The management of intrauterine devices following uterine perforation

Abstract

The generally accepted indications for removal of an intra-abdominal intrauterine device (IUD) are: a) a closed variety of IUD, b) medicated IUDs with copper or hormone release, and c) a medico-legal or psychological problem. A perforated IUD can be left in the peritoneal cavity if it is made of non-irritating plastic. The copper IUD causes adhesions, but these lead to few cases of serious complications. The reason for removal of the IUD stems only from the fear of adhesion formation. Our experience, supported by the literature, leads us to believe that this indication should no longer be accepted.

PIP: Management of 11 cases of translocated IUDs, from 1978-1986, at the Hadassah University Hospital, Jerusalem, suggested that leaving the IUD in place is less risky than laparotomy. The IUDs were 4 Lippes loops, 4 Nova Ts, and 3 MLCu 250s, inserted at postpartum Weeks 6-18. The indications were missing threads in 5 cases and pregnancy in 6. Women with missing threads were managed by ultrasound and plain x-ray, and a uterine sound if results were inconclusive. Pregnant women were terminated if they had requested, and the IUD was removed. If the IUD was not found, ultrasound and x-ray were done. IUDs were removed by laparoscopy if possible (3 cases), or laparotomy (8 cases). In 2 cases ultrasound located the IUDs in the uterus incorrectly. IUDs were embedded in the omentum in 4 cases, adherent to the broad ligament in 3 cases, and free in the peritoneum without an adhesion in 1 women. The 9 cases with adhesions did not have bands of adhesions. This experience suggests that adhesions form briefly, and do not develop further. Since removal of the IUD does not cause adhesions to dissolve, but does confer the risks of laparotomy, it is suggested that open 3rd generation IUDs should not be removed unless there are clinical symptoms such as bowel obstruction.