{"id":2159,"date":"2019-04-30T17:50:40","date_gmt":"2019-04-30T17:50:40","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmjsrh\/?p=2159"},"modified":"2019-05-01T09:50:18","modified_gmt":"2019-05-01T09:50:18","slug":"bowel-perforation-following-iud-insertion","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/","title":{"rendered":"Perforation Following IUD Insertion"},"content":{"rendered":"<h6 style=\"text-align: right\"><em><span style=\"color: #b00000;font-family: Calibri\">by John Reynolds-Wright and Rebecca Heller<\/span><\/em><\/h6>\n<p><span style=\"color: #000000;font-family: Calibri\">\u00a0<\/span><\/p>\n<p><span style=\"color: #000000;font-family: Calibri\">We all know perforation is a recognised risk of IUD insertion. However, that doesn\u2019t 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\u2019t 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!<\/span><\/p>\n<p><span style=\"color: #000000;font-family: Calibri\"><strong>Thankfully perforation is a relatively rare occurrence<\/strong> 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.<\/span><\/p>\n<p><span style=\"font-family: Calibri\"><span style=\"color: #000000\"><a href=\"https:\/\/srh.bmj.com\/content\/early\/2019\/04\/26\/bmjsrh-2018-200288\">Our case study<\/a> 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 &#8211; 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 \u2018works itself free\u2019 into the abdominal cavity and subsequently perforates the bowel.\u00a0 <\/span><\/span><\/p>\n<p><span style=\"color: #000000;font-family: Calibri\">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. <\/span><\/p>\n<p><span style=\"color: #000000;font-family: Calibri\">\u00a0<\/span><\/p>\n<p><strong><span style=\"color: #000000;font-family: Calibri\">What this case means to you:<\/span><\/strong><\/p>\n<p><span style=\"color: #000000;font-family: Calibri\">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.<\/span><\/p>\n<p><span style=\"color: #000000;font-family: Calibri\">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.<\/span><!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>by John Reynolds-Wright and Rebecca Heller \u00a0 We all know perforation is a recognised risk of IUD insertion. However, that doesn\u2019t 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 [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":364,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[599],"tags":[15139,997],"class_list":["post-2159","post","type-post","status-publish","format-standard","hentry","category-screening","tag-larc","tag-pregnancy"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Perforation Following IUD Insertion - BMJ Sexual &amp; Reproductive Health blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Perforation Following IUD Insertion - BMJ Sexual &amp; Reproductive Health blog\" \/>\n<meta property=\"og:description\" content=\"by John Reynolds-Wright and Rebecca Heller \u00a0 We all know perforation is a recognised risk of IUD insertion. However, that doesn\u2019t 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 [...]Read More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/\" \/>\n<meta property=\"og:site_name\" content=\"BMJ Sexual &amp; Reproductive Health blog\" \/>\n<meta property=\"article:published_time\" content=\"2019-04-30T17:50:40+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2019-05-01T09:50:18+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"3 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/2019\\\/04\\\/30\\\/bowel-perforation-following-iud-insertion\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/2019\\\/04\\\/30\\\/bowel-perforation-following-iud-insertion\\\/\"},\"author\":{\"name\":\"\",\"@id\":\"\"},\"headline\":\"Perforation Following IUD Insertion\",\"datePublished\":\"2019-04-30T17:50:40+00:00\",\"dateModified\":\"2019-05-01T09:50:18+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/2019\\\/04\\\/30\\\/bowel-perforation-following-iud-insertion\\\/\"},\"wordCount\":588,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/#organization\"},\"keywords\":[\"LARC\",\"pregnancy\"],\"articleSection\":[\"screening\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/2019\\\/04\\\/30\\\/bowel-perforation-following-iud-insertion\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/2019\\\/04\\\/30\\\/bowel-perforation-following-iud-insertion\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/2019\\\/04\\\/30\\\/bowel-perforation-following-iud-insertion\\\/\",\"name\":\"Perforation Following IUD Insertion - BMJ Sexual &amp; Reproductive Health blog\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/#website\"},\"datePublished\":\"2019-04-30T17:50:40+00:00\",\"dateModified\":\"2019-05-01T09:50:18+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/2019\\\/04\\\/30\\\/bowel-perforation-following-iud-insertion\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/2019\\\/04\\\/30\\\/bowel-perforation-following-iud-insertion\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/2019\\\/04\\\/30\\\/bowel-perforation-following-iud-insertion\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Perforation Following IUD Insertion\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/#website\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/\",\"name\":\"BMJ Sexual &amp; Reproductive Health blog\",\"description\":\"For readers of the journal and health professionals in contraception and sexual health care.\",\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/#organization\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":\"Organization\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/#organization\",\"name\":\"BMJ Sexual &amp; Reproductive Health blog\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/\",\"logo\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/#\\\/schema\\\/logo\\\/image\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/files\\\/2017\\\/11\\\/blog-logo-bmj-srh.png\",\"contentUrl\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/files\\\/2017\\\/11\\\/blog-logo-bmj-srh.png\",\"width\":328,\"height\":34,\"caption\":\"BMJ Sexual &amp; Reproductive Health blog\"},\"image\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/#\\\/schema\\\/logo\\\/image\\\/\"}},{\"@type\":\"Person\",\"@id\":\"\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/bmjsrh\\\/author\\\/\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Perforation Following IUD Insertion - BMJ Sexual &amp; Reproductive Health blog","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/","og_locale":"en_US","og_type":"article","og_title":"Perforation Following IUD Insertion - BMJ Sexual &amp; Reproductive Health blog","og_description":"by John Reynolds-Wright and Rebecca Heller \u00a0 We all know perforation is a recognised risk of IUD insertion. However, that doesn\u2019t 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 [...]Read More...","og_url":"https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/","og_site_name":"BMJ Sexual &amp; Reproductive Health blog","article_published_time":"2019-04-30T17:50:40+00:00","article_modified_time":"2019-05-01T09:50:18+00:00","twitter_card":"summary_large_image","twitter_misc":{"Written by":"","Est. reading time":"3 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"Article","@id":"https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/#article","isPartOf":{"@id":"https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/"},"author":{"name":"","@id":""},"headline":"Perforation Following IUD Insertion","datePublished":"2019-04-30T17:50:40+00:00","dateModified":"2019-05-01T09:50:18+00:00","mainEntityOfPage":{"@id":"https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/"},"wordCount":588,"commentCount":0,"publisher":{"@id":"https:\/\/blogs.bmj.com\/bmjsrh\/#organization"},"keywords":["LARC","pregnancy"],"articleSection":["screening"],"inLanguage":"en-US","potentialAction":[{"@type":"CommentAction","name":"Comment","target":["https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/#respond"]}]},{"@type":"WebPage","@id":"https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/","url":"https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/","name":"Perforation Following IUD Insertion - BMJ Sexual &amp; Reproductive Health blog","isPartOf":{"@id":"https:\/\/blogs.bmj.com\/bmjsrh\/#website"},"datePublished":"2019-04-30T17:50:40+00:00","dateModified":"2019-05-01T09:50:18+00:00","breadcrumb":{"@id":"https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/blogs.bmj.com\/bmjsrh\/2019\/04\/30\/bowel-perforation-following-iud-insertion\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/blogs.bmj.com\/bmjsrh\/"},{"@type":"ListItem","position":2,"name":"Perforation Following IUD Insertion"}]},{"@type":"WebSite","@id":"https:\/\/blogs.bmj.com\/bmjsrh\/#website","url":"https:\/\/blogs.bmj.com\/bmjsrh\/","name":"BMJ Sexual &amp; Reproductive Health blog","description":"For readers of the journal and health professionals in contraception and sexual health care.","publisher":{"@id":"https:\/\/blogs.bmj.com\/bmjsrh\/#organization"},"potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/blogs.bmj.com\/bmjsrh\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"},{"@type":"Organization","@id":"https:\/\/blogs.bmj.com\/bmjsrh\/#organization","name":"BMJ Sexual &amp; Reproductive Health blog","url":"https:\/\/blogs.bmj.com\/bmjsrh\/","logo":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/blogs.bmj.com\/bmjsrh\/#\/schema\/logo\/image\/","url":"https:\/\/blogs.bmj.com\/bmjsrh\/files\/2017\/11\/blog-logo-bmj-srh.png","contentUrl":"https:\/\/blogs.bmj.com\/bmjsrh\/files\/2017\/11\/blog-logo-bmj-srh.png","width":328,"height":34,"caption":"BMJ Sexual &amp; Reproductive Health blog"},"image":{"@id":"https:\/\/blogs.bmj.com\/bmjsrh\/#\/schema\/logo\/image\/"}},{"@type":"Person","@id":"","url":"https:\/\/blogs.bmj.com\/bmjsrh\/author\/"}]}},"_links":{"self":[{"href":"https:\/\/blogs.bmj.com\/bmjsrh\/wp-json\/wp\/v2\/posts\/2159","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.bmj.com\/bmjsrh\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.bmj.com\/bmjsrh\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.bmj.com\/bmjsrh\/wp-json\/wp\/v2\/users\/364"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.bmj.com\/bmjsrh\/wp-json\/wp\/v2\/comments?post=2159"}],"version-history":[{"count":0,"href":"https:\/\/blogs.bmj.com\/bmjsrh\/wp-json\/wp\/v2\/posts\/2159\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.bmj.com\/bmjsrh\/wp-json\/wp\/v2\/media?parent=2159"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.bmj.com\/bmjsrh\/wp-json\/wp\/v2\/categories?post=2159"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.bmj.com\/bmjsrh\/wp-json\/wp\/v2\/tags?post=2159"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}