IUCD: Uterine perforation Aboubakr Elnashar

Benha university hospital, Egypt ABOUBAKR ELNASHAR

IUCD CONTRAINDICATIONS

ABSOLUTE 1. Pregnancy 2. PID or STI 3. Puerperal sepsis 4. Immediate post-septic abortion 5. Severely distorted uterine cavity 6. Unexplained vaginal bleeding 7. Cervical or endometrial cancer 8. Malignant trophoblastic disease 9. Copper allergy (for copper IUDs) 10.Breast cancer (for LNG-IUS)

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RELATIVE

1. Risk factor for STIs or human HIV

2. Impaired response to infection

- in HIV-positive women

- in women undergoing corticosteroid therapy

from 48 h to 4 w postpartum

3. Ovarian cancer

4. Benign gestational trophoblastic disease

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IUCD RISKS

1. Uterine perforation 2. Infection 3. Expulsion 4. Failure

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UTERINE PERFORATION

Rare

0.6 to 1.6/1000 insertions.

All uterine perforations, either partial or complete, occur or are initiated at the time of IUD insertion.

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Risk factors

1. Postpartum insertion,

2. An inexperienced operator

3. A uterus that is immobile,

4. Extremely anteverted

5. Extremely retroverted

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Counseling prior to IUD

Benefits and risks

Efficacy

Bleeding Pattern

Perforation 1 in 1000

Ectopic Rate

Expulsion 3-15/100 women

PID: IUD does not protect against STIs or HIV.

Informed consent:

risks, benefits, alternative methods

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Preparation for Fitting

Practical training strongly advised from FFP

of RCOG1

Use of assistant recommended

Consider analgesics or local anaesthesia -

pre-counselling and during fitting

Insert within 7 days of onset of menstruation1

References :

1. Mirena SPC September 1999

ABOUBAKR ELNASHAR

Pain relief prior to, and during, IUD insertion

should be discussed with women

1. Topical anaesthesia: Lignocaine Gel 2% –

Instillagel/Instillaquill

2. Intra-Cervical-- warm 1% lignocaine 3mls at 12,

4, 8 o’clock

3. Para-cervical: 5mls at 3 and 9 o’clock

4. Oral Valium

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Timing of insertion

• At any time during the menstrual cycle once

pregnancy or the possibility of pregnancy can

be excluded.

During or shortly after menses {ruling out

pregnancy and the masking of insertion-

related bleeding} no evidence to support the

common practice of inserting the IUD only

during menses.

Infection and expulsion rates may be higher

when inserted during menses.

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Postpartum

immediate insertion (within 10–15 minutes after

delivery of the placenta): higher risk of expulsion

and uterine perforation.

6 weeks postpartum.

until the uterus is completely involuted

immediately after a first trimester pregnancy

termination.

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Removal and replacement

at the same time on any day of the menstrual cycle.

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Cochrane Collaboration review:

neither doxycycline nor azithromycin before IUD

insertion conferred benefit.

American Health Association:

For prevention of bacterial endocarditis (SBE),

antibiotic prophylaxis is not necessary prior to IUD

insertion if there is no obvious infection.

ANTIBIOTIC PROPHYLAXIS

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FOLLOW UP

1. Exclusion of infection

2. Assessment of bleeding patterns,

3. Assessment of patient and partner satisfaction

4. Reinforce the issue of condom use for protection against STIs and HIV.

After this visit, an IUD user should continue annual well-woman care as for any sexually active woman.

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An IUD user should be instructed to contact her

healthcare provider if any of the following occur:

1. She cannot feel the IUD’s threads

2. She or her partner can feel the lower end of the IUD

3. She thinks she is pregnant

4. She experiences persistent abdominal pain, fever, or

unusual vaginal discharge

5. She or her partner feel pain or discomfort during

intercourse

6. She experiences a sudden change in her menstrual

periods

7. She wishes to have the device removed or wishes to

conceive

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TROUBLE SHOOTING

1. Lost strings

2. Pregnancy with an iud in place

3. Amenorrhea or delayed menses

4. Pain and abnormal bleeding

5. Difficulty removing the iud

6. Sti identified with iud in place

7. Actinomycosis on pap smear

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LOST STRINGS

Speculum exam

If the strings are not seen

1. expelled,

2. perforated the uterine wall, or

3. The strings may have been drawn up into

the cervical canal.

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Pregnancy should be excluded.

Once pregnancy is excluded, the cervical canal

should be explored (with a cotton swab, forceps, or

similar instrument) to see if the strings can be found.

If the strings cannot be found: ultrasound

If the device is seen within the uterus, it can be left in

situ.

If the device is not identified within the uterus or the

pelvis, a plain x-ray of the abdomen

Both the LNG-IUS and the copper IUD are radio-

opaque.

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PAIN AND ABNORMAL BLEEDING

Increased menstrual bleeding with or without an

increase in menstrual cramping may occur in IUD

users.

In the event of partial expulsion or perforation, the

device should be removed and consideration

given to inserting another IUD.

In the first few months after insertion, pain and

spotting can also occur between menses.

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Once partial expulsion, perforation, pregnancy,

and infection are ruled out, treatment with NSAIDs

may be helpful in treating these symptoms.

The number of days of bleeding or spotting usually

decreases over time.

If pain or bleeding persists or worsens, removing

the IUD must be considered.

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Suspected perforation

Procedure should be stopped

vital signs and level of discomfort

monitored until stable.

Follow up should be arranged to include

ultrasound scan and/or plain abdominal x-

ray to locate the device if it has been left

in situ.

ABOUBAKR ELNASHAR

Thank you

ABOUBAKR ELNASHAR