UOTW: Chronic Abdominal Pain

Authors: Molly Hartrich, MD, Joseph Colla, MD, and Naomi Bromell, BA, MS

Case Presentation

A 38-year-old previously healthy non-pregnant woman presented to the emergency department with diffuse, post prandial abdominal pain worsening over six months. Exam was notable for mild tenderness to the suprapubic area without signs of peritonitis. Complete blood count, complete metabolic profile and urinalysis were normal. Urine pregnancy was negative. The emergency physician performed abdominal point-of-care ultrasound (POCUS) to assess for proper placement of patient’s intrauterine device. POCUS findings are shown in figures 1A and 1B. Diagnosis was confirmed on CT scan of the abdomen (Figure 2) as uterine perforation by IUD.

Figure 1A: dotted arrow - irregularity in anterior inferior segment of uterus indicating perforation.

Figure 1B: solid arrow - fluid collection adjacent to right uterine wall

Figure 2: shows coronal CT images of malpositioned IUD, not definitively in uterus

Ultrasound demonstrated hyperechoic linear structure tracking through the anterior inferior uterus with an associated fluid collection inferiorly, consistent with uterine wall perforation. Gynecology was consulted and the patient was admitted to the gynecology service for observation with a plan to remove the IUD and repair the uterine perforation laparoscopically at a later date. Unfortunately, the patient was lost to follow up and no further records are available.

Discussion

Uterine perforation is an uncommon but serious complication of IUDs, with an incidence of between 0.6 and 3.6 out of 1,000 insertions¹. Perforation may be complete, with the device completely in the abdominal cavity, or partial, with the device embedded within the uterine wall to varying degrees.² Symptoms may range from asymptomatic to severe peritonitis. Urgent gynecology consult is recommended even with mild symptoms as rectouterine or vesicouterine fistulae may occur as well as dense adhesions, particularly from copper IUDs, risking obstruction, among other complications^{1, 2}.

References

1. Kho KA, Chamsy DJ. Perforated intraperitoneal intrauterine contraceptive devices: diagnosis, management, and clinical outcomes. J Minim Invasive Gynecol. 2014 Jul-Aug 2014;21(4):596-601. doi:10.1016/j.jmig.2013.12.123

2. Rowlands S, Oloto E, Horwell DH. Intrauterine devices and risk of uterine perforation: current perspectives. Open Access J Contracept. 2016;7:19-32. doi:10.2147/OAJC.S85546