This case presentation discusses a 35-year-old woman who presented with lower left quadrant tenderness for 3 months. Imaging revealed an intrauterine device (IUD) located in her bladder, indicating extrauterine migration of the IUD which had been placed 8 years ago. Risk factors for uterine perforation include multiparity, Cesarean sections, and insertion in the early postpartum period. Perforations can be complete, through the uterine wall, or partial within the myometrium. Complications include infection, abscess, bleeding, and perforation of other organs. Treatment involves minimally invasive laparoscopic removal of the migrated IUD when possible.

1. CASE PRESENTATION
OBGYN -GPHC
Migration of
Intrauterine Devices
Dr. Rafi Rozan
Obstetrician & Gynecologist
Laparo, Mastology & Cosmetic Gyne

2. C/C : Lower left quadrant tenderness for 3/12
HPI : 35 y/o G3p3003 with no significant PMH refers
that 3 months ago she started with a LLQ pain of
moderate intensity, sharp which is aggravated by
change in position and is alleviated by lying down. No
PV bleeding, dysuria, vomiting, fever or any other
symptoms.

3. PMH : Nil Obst Hx:G3p3003
PSH : Nil Menarche : 14y/o
FH : Mother (HTN + DM) Menses : 4/28
SH : No smoking, no EtOH Contraception : IUD
DH : Nil placed 8 years ago
Allergies : Nil inVenezuela
Trauma : Nil FP : BTL
Transfusions : Nil Pap smear :Negative
2 years ago

4. P/E :
Mucous Membranes : Pink and moist
Resp : BAE clear X 2
CVS : S1/S2/Mo
Abdomen : Soft, mildly tender on palpation to LLQ, no
guarding or rigidity. +BS
CNS : Conscious and oriented X 3

5. Labs :
Hb : 12.4g/dL
PLT : 331 X 109/L
Urine BhCG : Negative
UA : Negative
Abdominal X-ray : OpaqueT-shaped shadow resembling an IUD
located in the anterior lower segment of the uterus projecting
outwards
Abdominal USG : Presence ofT IUD in the bladder

6. Cystoscopy Showing IUD

7. IUD EXTRACTED

8. Extrauterine Migration of an IUD

9. INTRODUCTION
•The intrauterine device (IUD) has been used as a
contraceptive device since the latter half of the 20th
century.
•Currently, the most used devices are either the
TCu380A(copper IUD) or the Mirena® LNg
(levonorgestrel-releasing IUD)
•Uterine perforation is a rare yet serious event and
occurs at a rate between 1 out of 10,000 and 1 out of 350
IUD insertions

10. RISK FACTORS FOR UTERINE
PERFORATION
1. Uterine factors: myometrial weakness (multiparity,
Cesarean section), pronounced retro- or anteversion,
uterine hypoplasia, insertion in the early post-
partum period; lactation period
2. IUD insertion technique including operator
experience
3. IUD type: perforation might be more frequent with
copper IUDs.

11. CLASSIFICATION OF UTERINE
PERFORATIONS
• Complete perforation: which is the device passing
through all uterine layers – endometrium,
myometrium, and serosa – to lie freely in the peritoneal
cavity or enveloped by omentum or traveling into other
rarer locations.
•Partial perforation : IUD penetrates only into the
myometrium

13. CLINICAL FEATURES
•Patients may present with signs of perforation or
infection and have a very tender pelvic or abdominal
examination on arrival. More often, they may have a
more subtle presentation and have only mild
tenderness on examination.
•They can both present with vaginal discharge, fevers,
vaginal bleeding, and a lack of visualization of strings
on physical examination.

14. If the strings are not visualized, there are three
possible explanations:
1. the IUD is still in the uterus, but the strings are
broken or curled up;
2. the IUD has been expelled;
3. or the uterus is perforated and the IUD is
somewhere in the uterine wall or abdominal cavity.

15. COMPLICATIONS OF
UTERINE PERFORATION
1. Infection
2. Abscess formation
3. Bleeding
4. Perforations of other intraperitoneal organs, most
often involving the bowel or bladder.

16. Investigations
•TAUS
•TVUS
•Plain abdominal radiograph
•CT scan of the abdomen

17. PREVENTION OF UTERINE
PERFORATION
•Avoidance of insertion or taking extra care (with
special consent) from 48 hours to 4 weeks
postpartum, especially if the woman is breast-feeding
•Use of a plastic rather than a metal sound
•Use of a suitable tenaculum and applying appropriate
traction to it
•Skilled insertion training for clinicians
•Insertion by experienced clinicians

18. TREATMENT
•Minimally-invasive laparoscopic removal is to be
preferred, but 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 be
converted to laparotomy.

19. REFERENCES
• http://www.medscape.com/viewarticle/807807_3
• http://www.academia.edu/22491368/Extrauterine_Migration_of_a_
Mirena_Intrauterine_Device_A_Case_Report
• https://www.dovepress.com/intrauterine-devices-and-risk-of-
uterine-perforation-current-perspecti-peer-reviewed-fulltext-
article-OAJC

20. THANK YOU