienced clinicians

There is no evidence that utilise of ultrasound command during the routine insertion of IUDs reduces the take chances of perforation occurring. Yet, complex insertions (eg, after failed insertion elsewhere as a result of acute uterine ante- or retroversion or in cases of circumstantial fibroids) are carried out under ultrasound guidance in many specialist centers, which volition assistance to minimize the risk of uterine perforation. Ultrasound is as well a very useful tool in verifying the location of an IUD/IUS afterwards insertion, especially if at that place is business organization about possible perforation.

Removal of devices that have perforated

Information technology is conventional clinical practice to remove all devices that have completely perforated the uterine wall. Originally, this was considered vital⁹⁹ equally older, at present obsolete, devices were "airtight" (examples are Gräfenberg ring, Ota ring, Incon ring, Hall-Stone ring, Antigon and Birnberg bow – Effigy 1) and a loop of bowel could pass through the device with resultant intestinal obstruction.^{100 – 103} Ring-shaped IUDs have continued to be used in China until contempo years.

There is no such risk with newer, mainly T-shaped, devices (Figure 1). Many of these devices remain in the belly, for periods of years in some cases, without doing whatever harm before they are discovered. Some authorities accept suggested that removal of a modern IUD is not warranted and that the risks of laparoscopy or even laparotomy are non justifiable when a adult female with a perforated device is asymptomatic.¹⁰⁴ In one example report, a 62-year old woman who had a Lippes loop in her abdomen for 42 years was followed up without recourse to surgery.¹⁰⁵ Another reason for conservative direction would be a woman with circuitous medical issues who is deemed unfit for surgery.¹⁰⁶

At that place is, nevertheless, the question every bit to whether the components of IUDs (plastic frame and copper) or IUSs (plastic frame, progestin, silicone matrix and sleeve, and silverish in the case of Jaydess^®/Skyla^®) induce peritoneal adhesions. A study on rabbits plant that polyethylene strange bodies elicited a peritoneal reaction with adhesion formation in well-nigh animals subsequently 2 weeks.¹⁰⁷ Several human studies have shown just local and delicate peritoneal adhesion formation; bands of adhesions that could crusade bowel obstruction did not develop.^{104 , 108 – 110} An Israeli study showed no difference in the peritoneal reaction between IUDs and the IUS,¹¹⁰ just ii other studies found that adhesion formation was more common with IUDs than the IUS.^{11 , 12} Adoni and Ben Chetrit¹⁰⁴ were of the opinion that adhesions class during a limited period only; once formed, the authors suggested that they do non develop further. However, in i series, adhesions were more common when the interval from insertion to surgical intervention was greater than 8 months.¹² If they form, adhesions are localized to the IUD/IUS site and preclude the device from moving further.¹⁰⁹

The precise surgical details of removal of IUDs from the abdomen are outside the scope of this article. The first laparoscopic removal of an IUD took identify in 1969.¹¹¹ Laparoscopic removals accept been successfully performed in pregnancy.¹¹² Perforated IUSs have been purposely left in situ during pregnancy¹¹³ or mistakenly thought to exist intrauterine⁹⁵ and then removed at cesarean department.

Minimally-invasive laparoscopic removal is to be preferred, simply when the removal is more complicated open laparotomy may be safer. In a 2012 systematic review of laparoscopies carried out for removal of perforated IUDs, 64% were successful and 35% needed to exist converted to laparotomy.¹¹⁴ The example series in that review were reported betwixt 1972 and 2002, and the scope of laparoscopic surgery has certainly progressed in recent years. Information technology could therefore exist argued that a woman whose perforated IUD cannot be removed at initial laparoscopy should be referred to a surgeon with special skills in minimal admission surgery, who may be more probable to remove a device successfully and safely than a full general gynecologist. Occasionally "discretion is the better part of valor" and laparoscopy or laparotomy is abased when retrieval is unsuccessful in cases where the device has become densely adherent to, or buried in, vital structures. Information technology should be noted that surgery to remove an IUD may itself cause adhesion formation.¹⁰⁹ Laparoscopic removal is not viable in blazon A and B perforations.¹¹⁵ However, type A perforations may well be amenable to removal of the device at hysteroscopy.

In certain cases, early laparoscopy is not the preferred approach. In a retrospective serial of 95 cases of perforation, two devices were removed at cesarean section and 1 at post-partum sterilization.¹¹⁶ Nitke et al⁸⁴ noted that in several of their cases IUSs were located at a higher level in the abdomen at laparoscopy than had been indicated by the diagnostic erect X-ray. They postulated that IUSs attach to omentum which then shifts from pelvis to upper abdomen when the patient is in the Trendelenburg position for laparoscopy. This may too explain the more precise localization by CT scanning, during which the patient is supine. Some surgeons use Ten-ray imaging when the patient is positioned for surgery.

Healing of the myometrium after perforation is rapid. Often at laparoscopy a few days or weeks later IUD insertion and perforation, no scar is visible on the uterus to show the get out point.¹¹⁷ In the Kho and Chamsy¹² series, the perforation site was identifiable in simply i-third of cases. Zakin et al⁸ concluded that scars would disappear by two months after perforation. This is, however, not invariably truthful and sometimes a scar does persist long-term.¹¹⁸

Medicolegal aspects

Perforation of the uterus is a recognized complication of IUD insertion. Provided that preinsertion counseling and assessment have been carried out, with provision of written data, and the procedure is carried out using a prophylactic technique and the patient then followed upward with full documentation in the medical records, clinicians should not be vulnerable to litigation.¹¹⁹ Perforation is a gamble each time IUD insertion is carried out in the same individual; risks should be explained at every procedure, not just the first.¹²⁰

Consent for IUD insertion does non demand to be in written form for nonanesthetized women, just a brief explanation of perforation along with the other complications is needed in social club to obtain valid consent, including the information that the 1 in 1,000 run a risk of perforation is uncommon. This level of adventure can be presented on a chance scale to make it easier to comprehend.¹²¹

Determination

While being an uncommon phenomenon, uterine perforation with an IUD is an important hazard that must be explained to patients, prevented if possible by taking all steps to insert devices safely, and diagnosed and managed accordingly. About cases are due to traumatic perforation that occurs at the time of insertion. However, "secondary" perforation tin can likewise occur by gradual erosion. A partial perforation may convert into a complete perforation.

Perforation occurs in i in 1,000 IUD or IUS insertions and occurs with all types of devices. The prove on perforation and lactation is conflicting: although some studies show a positive association, others exercise not and so a causal human relationship has non been established. Most perforations are uncomplicated, with the device lying in a quiescent country in the abdomen. Withal, rarely other organs can be affected, either past direct trauma at the time of insertion or by subsequent erosion. Both the bowel and the urinary tract lie in close proximity to the uterus and can be affected.

Well-nigh cases are "silent" and non recognized at the time of insertion. IUSs are quite normally missed when abdominal ultrasound is the only imaging modality used. Transvaginal ultrasound scanning past the clinician searching for a "missing" device is usually the offset line of investigation, but in that location is still much to be said for requesting a plain 10-ray of belly and pelvis if the device is not located immediately by ultrasound scan. When perforation is diagnosed, most devices can be and should exist removed. This can nigh oftentimes exist achieved by laparoscopy; sometimes laparotomy may exist needed.

IUDs are remarkably simple, safe and cost-effective, long-acting contraceptives. Overall, this review demonstrates the low morbidity associated with their utilise, even when uterine perforation occurs.

Acknowledgments

We thank the staff at the Library, Royal Bournemouth Hospital Education Centre, for conducting the literature searches and for providing references.

Footnotes

Disclosure

The authors accept received fees for consultancy and provision of preparation from the manufacturers of intrauterine devices. The authors report no other conflicts of interest in this work.

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Articles from Open up Admission Journal of Contraception are provided here courtesy of Pigeon Press

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683155/

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