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
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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,
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Gynaecology, 7th edition, UK, Blackwell Publishing, 2007; 32:
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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):
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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.