by John Reynolds-Wright and Rebecca Heller
We all know perforation is a recognised risk of IUD insertion. However, that doesn’t make it any less upsetting for either the clinician or the patient. It is often not recognised at the time it occurs and can go unnoticed for weeks, if not months. This can be distressing for patients, as well as confusing, shake their confidence in both the clinician and the contraceptive method, and put them at risk of unplanned pregnancy. Likewise, it is a stressful event for us as clinicians, as we haven’t altered our usual practice and perhaps not detected any sign of perforation. This knocks our confidence in our own skill and can make us question every IUD we have ever inserted!
Thankfully perforation is a relatively rare occurrence and the majority of patients who have a perforation are clinically well with no long-lasting repercussions. However, there are occasions where the IUD not only perforates the uterine wall but damages other pelvic structures, particularly the bowel and bladder. In these situations, patients tend to present acutely unwell with peritonitis and are managed surgically.
Our case study presents an IUD that was passed in a bowel movement eleven years after insertion, with an apparently completely silent clinical course. This is what we found so interesting; the fact that this patient had no symptoms whatsoever of bowel perforation is unique. We have not found any cases in the literature that give such a history. A prolonged interval between insertion of an IUD and discovery of perforation is unusual but not unheard of – in the literature there are cases where patients present with bowel perforation several years after insertion. These patients present acutely unwell and the proposed mechanism is a partial perforation at the time of insertion that than ‘works itself free’ into the abdominal cavity and subsequently perforates the bowel.
Most importantly, this situation may have been avoided. Our patient had her IUD inserted at an interval of several weeks following childbirth. While this is of course acceptable, as reflected in a UKMEC category 1 for insertion after four weeks postpartum, in the 36 weeks following delivery there is a small increase in the risk of perforation compared to non-peripartum times. Insertion in the immediate postpartum period however (usually meaning the first 48 hours after delivery), employs a modified insertion technique that reduces the risk of perforation to virtually zero. If this had been available to our patient, she may well have avoided a uterine perforation and subsequent unplanned pregnancy.
What this case means to you:
Immediate post-partum insertion of intrauterine contraception using a modified technique widens access to LARC and minimises the risk of perforation in the post-partum period. As SRH clinicians we should help champion this method of contraception in our local areas and support providers in midwifery and obstetrics to adopt this practice.
Never just assume an IUD has expelled. This patient should have been offered a post-delivery abdominal X-ray to confirm if the IUD was present in the abdominal cavity. It can be difficult to coordinate care and arrange appropriate follow-up around pregnancy as the patient interacts with so many different care groups. Improving communication between colleagues and an individual taking ownership of arranging this investigation is key to ensuring that patients receive the best quality care. As an SRH specialist, volunteering pro-actively to speak to your obstetric colleagues about postpartum contraception and immediate insertion of IUDs could be an excellent way to build relationships and develop communication between specialties.