Discussion
Our case is 30-year-old woman who had an IUD implantation 2 months before admittance, a following work up due to IUD failure and pregnancy revealed that the device had perforated and penetrated abdominal cavity. Ultrasonographic imaging couldn’t precisely locate the device since the device was fast shifting. The patient stated that she suffered from an unbearable pain which indicated that the device should be removed. During her first laparoscopic assessment we couldn’t find and retrieve the device; therefore, tried using ultrasonographic guidance and it proved to be helpful and the surgery resulted in success. Even though the device was barely visible since it was embedded within the omentum, we removed it.
IUDs rarely perforate uterine but these few instances can possibly cause damage to internal organs. Several risk factors such as “inexperienced clinician, lactation, low parity and post-partum insertions particularly within 6 months after labor” are thought to be in association. Several cases of penetration into bowel and urinary tract have been reported. Patients with such perforations are prone to peritonitis. [5] [8] [4] [11]
Although several imaging modalities can locate the device the most preferred method in ultrasonography and as described by Rowlands et al the first alarming sign for perforation is missing threads and the backbone of diagnosis is ultrasonography. [5]All IUD devices are radio opaque therefore they can be found on plain radiographs but this doesn’t exactly reveal the position of device. A CT-scan can provide a more comprehensive view on the matter and in a few select cases the perforation was classified using this method. [5] [8] [16] [14]
Our patient was a pregnant woman therefore, we could solely use ultrasonography. We assume that since the device was cloaked with granulation tissue and omentum “which is quite loose and unrestricted” the position of the device couldn’t be accurately found. Thus, more skill was required to locate the device and it could only be removed with ultrasonographic guide. During the surgery, the device was barely visible and could only be found with guidance and palpation.
The current consensus states that these devices should only be removed if the patient is symptomatic or there is a great risk of adhesions and complications such as perforation and peritonitis. Our patient was neither severely ill nor any signs of perforation was noted but since she was pregnant and prone to other complications and the pain was too great for her to bear, we decided to remove the device. [8] [9] [18] [14] [12]
Our experience with this patient has led us to presume that in patients whose foreign body can not accurately be positioned another imaging modality such as CT-scan must be utilized. If the patient has any contraindications, an ultrasonographic guide can be extremely helpful. In cases whose device is fast shifting and device is changing position too often, it must also be considered that the device might be lodged in tissues such as omentum that is loose and untethered; thereafter, a guidance can help with retrieving it. Our patients also posed another challenge which was due to its embedment within omentum this particular phenomenon indicates internal organs be thoroughly examined and palpated.
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