A barrier beyond all barriers – Migrated intrauterine contraceptive device

A 24-year-old woman presented with swelling in the periumbilical region, with serosanguinous discharge and intermittent pain. She had an intrauterine contraceptive device (IUCD) insertion five years ago, which she assumed to have been expelled when the threads could no longer be felt. A year later, after conception, another postpartum IUCD was inserted.

Ultrasound of the periumbilical region showed a linear echogenic structure within the rectus sheath with a surrounding minimal hypoechoic collection (Figure 1a). The other IUCD (intrauterine contraceptive device) was within the endometrial cavity (Figure 1b). A plain abdominopelvic radiograph showed two IUCDs, one in the periumbilical region and the other in the pelvis (Figures 2a and 2b). Computed tomography (CT) of the abdomen and pelvis was performed, which confirmed the presence of a displaced IUCD in the right rectus sheath (Figures 3a, 3b and 4). The other IUCD was in situ.

The displaced device was removed surgically under spinal anaesthesia. The surgery was uneventful, with a postoperative course. The IUCD in situ was left behind. The patient was discharged under antibiotic coverage, and on the outpatient follow-up visit, the periumbilical swelling and discharge had completely resolved.

IUCDs are a commonly used, highly effective, and reversible form of contraception. The majority of IUCDs are implanted without imaging assistance.

The displacement of an IUCD device from its normal position, i.e., in the endometrial cavity of the uterine fundus, is an expected complication. The commonly encountered presentations are spontaneous expulsion and uterine perforation. Spontaneous expulsion is usually self-evident and may be reported by the patients themselves. The first clinical suspicion of expulsion or perforation arises when the patient does not feel the IUCD threads. Although uterine perforation is an uncommon complication of IUCD placement, it is the most serious [1]. It is most likely to happen when the IUCD is introduced in the puerperium, but it can also happen if a previously implanted device is not removed in the early gestation or is expelled at the time of birth. The incidence of perforation is 2.5 per 1000 insertions in the puerperium, whereas the total incidence is 1 per 1000 insertions [1,2]. The perforation itself may sometimes be clinically silent, and the symptoms produced are related to the structures involved by the device. It occurs most commonly at the time of the device insertion [3], making patient education and follow-up essential to reduce the likelihood of complications.

Ultrasound is the most commonly deployed first-line investigation to evaluate a missing device that displays the pelvic anatomy in great detail [3]. When a device is not visible on pelvic ultrasound, an abdominopelvic radiograph can be performed for device localisation since all IUCDs are radiopaque [4]. Radiography is useful in detecting an extrauterine device and is essential for confirmation of IUCD expulsion [5]. It causes minimal radiation exposure, and the radiopaque IUCD is identifiable when it is not expelled. CT is the best investigation to diagnose the complications of intra-abdominal devices, such as bowel obstruction/perforation and formation of abscesses. However, IUCDs are frequently discovered incidentally during CT examinations done for other indications [3].

The World Health Organization advises surgical removal of an intra-abdominal device as a suitable therapy to avoid the risk of adhesions [6].

The diagnosis of migrated IUCD in a patient with asymptomatic perforation can be made by a clinical suspicion based on history followed by proper imaging techniques. This case report brings to light an unusual location for a misplaced IUCD.