Colocolic fistula caused by a previously inserted intrauterine device. Case report

Abstract

Uterine perforation remains the most serious complication of the intrauterine contraceptive device (IUD). It is more common in the puerperium, usually occurring at the time of insertion of a new device. Perforation may, however, also occur in the puerperium if a pre-existing device is not removed in early pregnancy or extruded at the time of delivery. The case is presented of a 30-year-old woman who became pregnant for the third time following insertion of an IUD in the puerperium of her second pregnancy. An uneventful pregnancy and delivery followed. Failure to detect the IUD at the time of delivery led to laparoscopy and laparotomy to locate the device. A colotomy was necessary to retrieve the device, which had formed a colocolic fistula. It is concluded that the puerperium remains the time of greatest risk of uterine perforation by an IUD. Although most occur at the time of insertion, this complication can also occur with a previously inserted device. Severe intra-abdominal complications may ensue if the device is not localized and removed. Laparotomy is justified if the laparoscopic removal is unsuccessful. A high degree of suspicion is necessary if serious consequences are to be avoided.

PIP: The incidence of uterine perforation following IUD insertion has been estimated as 1.2/1000 insertions. Presented is the case of a 30-year-old woman from Scotland who became pregnant for the third time following insertion of a Multiload Copper 250 device 6 weeks after the delivery of her second child, while she was still breast feeding. The IUD was not removed antenatally because the locator strings could not be visualized. The pregnancy was uncomplicated, with no gastrointestinal symptoms. Failure to detect the IUD at the time of delivery necessitated laparoscopy and laparotomy to locate the IUD and colotomy to retrieve the device. The IUD was located on the left side of the pelvis in the region of the descending colon. One arm had eroded through the full thickness of the sigmoid colon and the other had penetrated the adjacent loop of the colon, forming a colocolic fistula. This case confirms the observation that the puerperium is the time of greatest risk of IUD-caused uterine perforation. Although perforation is most common at the time of insertion, this complication also can occur with a previously placed device. Failure to localize and remove the IUD can result in severe intra-abdominal complications.