Re: The perforated uterus


Dear Sir

I read with much interest the recent article on ‘The perforated uterus.[1] There was little, if any, discussion of perforation in relation to intrauterine devices (IUD) and systems (IUS). Much work has been published and reviewed in this area with a recent 40-year Canadian review of the world literature wherein it was observed that almost all 179 uterine perforations occurred at insertion with the most common locations being the pouch of Douglas and omentum (48%), bowel serosa or lumen (18%), odd rare locations, i.e. ovary, fallopian tube, appendix, urinary bladder or abdominal wall (11%), and free within adhesions (5%).[2] Most IUD/IUS related perforations are asymptomatic and may remain undetected for a long time, other presentations being a pregnancy with lost threads and symptoms of abnormal bleeding and/or pain at a later date.

The most important risk factor/red flags for device related uterine perforation are inexperience of the operator, postpartum lactational amenorrhoea, retroverted immobile uterus and increasing number of abortions.[3] In the Finnish National Hospital Register retrospective study (1996–2000) of uterine perforations by an intrauterine device or system, more than half the devices were inserted at under 6 months postpartum. Breastfeeding at the time of insertion was noted in 32% of their patients. Of the breastfeeding women, 90% had delivered within 6 months prior to insertion. Other red flags are severe pain or loss of resistance with sounding at insertion of the device creating a myometrial defect, symptoms of abnormal bleeding and/or severe pain and unsuccessful removal of the device on traction.[4]

Partial cervical and uterine perforations are known to occur in a small proportion of women at IUD insertion. In the Finnish series, partial perforation (myometrial embedding) was noted in 9% of women with visible threads. In partial cervical perforation, the strings of the device are seen at the cervical os. I have managed to push the device into a cranial direction to dis-impact it first and then remove but should not be attempted in the absence of expertise. If the partial perforation occurs in the uterus, it would be more appropriate to remove the device under hysteroscopic control with facilities for laparoscopy and general anaesthesia as the other end of the device may be adherent to the urinary bladder or bowel.

We recommend stopping the procedure, assessment of vital signs, removal of the perforated device if the diagnosis is made at time of insertion, antibiotics and consider transporting the patient from the community to an emergency facility if indicated.[5] When the diagnosis of perforation is made at a later date, laparoscopic retrieval of the device is possible in 65% of women, the remaining need recourse to a laparotomy.[2] Intrauterine devices and/or systems embedded in the omentum can be hard to find even after finding the device on X-ray, as when the patient is placed into trendelenberg position for a laparoscopy, both the omentum and the device can shift into the upper abdomen.

Women whose IUDs have perforated and been removed successfully may opt to have an IUD/IUS at a later date but this would best be carried out under ultrasound guidance.