Name: Mrs. J.K Hospital No: 752906
Age: 32 years Date of Admission: 17.06.13
Parity: 4+0, 4 alive Date of Discharge: 17.08.13
LCB: 2005
LMP: 12.06.13
PRESENTING COMPLAINT
Inability to feel the string of her intrauterine contraceptive device for 1 week
HISTORY OF PRESENTING COMPLAINT
Mrs. J. K was referred from the family planning clinic with the complaint of inability to feel the tail of a copper T contraceptive device inserted 2 years earlier. She noticed this problem a week prior to presentation because she had regularly felt the stings. There was no history of expulsion of the device per vaginam. She had no abnormal vaginal discharge, no urinary or gastrointestinal symptoms. She had no abdominal pains. Attempt to remove the intrauterine contraceptive device at the family planning clinic felt.
GYNAECOLOGICAL HISTORY
Mrs. J.K attends menarche at the age of 14 years. She menstruated for 3 – 4 days in a regular cycle of 28 days. The flow was moderate and there was no dysmenorrhoea. She was aware of contraceptives and was using intrauterine contraceptive device.
PAST OBSTETRIC HISTORY
She was para 4+0, 4 alive. Between 1997 and 2005, she had 2 boys and 2 girls. All her pregnancies were booked at JUTH and had spontaneous vaginal deliveries at term. There were no complications.
PAST MEDICAL HISTORY
There was nothing significant.
FAMILY AND SOCIAL HISTORY
She was the only wife of a trader. She had secondary education. She neither smoked cigarette, nor drank alcohol.
PHYSICAL EXAMINATION
She was a young woman who was afebrile (T=36.9OC), not pale and anicteric. She had no pedal oedema.
RESPIRATORY SYSTEM
Her respiratory rate was 18 cycles / minute. The lung fields were clinically clear.
CARDIOVASCULAR SYSTEM
Her pulse rate was 84 beats/minute. Her blood pressure was 110/70 mmHg. The heart sounds were normal.
ABDOMEN
Her abdomen was full, soft and non tender. The liver and spleen were not palpable. The kidneys were not ballotable.
PELVIC EXAMINATION
Her vulva and vagina were normal. The cervix was healthy looking and the cervical os was closed. The tail of the intrauterine contraceptive device was not visible at the external os. The uterus was normal in size. There was no adnexal mass or tenderness.
DIGITAL RECTAL EXAMINATION
There was good perianal hygiene. The anal sphincter tone was also good. The rectal mucosa was normal. The pouch of Douglas was not bulging.
DIAGNOSIS
Missing intrauterine contraceptive device.
MANAGEMENT
Mrs. J. K was counseled on the need to locate the device and remove it in the theatre. She gave her written consent for the procedure. She was asked to do some investigations.
RESULTS OF INVESTIGATIONS
PCV: 37%
Urinalysis: Negative for protein and sugar
Ultrasound scan: A normal size anteverted uterus with a highly
echogenic device within the endometrial cavity. There was no adnexal mass and no fluid in the pouch of Douglas.
The results of investigations were explained to her. She was booked for examination in the theatre and retrieval.
OPERATION (17.09.08)
Examination in theatre and retrieval of intrauterine contraceptive device.
ANAESTHESIA
Sedation with 10mg of diazepam and 60mg of pentazocine.
FINDINGS
• Normal sized anteverted uterus, with copper-T embedded on
the posterior wall.
· Healthy looking parous cervix
· No adnexal masses
· Hysterometry was about 8cm.
PROCEDURE
The patient was under sedation with diazepam and pentazocin. The vagina and perineum were cleansed, and the perineum was draped in lithotomy position. The urinary bladder was emptied using a metal urethral catheter. Bimanual pelvic examination was done, and above findings was noted.
A self retaining Auvard’s speculum was passed to retract the posterior vaginal wall, and the anterior lip of the cervix was grasped with a vulsellum forceps. Hysterometry was done with a uterine sound. Graded cervical dilatation was performed with Higgar’s dilators up to size 8. The uterine sound was then used to explore the uterus for the copper-T, which was felt to be on the posterior uterine wall. Using Alligator forceps, the endometrium was probed and the device was grasped. With gentle traction the device was removed and it was copper T. This was shown to the client. Her immediate postoperative condition was satisfactory.
POST OPERATIVE MANAGEMENT
Her vital signs were stable. She was placed on Doxycycline capsules 100mg twice daily for 7 days and tablets of Metronidazole 400mg 8 hourly for 7 days, and Ibuprofen 400mg 8 hourly for 3 days.
She was discharged home and was given 4 weeks appointment for follow up in the gynaecological clinic.
GYNAECOLOGICAL CLINIC (15.10.08)
She had no complaints. Her LMP was 10.10.08, lasted 4 days. Physical and pelvic examination revealed no abnormality. She was counsel on the possibility of inserting a new intrauterine contraceptive device and on the other method of contraception. She selected depo medroxyprogesterone acetate injection. She was then referred to the family planning unit for the contraceptive of her choice.
COMMENTARY
Intrauterine contraceptive devices (IUCD) are contraceptive devices that are placed within the uterine cavity at a time that is unrelated to intercourse and serve to prevent conception1.
IUCD is an effective, reliable and long-time reversible method of contraception that is used worldwide2. In Nigeria, it is the preferred contraceptive method of choice in about 60.3% in Ikeja3, 35.0% in Sokoto4 and 14.5% in Gindiri5.
The exact mechanism of action of IUCDS is not known. However, the copper element in IUCD is thought to stimulate a marked inflammatory reaction in the uterus leading to increase concentration of macrophages and leucocytes, prostaglandins and various enzymes in both uterine and tubal fluid. These substances are toxic to both sperm and egg and interfere with sperm transport 2,6. IUCD also causes anovulation in about 10-15% of cycles and changes the characteristics of the endometrium to reduce the likelihood of implantation2. In addition, levonorgestrel intrauterine device (LNG-IUD) thickens cervical mucus to impede the ascent of sperm 2,6.
IUCDS are effective as the failure rate with copper T-380A is 0.6 pregnancies per 100 women-years after one year of use and LNG-IUD has a failure rate of 0.1 pregnancies pre 100 women-years. Copper -T has a life span of 10 years while, LNG-IUD has 5 years2. Despite this, IUCDS are not without complications. These include expulsion, pelvic infection, uterine perforation, ectopic pregnancy, dysmenorrhoea and heavy menstrual loss.
Mrs. J.K had IUCD inserted 2 years ago and she had not felt the strings of the IUCD for a week. The inability to feel the strings of an IUCD is a source of worry to both the patient and the physician. This is because the device may have been expelled, drawn up into the uterine cavity as was the case in Mrs. J.K or perforate the uterus and is lying in the peritoneal cavity3,8,9. In Lagos, the inability to feel the string of IUCD account for 23.8% of reasons for referral to the family planning clinic8. In Ilorin, this reason account for 0.25% of total IUCD continuous users and 0.89% of total new IUCD acceptors9.
Missing IUCD can be localized by ultrasound as was done in this case. Simple uterine sounding following pelvic ultrasound was employed; this requires less effort and expense on the part of the patient when compared with the more invasive procedures like HSG, laparoscopy, hysterotomy and laparotomy which are often used in difficult case10.
In a case where the thread cannot be felt, and the IUCD is intra-uterine, removal can be achieved with a pair of artery forceps or a specially designed IUCD remover (alligator forceps)6,10. The IUCD was removed with a pair of alligator forceps in this case. If the missing IUCD is intra-abdominal, it can be retrieved laparoscopically; left for months for local adhesion formation or it may often necessitates laparotomy9.
Complications that could arise in the course of retrieval of IUCD include uterine perforation and bleeding. These were avoided in this patient by carefully dilating the cervix with Higgar’s dilator; hysterometry and by carefully searching and retrieval of the IUCD with alligator forceps.
REFERENCES
1. Annan BDRT and Adanu RM. Family Planning. In: Kwawukume EY and Emuveya EE (eds). Comprehensive Obstetrics In the tropics. Accra, Asante & Hittscher Printing press, 2002; 49:375-392.
2. Burkman RT. Contraception and Family Planning. In: Decherney AH, Nathan L, Goodwin TM and Laufer N (eds). Current Obstetrics and Gynaecology, Diagnosis and Treatment, 10th edition, USA, McGraw Hill, 2007; 36: 579-597.
3. Odusanya OO, Oyegbile SA, Balogun RAA, Alakija W and Akensode FA. A Review of the Use of Family Planning Methods Among Clients at the Family Planning Clinc, General Hospital, Ikeja, 1991-1998. Nig Med Pract, 2001; 39 (5/6): 76-78.
4. Ibrahim MI and Okolo RU. Profile of Contraceptive Acceptors in UDUTH, Sokoto, Nigeria. Nig Med Pract, 1997; 33 (1/2): 9-13.
5. Mutihir JT, Dashala HL and Madaki JKA. Contraceptive Pattern at a Comprehensive Health Centre in a Sub-Urban Setting. Trop J Obstet Gynaecol, 2005; 22 (2): 144-146.
6. Glasier A. Contraception. In: Edmonds DK (ed), Dewhurst’s Textbook of Obstetrics and Gynaecology, 7th edition, UK, Blackwell Publishing, 2007; 32: 299-317.
7. Wylie AH, and Gebbie AE. Impact of Contraception on Subsequent Fertility. The Obstetrician and Gynaecologist, 2002; 4 (3): 151-155.
8. Lawal SO, Giwa-Osagie OF, Ogedengbe OK and Usifor C. A Review of Referred IUCD Related Problems in Lagos University Teaching Hospital. West Afr J Med, 1993; 12 (3): 144-147.
9. Jimoh AAG and Balogun OR. Missing IUD Strings: Diagnosis and Management at Ilorin. Nig J Med, 2004; 13 (2): 118-123.
10. Glasier A. Contraception, Sterilization and Abortion. In: Shaw RW, Sconter WP and Station SL (eds). Gynaecology, 2nd edition, Churchil Livingstone, 1997; 26: 393-410.
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