VCOM Carolinas Research Day 2023

Clinical Case-Based Reports

Retained Copper Intrauterine Device in Pregnancy (A case report of copper intrauterine device with initial partial perforation and subsequent pregnancy, followed by complete perforation and migration into pelvis) Adrianna Soucy, OMS-III, Dr. Felix Oluwamuye Akinbote, MD Edward Via College of Osteopathic Medicine, Spartanburg, SC. Roper St. Francis Physician Partners OB/GYN, Charleston, SC

Abstract # CBR-19

Abstract

Discussion

Case Presentation

Initial Presentation: • A 25-year-old female G4 P3003 presented to the office with vaginal bleeding and a positive pregnancy test. • Copper IUD was placed by the health department six months following her most recent delivery, with positive pregnancy test 3 months later after placement. • IUD removal was attempted until the string pulled out from the device. • Routine prenatal labs were unremarkable. • Patient was referred to MFM. • Past medical history significant for obesity, short interval pregnancies, and three prior term uncomplicated spontaneous vaginal deliveries. Antepartum Appointment (14 weeks gestation): • Transabdominal ultrasound confirmed intrauterine pregnancy, no fetal abnormalities seen. • Limited by maternal body habitus and gestational age. • Cu-IUD was visualized within the posterior wall of the uterus. • Risks associated with pregnancy with IUD in situ and management scheme was discussed. • Patient complained of cloudy foul-smelling urine with incomplete emptying. • Urine culture collected and empiric treatment with Nitrofurantoin was started. Anatomy Scan (20 weeks gestation): • Transabdominal US confirmed continued singleton IUP with Cu-IUD in situ. • IUD was noted in cervix to right. Antepartum Appointment (29 weeks gestation): • Repeat transabdominal US showed no fetal abnormalities. • Biophysical profile was normal with a score of 8/8. Labor and Delivery (38 weeks gestation): • Presented to the hospital in labor, had an uncomplicated vaginal delivery. • IUD was not visualized during the delivery, • CT abdomen pelvis revealed complete perforation, with the Cu-IUD now located in the pelvis, see Images 1 and 2 below . Postpartum Day 1: • Developed postpartum fever due to pyelonephritis. Treated with IV antibiotics and discharged home. Laparoscopic IUD Removal and Bilateral Tubal Ligation: • One month after delivery. • Bilateral tubal ligation was successfully performed. • While attempting IUD removal, the base of the vertical arm of her IUD was embedded in the serosa of her colon, and the left horizontal arm was nested in her left ovary. • General surgery was consulted and separate surgery for IUD removal was scheduled.

References 1. Teal S, Edelman A. Contraceptive Selection, Effectiveness, and Adverse Effects: A Review. JAMA. 2021. 326(24):2507-2518. doi: 10.1001/jama.2021.21392. 2. Zheng, T. Comprehensive Handbook Obstetrics & Gynecology. 3rd edition. Phoenix Medical Press LLC; 2020. 3. Hubacher D, Kavanaugh M. Historical record-setting trends in IUD use in the United States. Contraception. 2018; 98 (6): 467-470. doi: https://doi.org/10.1016/j.contraception.2018.05.016. 4. Daniels K, Abma JC. Current Contraceptive Status Among Women Aged 15-49: United States, 2015-2017. NCHS Data Brief No 327. 2018. https://www.cdc.gov/nchs/products/databriefs/db327.htm 5. Le T, Bhushan V, Deol M, Reyes G. First Aid for the USMLE Step 2 Clinical Knowledge. 10th edition. McGraw Hill Education; 2019. 6. Trussell J. Contraceptive failure in the United States. Contraception. 2011; 83(5):397-404. doi: 10.1016/j.contraception.2011.01.021. 7. Tibaijuka L, Odongo R, Welikhe E, et al. Factors influencing use of long-acting versus short-acting contraceptive methods among reproductive-age women in a resource-limited setting. BMC Womens Health. 2017; 17(1):25. doi: 10.1186/s12905-017-0382-2. 8. Espey E, Hofler L. Long-acting Reversible Contraception: Implants and Intrauterine Devices. The American College of Obstetricians and Gynecologists. 2017. Bulletin Number 186. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/11/long-acting-reversible-contraception-implants-and-intrauterine-devices 9. Dinehart E, Lathi RB, Aghajanova L. Levonorgestrel IUD: is there a long-lasting effect on return to fertility? J Assist Reprod Genet. 2019; 37(1): 45 – 52. doi: 10.1007/s10815-019-01624-5 10. Cdc.gov. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use. Updated 2020. https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility criteria_508tagged.pdf 11. Tosun M, Celik H, Yavuz E, Cetinkaya M. Intravesical migration of an intrauterine device detected in a pregnant woman. Can Urol Assoc J. 2010; 4(5): E141 – E143. doi: 10.5489/cuaj.938 12. Rowlands S, Oloto E, Horwell D. Intrauterine devices and risk of uterine perforation: current perspectives. Open Access J Contracept. 2016; 7:19 – 32. doi: 10.2147/oajc.s85546 13. Mederos R, Humuran L, Minervini D. Surgical removal of an intrauterine device perforating the sigmoid colon: A case report. International Journal of Surgery. 2008; 6(6): E60-E62. doi: https://doi.org/10.1016/j.ijsu.2007.02.006. 14. Caliskan E, Ozturk N, Dilbaz BO, Dilbaz S. Analysis of Risk Factors Associated with uterine perforation by intrauterine devices. Eur J Contracept Reprod Health Care. 2003; 8(3):150-155. https://pubmed.ncbi.nlm.nih.gov/14667326/ 15. Brahmi D, Steenland M, Renner R, Gaffield M, Curtis K. Pregnancy outcomes with an IUD in situ: a systematic review. Contraception. 2012; 85(2): 131-139. doi: 10.1016/j.contraception.2011.06.010 16. Robinson JA, Burke AE. Obesity and Hormonal Contraceptive Efficacy. Womens Health (Lond Engl). 2013; 9(5): 453 – 466. doi: 10.2217/whe.13.41 17. Bahamondes L, Faundes A, Sobreira-Lima B, Lui-Filho J, Pecci P, Matera S. TCu 380A IUD: a reversible permanent contraceptive method in women over 35 years of age. Contraception. 2003; 72 (5): 337-341. doi: https://doi.org/10.1016/j.contraception.2004.12.026 18. Andersson K, Ryde-Blomqvist E, Lindell K, Odlind V, Milsom I. Perforations with intrauterine devices. Report from a Swedish survey. Contraception. 1998; 57(4): 251 – 255. doi: 10.1016/s0010 7824(98)00029-8 19. Wildemeersch D, Hasskamp T, Goldstuck N. Malposition and displacement of intrauterine devices – diagnosis, management and prevention. Clin Obstet Gynecol Reprod Med. 2016; 2(3)183-188. doi: 10.15761/cogrm.1000145 20. Ozgu-Erdinc A.S, Tasdemir UG, Uygur D, Aktulay A, Tasdemir N, Gulerman, HC. Outcome of intrauterine pregnancies with intrauterine device in place and effects of device location on prognosis. Contraception 2014; 89(5):426-30. doi: 10.1016/j.contraception.2014.01.002. 21. Cheung M, Rezai S, Jackman J. Patel N, Bernaba B, Hakimian O, Nuritdinova D, Turley C, Mercado R, Takeshige T, Reddy S, Fuller P. Retained Intrauterine Device: Triple Case Report Review of the Literature. Case Reports in Obstetrics and Gynecology. 2018. doi: https://doi.org/10.1155/2018/9362962 Dr. Felix Oluwamuye Akinbote, MD for his medical expertise and for being my research mentor. Acknowledgements • None of the most common complications of IUD retention during pregnancy, including spontaneous abortion, septic abortion, PROM, preterm labor, or chorioamnionitis, occurred as evidenced by the patient’s uncomplicated, term labor and delivery. Prevalence: • Pregnancy incidence among IUD users is low, with approximately 8 out of every 1000 Cu IUD users becoming pregnant, and 2 out of every 1000 LNg-IUD users who experience contraceptive failure 15 . • Incidence of uterine perforation is also low, ranging from 0.87 to 1.6 in every 1000 IUD placements 14 , likely underestimated due to the typical asymptomatic presentation of most perforations. • It has been found that a shocking 90% majority of perforations occurred during the first postpartum year after a full-term pregnancy 18,14 . Clinical Course: • IUD removal was not feasible secondary to the patient’s partial uterine perforation at the beginning of her pregnancy. • “Copper IUDs are more likely to result in contraceptive failure if they are dislocated than levonorgestrel-releasing IUDs, particularly if the IUD is dislocated in the lower uterine segment of the cervix” 19 . • Our patient’s copper IUD was found initially on ultrasound in the posterior portion of the uterus, near the cervix. • CT imaging after delivery revealing migration to the pelvis later in her clinical course indicated complete perforation. • The patient’s presentation of uterine perforation despite IUD placement six months after delivery begs the question whether six months is enough time between delivery, and whether the current standard of care for postpartum IUD placement is sufficient. Outcomes : • Perforation and pregnancy refractory to IUD placement six months post-partum suggests reevaluation of the current standard of care for post-partum copper IUD placement is warranted. • Early IUD removal in pregnancy leads to improved pregnancy outcomes, and thus, IUD remaining in situ leads to greater risk of adverse outcomes 15 . • Higher rate of SAB (54%) is seen in pregnancies with retained IUD, while only 20% of pregnancies with a removed Cu-IUD resulted in SAB 15 .

As one of the most efficacious contraceptive options to date, IUD use remains very prevalent across the world. Our patient’s pregnancy, a rare but potential complication of intrauterine device placement, serves as valuable insight for any patient and their providing physician considering intrauterine device (IUD) utilization. Device removal to minimize risks throughout pregnancy was not feasible due to the nature of the patient’s IUD being embedded in the myometrial layer of the uterus, a partial perforation, during pregnancy. Observing how this patient and her fetus tolerated the pregnancy with an IUD in situ creates a scenario which allows us to better understand the prevalence and severity of the risks associated with Cu IUD retention, without placing our patient at further risk to conduct research. Implications of this report can lead to more information regarding pregnancy outcomes with IUD in situ, and potentially modify the existing standard of care for IUD in situ during pregnancy.

Background

• The most common birth control methods used in women aged 15-49 include permanent sterilization, the pill, LARC, and the male condom, respectively (see Figure 1 below) 4 .

Figure 1. Prevalence of Birth Control Methods in Women in the United States Aged 15-49.

• LARC methods include the levonorgestrel (LNg-IUD) and copper (Cu-IUD) IUDs • Eliminate user failure and thus have higher efficacy, are more user-friendly, and are less costly than the short acting alternatives 7 . • The non-hormonal Cu-IUD prevents fertilization due to the toxic effects from copper accumulation on sperm and oocytes throughout the reproductive tract 9 . • Most uterine perforations are asymptomatic, but typically occur at time of placement. • A partial perforation occurs when the IUD penetrates and remains in the myometrial layer of the uterus, while a complete perforation through intraabdominal organs will cause bladder or bowel changes 12 . • It has been concluded that it is safer to delay IUD placement until six months after delivery to prevent perforation due to low estrogen levels promoting migration in the postpartum period 14 . • Known complications of a retained IUD during pregnancy can range from an uncomplicated pregnancy, to spontaneous abortion, preterm labor, septic abortion, or chorioamnionitis. 15 • Early IUD removal is the standard of care for pregnancy complicated by IUD in situ due to improved outcomes compared with women who retain their IUDs throughout pregnancy.

Imaging

Image 2. Axial plane of CT scan abdomen pelvis showing Cu-IUD in pelvis .

Image 1. Coronal plane of CT scan abdomen pelvis showing Cu-IUD in pelvis.

33

2 0 2 3 R e s e a r c h R e c o g n i t i o n D a y