Keywords : missed intrauterine device ● multiple intrauterine devices missed abortion
Intrauterine contraceptive device (IUCD) is the most widely used family planning method with over 80 million women using it worldwide. Various complications of IUCD are pelvic infection, menstrual complaints, perforation, missing IUCD, pregnancy etc. Failure rate of IUCD is 1-3% 1. Accidental insertion of multiple IUCDs in a single uterus is a very rare phenomenon. There are some reports of multiple IUCDs in a single uterus 2-4. After thorough medline search we could not find any case with multiple IUCD in a pregnant uterus. We report a case in which two IUCDs were introduced into a uterus, which was later on found to have been pregnant and ended in missed abortion.
A 24 year old woman, para one having a two year old baby girl, having lactational amenorrhea and using IUCD (CuT 200B) for the last one and a half years was referred to the gynecological department with a diagnosis of translocated IUCD by a medical officer at Primary Health Center (PHC). She carried with her an x-ray (Figure 1) showing two IUCDs and a fetus. She had an IUCD inserted in January 2002. On 7th July, 2003, she reported to the medical officer at the PHC since she could not feel the IUCD thread. The medical officer inserted another IUCD presuming that the previous IUCD had got expelled. She complained of slight vaginal bleeding for two days. Her general condition was good. An abdominal examinatin revealed a 16 weeks size soft uterus. On speculum examination, the cervical os was closed with a string of IUCD seen. The IUCD was removed and dark altered blood appeared in the vagina. The uterus was 16 weeks pregnant. Ultrasonography showed a single live fetus corresponding to 16 weeks of gestation with no gross congenital malformation. There was a small retroplacental clot of about 2x2 cm in size and one IUCD which was embedded posteriorly into the myometrium. She was explained about the risks of continuation of pregnancy due to invivo IUCD and x-ray exposure. After thorough counseling she opted for continuation of pregnancy. As vaginal bleeding continued and she was advised admission which she refused it. She came for follow up after 2 weeks. Repeat ultrasonography showed a dead fetus.
Investigations – The hemoglobin count was10.5g/dL. Coagulation profile was normal and blood group was B+ve. She was admitted and aborted after three 6 hourly doses of 400 mg of vaginal misoprostol. The IUCD did not get expelled.
Post-abortal period was uneventful and she was discharged after one day with the advice to come after one week for follow up. She was explained that the misplaced IUCD will be removed postmenstrually after one month once the uterine involution is complete.
She came for follow up after 3 months of abortion. On speculum examination the string of the IUCD was not visible and vaginal examination revealed a normal sized uterus. Ultrasonography showed intrauterine IUCD. It could be easily removed with intact strings with Shirodkar’s hook. She did not opt for contraception.
Missed IUCD is defined as the condition when strings of IUCD are not felt by the patient or the strings are not visible on speculum examination. Various causes of missed IUCD can be expulsioin, uterine perforation, pregnancy, breaking of strings, curling of strings inside the uterus etc. In the present case the patient reported to the doctor when she was not able to feel the threads of the IUCD. She never expected to be pregnant as she was in lactational amenorrhea and was using IUCD. The medical officer was posted at a PHC, where there was no facility for ultrasonography or x-ray. After confirming it as a missed IUCD, he inserted another IUCD. It seems that before inserting another IUCD, he neither did abdominal nor vaginal examination. Otherwise pregnancy would have been diagnosed and he would not have ventured to introduce another IUCD. He might have also done some instrumentation leading to vaginal bleeding and retroplacental hematoma which later on progressed and resulted in a missed abortion. Had he not inserted another IUCD, the pregnancy might have continued till term. The usual teaching for missed IUCD is that ultrasonography is the best way to locate it.
