Gynecology and Obstetrics Open Access Open Journal

Case Report

Ileal Perforation after Intrauterine Device Insertion
SuleimanGhunaim1*, Raja Sayegh2
, Dina Chamsy1
, Bassem Safadi3
, Dib Sassine1
, Omar Odeh4
, Johnny Awwad1
1
Department of Obstetrics and Gynecology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
2
Department of Obstetrics and Gynecology, Boston Medical Center, Boston, USA
3
Department of Surgery, Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University Medical Center, Beirut, Lebanon
4
School of Medicine, the University of Jordan, Amman, Jordan

*Correspondence to: Suleiman Ghunaim, Department of Obstetrics and Gynaecology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
PO Box 11-236. Riad El-Solh 1107 2020; Tel: 00962795933952; E mail:suleimanghunaim@gmail.com
Received: Jan 29th, 2021; Accepted: Feb 3rd, 2021; Published: Feb 5th, 2021
Citation: Ghunaim S, Sayegh R, Chamsy D, Safadi B, Sassine D, Odeh O, Awwad J. Ileal perforation after intrauterine device insertion. Gyne and Obste Open A
Open J. 2021; 2(1): 35-37. doi: 10.33169/gyne.Obste.GAOOAOJ-2-109

Abstract
The intrauterine contraceptive device is the second most popular form of contraception worldwide. Uterine perforations may rarely complicate
intrauterine contraceptive device use and are believed to occur mostly at the time of insertion. In the majority of cases, perforations are not recognized by the operator and remain asymptomatic. In rare instances however, severe delayed complications involving adjacent organs may ensue.
We report an unusual case of uterine perforation with bowel injury diagnosed two years after the insertion of a copper intrauterine contraceptive
device. We aim to address the use of transvaginal sonography to confirm proper intrauterine contraceptive device placement following a technically challenging insertion, clinical surveillance, and prompt removal of an intraperitoneal intrauterine contraceptive deviceto prevent potential
serious complications, such as bowel embedment.
Keywords: Bleeding; Bowel injury; Contraception; Intrauterine contraceptive device; Uterine perforations.
Abbreviations
IUD: intrauterine contraceptive device; G2P2: Gravidity 2 Parity 2.

Introduction
The intrauterine contraceptive device (IUD) is the second most popular
form of contraception worldwide, thanks to its record of safety, reversibility, and long-term user independent efficacy. While IUD insertions
are easily done by a multitude of trained and licensed professionals in an
office setting, proper informed consent is required to ensure the patient
is aware of side effects, alternative contraceptive options as well as rare
potential risks.
One such rare but potentially serious risk of IUD insertion is
uterine perforation, with an estimated incidence of0.4-2.2/1000.1
Uterine perforations are believed to happen mostly at the time of insertion.2
Factors associated with perforation risk at insertion include technical
proficiency of the operator, interval since delivery in postpartum and
lactating women,3
and cervical/uterine anatomy. In the majority of cases, perforations are asymptomatic or may manifest mild symptoms of
abnormal uterine bleeding and/or abdominal pain.4
In rare instances,
they may lead to more severe complications involving adjacent organs
namely bowel and bladder.2,5
We here in report on an unusual case of uterine perforation
with bowel injury diagnosed two years after the insertion of a Multiload
375® copper IUD.
Case Report
26 year old G2P2 presented for an IUD checkup. She had a Multiload-375 Copper IUD inserted 6 weeks post her cesarean delivery 2
years prior to insertion. Insertion was reported to be difficult and traumatic and had to be finally completed under intravenous sedation in
an operating room setting. We have no documentation as to whether
insertion was done under ultrasound guidance or not. One month after
the insertion, the IUD strings were visualized on routine checkup. The
patient had been completely asymptomatic for the past 2 years however

more recently, she reported new onset of intermittent diffuse abdominal
cramping, unrelated to her menstrual cycle.
Upon examination, the IUD strings were not visualized. A
pelvic ultrasound was performed in the office and failed to identify the
IUD in the endometrial cavity. Plane frontal radiography was obtained,
however, was inconclusive because the IUD appeared in the lower midpelvis and would not differentiate between an intrauterine versus an
extra-uterine location.
Therefore, Computerized Tomography of the abdomen and
pelvis was obtained, and revealed the IUD to be located in the abdomenat the level of the second sacral vertebra. Patient agreed to proceed
with laparoscopic surgery to retrieve the intraperitoneal IUD. Diagnostic laparoscopy showed two threads protruding from a dense mass of adhesions involving a loop of small bowel and the sigmoid colon. The body
of the IUD was completely embedded within and could not be visualized
(Figure1). Careful sharp dissection of the matted loops of bowel revealed
most ofthe IUD to be actually embedded within the lumen of the ileum
(Figure 2). At this time, the general surgery team was consulted for assistance and apartial ileal resection and end-to-end anastomosis was accomplished laparoscopically. The attenuated serosa of the sigmoid colon
at site of adhesiolysis was also reinforced with intra-corporeal sutures
and tested by air insufflation using intraoperative sigmoidoscopy. The
patient had a smooth recovery and was discharged on the second postoperative day.
Discussion
Uterine perforation is a rare and often asymptomatic complication of
IUD insertions with an estimated incidence of less than 0.1%, but may
be associated with serious delayed complication as illustrated in this
case.
Bowel injury is believed to occur inonly a small fraction
of perforated IUD insertions. In a systematic review, Gill et al. 2012
evaluated 179 uterine perforations from IUD insertions reported in the
literature. Nineteen cases involved bowel injuries with four requiring
bowel resection. Although valuable in confirming the medical hazards
of perforated IUDs, this case series may have overestimated the rate of
bowel injury as a result of publication bias.
A few studies argue for expectant management of perforated
IUDs due to the low risk of delayed visceral injuries,6,7 however, the
main limitation was the short term follow up post IUD insertion probably leading to under-reporting to the late severe complications.
Despite the rarity of visceral injury resulting from perforated IUDs, the morbidity from such a complication has led the World
Health Organization as well as the American College of Obstetrics and
Gynecology to recommend prompt surgical removal of the perforated
IUD.
Although most perforated IUD retrievals are straightforward, ours was challenging due to bowel involvement. Given that the
patient was lost to follow up for two years post IUD insertion, the exact chronology and sequence of events that led to this delayed visceral
injury are not precisely determined. We offer below some hypothesis
and reasoning behind this patient’s IUD perforation, migration, and
subsequent bowel embedment:
Uterine Perforation
We speculate that partial perforation likely occurred at the time of the
difficult IUD insertion. This patient did indeed have a number of risk
factors which have been reported in the literature to be associated with
a 2-8 fold increase in risk of perforation, including lactational amenorrhea, short interval since delivery and technical difficulties during
insertion requiring use of intravenous sedation.3,5,8 While ultrasound
use during, or immediately post insertion may have helped detect a
significant perforation, the sensitivity of sonography for detection of
minor or partial perforations is not clear and may depend on the skill of
the sonographer, resolution of machine and variable factors that impact
the sensitivity of sonography eg. Shadowing from bowel gas and presence of small fibroids. Furthermore, in the absence of conclusive cost
effectiveness studies, access to sonographic equipment at time of IUD
insertions remains variable. Perforation by IUD might occur as a result
of postpartum fragile uterus and abnormal placentation such as vesicular mole.9
However, the most encountered cause for uterine perforation
is the methods used in criminal abortion.10
IUDTransmigration
Progressive IUD migration of the IUD through the uterine perforation
into the peritoneal cavity may have occurred progressively over time
aided by uterine contractions once postpartum menstrual function had
resumed. The disappearance of the IUD strings from the initial postinsertion checkup to the patient’s evaluation 2 years later reinforces the
idea that intra-peritoneal IUD migration was progressive in nature and
not acute.Therefore, surveillance for IUD presence and stability after
Figure 1. Perforation site along with the IUD strings protruding away from the small bowel
Figure 2. Body of the IUD completely embedded in the Lumen
37
Gynecology and Obstetrics Open Access Open Journal
Case Report | Volume 2 | Number 1|
two to three menstrual cycles, particularly after difficult IUD insertions,
may be beneficial, even if an immediate post insertion sonography was
done and found to be reassuring. This can be done clinically at first
by looking for IUD strings on speculum exam and sonographically as
needed when the strings are not visible. This also adds the benefit of
the ability to intervene and prevent an unwanted pregnancy in women
who have unknowingly lost the contraceptive efficacy of the IUD due
to asymptomatic displacement. It should be noted that in a prospective
study, Kroon et al. suggested that routine ultrasound monitoring was
more likely to increase the rate of unnecessary interventions, and that it
should be reserved to clinically doubtful insertions.11
Bowel Perforation
We speculate that while the IUD was extruding through the fundus, its
copper containing elements came into contact with the adjacent rectosigmoid serosa resulting in chronic sterile inflammatory serositis and
ultimately involving a loop of ileum leading to small bowel adhesions
to sigmoid, engulfment of the IUD and progressive erosion and embedding into the bowel lumen after which the process became clinically
symptomatic. In fact, compared to levenorgestrel releasing IUDs, copper IUDs are known to be inflammatory in nature and as a result of
that, our patient was noted to have dense intra-peritoneal adhesions.
This copper induced inflammatory response has been theorized to occur
at the endometrial level and contribute to their contraceptive efficacy
of the properly placed copper IUD [6]. Based on our case report, the
laparoscopic approach offered a clear panoramic view of the pelvis and a
minimally invasive strategy for removal to minimize the risk of progressive bowel wall erosion and severe complications. This concurs with that,
most women with a transmigrated IUD, regardless of type, would want
it removed.
Taken together and on the basis of a single case report describing visceral injury due to a perforated copper IUD, the routine use of
ultrasound for confirmation of proper placement following a technically
challenging insertion may be of benefit. Moreover, clinical surveillance
for IUD stability after few menstrual cycles could potentially identify delayed IUD migration following partially perforated or improperly placed
IUDs. Prompt management of perforated and/or migrated copper-IUDs
is a must to avoid potentially serious long term bowel complications, and
this can be accomplished laparoscopically.
Acknowledgments
No funding of any kind has been provided for this manuscript.
Conflicts of Interest
None.
REFERENCES
1. Andersson K, Ryde-Blomqvist E, Lindell K, et al. Perforations with
intrauterine devices: Report from a Swedish survey. Contraception.
1998; 57(4): 251-255. doi: 10.1016/s0010-7824(98)00029-8
2. Zakin D, Stern WZ, Rosenblatt R. Complete and partial uterine
perforation and embedding following insertion of intrauterine deives.
I. Classification, complications, mechanism, incidence, and missing
string. Obstet Gynecol Surv. 1981; 36(7): 335. doi: 10.1097/00006254-
198108000-00001
3. Kaislasuo J, Suhonen S, Gissler M, et al. Intrauterine contraception:
incidence and factors associated with uterine perforation-a populationbased study. Hum Reprod. 2012; 27(9): 2658-2663. doi: 10.1093/humrep/des246
4. Kaislasuo J, Suhonen S, Gissler M, et al. Uterine perforation caused
by intrauterine devices: Clinical course and treatment. Hum Reprod.
2013; 28(6):1546-1551. doi: 10.1093/humrep/det074
5. Gill RS, Mok D, Hudson M, et al. Laparoscopic removal of an intraabdominal intrauterine device: Case and systematic review. Contraception. 2012; 85:15-18. doi: 10.1016/j.contraception.2011.04.015
6. Adoni A, Chetrit AB. The management of intrauterine devices following uterine perforation. Contraception. 1991; 43(1): 77-81. doi:
10.1016/0010-7824(91)90128-3
7. Markovitch O, Klein Z, Gidoni Y, et al. Extrauterine mislocated IUD:
Is surgical removal mandatory? Contraception. 2002; 66(2): 105-108.
doi: 10.1016/s0010-7824(02)00327-x
8. Heinemann K, Reed S, Moehner S, et al. Risk of uterine perforation
with levonorgestrel-releasing and copper intrauterine devices in the
European Active Surveillance Study on Intrauterine Devices. Contraception. 2015; 91(4): 274-279. doi: 10.1016/j.contraception.2015.01.007
9. Hegazy A. Clinical Embryology for medical students and postgraduate doctors. LAP; Lambert Academic Publishing, Berlin, 2014. Website:
https://www.lap-publishing.com/catalog/details/store/gb/book/978-
3-659-54516-0/clinical-embryology-for-medical-students-and-postgraduate-doctors
10. Singla R, Gaba N, Naik AL, et al. Rupture of Unscarred Uterus with
Intestinal Prolapse from Vagina following Criminal Abortion. Cureus.
2020; 12(9): e10601. doi: 10.7759/cureus.10601
11. Kroon CD, Houwelingen JV, Trimbos JB, et al. The value of transvaginal ultrasound to monitor the position of an intrauterine device
after insertion. A technology assessment study. Hum Reprod. 2003;
18(11): 2323-2327. doi: 10.1093/humrep/deg433