Uterine perforation by GyneFix frameless IUD: Two case reports

Abstract

Two cases of uterine perforation are described, occurring 11 days and 4 months, respectively, after the insertion of GyneFix, a frameless intra-uterine contraceptive device (IUD). In both the cases initial ultrasound scan showed the intra-uterine position of the device. Removal of the IUD, either by laparoscopy or laparotomy, had to be carried out. Awareness of this complication, insertion of GyneFix by a trained operator, appropriateness of ultrasound scan monitoring and possible underreporting of this complication are discussed. Case 1A 28-year-old nulliparous lady requested the insertion of an IUD, and a community family planning consultant subsequently inserted a GyneFix. A normal pelvic examination was noted and the GyneFix insertion was uneventful. At the time of the clinic attendance, she had been amenorrheic for 2.5 years on the progestogen-only pill, and was in a stable relationship. Eighteen months prior to this consultation she was seen in gynaecological clinic because of dyspareunia, and was suspected to have chronic pelvic inflammatory disease. Her Chlamydia culture was positive, with a co-existent Gardnerella infection for which she received doxycycline and Flagyl. At the time of GyneFix insertion she was entirely asymptomatic, hence further Chlamydia tests were not performed.Two days after insertion of GyneFix, she presented to her general practitioner (GP) complaining of chest pain and lower abdominal pain. She was seen at the local hospital in the gynaecology department where a clinical examination was unremarkable. An ultrasound scan examination showed an IUD in situ. She was reassured. However, in view of her prolonged amenorrhoea, a serum ß-HCG was performed and was found to be less than 2 units per litre (normal range 0 -10 u/L). It was planned that she should be reviewed in 4 weeks' time in the gynaecological clinic.One week following insertion of GyneFix she reattended the family planning clinic with crampy lower abdominal pain and requested removal of the GyneFix IUD. Clinical examination failed to locate the thread of the device, but transvaginal scan showed the IUD in situ. An attempt was made to remove the IUD under general anaesthetic, after dilatation of the cervix and using polyp removal forceps. However no device was felt in the cavity. On uterine sounding a small perforation was inadvertently made in the posterior uterine wall near the fundus. She was observed on the gynaecological ward and was commenced on prophylactic antibiotics in view of perforation of the uterus.In the next 48 hours her abdominal pain continued and she had ultrasound scan and an X-ray of her abdomen. The ultrasound scanning failed to show the IUD in the uterus, and X-ray revealed it to be in the pelvis.The patient underwent laparoscopic removal of the IUD 11 days after insertion. Laparoscopy was performed using the standard technique and carbon dioxide for insufflation. A normal sized uterus, tubes and ovaries with no signs of infection were noted. Approximately 20 mls of bloodstained fluid in the po...

Intravesical migration of intrauterine device resulting in pregnancy

“…Findings in our patient suggest that uterine perforation may be at insertion or delayed perforation. Uterine perforation by an IUD may depend on the operator's experience, the design of the device or the thinness of the uterine wall 8 . As we can not rule out whether the uterine perforation occurred at insertion, we suggest evaluating the patient with sonography immediately after insertion and periodically thereafter.…”

“…Uterine perforation by an IUD may depend on the operator's experience, the design of the device or the thinness of the uterine wall. 8 As we can not rule out whether the uterine perforation occurred at insertion, we suggest evaluating the patient with sonography immediately after insertion and periodically thereafter. The follow up with sonography also enables us to detect undesired pregnancies.…”

Perforation with the GyneFix<SUP>®</SUP> intrauterine implant: is there a common factor?

“…Notably four of the six reports mention previous use of long-term progestogen contraception; two with Depo-Provera, 1 one with Norplant ®2 and one with the progestogen-only pill. 3 The other two cases do not state the type of contraception used. 3,4 One of the previous cases speculates as to whether prolonged amenorrhoea may cause myometrial hypoplasia and thus make perforation more likely.…”

“…3 The other two cases do not state the type of contraception used. 3,4 One of the previous cases speculates as to whether prolonged amenorrhoea may cause myometrial hypoplasia and thus make perforation more likely. 3 The manufacturers of the device list hypoplastic uterus as a contraindication to insertion but do not recommend routine scanning to determine fundal myometrial thickness.…”

Frameless intra-uterine contraceptive device

“…This rate is similar to that reported for other IUDs (1.3 in every 1,000 insertions) 1. Late perforations have also been reported 10 , 11. Incorrect technique may increase the risk of perforation 12…”