Complete and partial uterine perforation and embedding following insertion of intrauterine devices. II. Diagnostic methods, prevention, and management.

Abstract

This paper discusses the various methods used to diagnose uterine perforation caused by an IUD. Radiography, or plain film, has a limited use in the diagnosis of uterine perforation since its usefulness depends on the radiopacity of the particular IUD; if the IUD appears on film, plain film does not allow one to conclude whether the device is in its proper position. Several modifications of plain film have been tried but all methods fall short of their goals. Hysterography permits the best diagnostic assessment since it allows the visualization of the entire uterine cavity so that the position of the IUD is immediately evident in cases of embedding and of perforation. Pelvic pneumography can differentiate between intraperitoneal or extraperitoneal locations of perforated IUDs; it can be enhanced by hysterosalpingography and can be done on an ambulatory basis. Ultrasonography simply determines the presence or absence of an IUD, but has the advantage of accurately demonstrating a concomitant pregnancy; the sonogram is not reliable if the IUD is surrounded by omentum or by loops of bowel; ultrasonography can be advantageously coupled with hysterography. Laparoscopy is still the method most used to diagnose uterine IUD perforation; when removal of the device is advisable laparotomy is usually carried out concomitantly; successful laparoscopy requires a skilled and experienced operator. Hysteroscopy is a new and extremely valuable technique which should not be chosen as a primary procedure because it carries a risk of complications. The best prevention of uterine perforation is a meticulous and well executed insertion technique, done only by an experienced operator and after a careful pelvic examination. Uterine size, consistency and position must be exactly known; IUD insertion is easier during or immediately after menstruation. Perforated IUDs should be removed even if considered innocuous, although this is a matter still debated by the specialists. Spontaneous IUD expulsion must be verified, when not proven, by the same methods used by perforation diagnosis, or by dilatation and curettage. Before deciding on the best method for removal it is necessary to know the type of perforation and the location of the ectopic IUD. Removal of an IUD, whether through the vagina or through hysteroscopic, laparoscopic, laparotomy, or hysterotomy procedures, is never easy. Emergency hysterectomy is done under certain circumstances, such as hemorrhage, while elective hysterectomy requires the presence of additional factors, such as a fibroid uterus. Colpotomy is done only when the IUD is lying in the posterior cul-de-sac.