An Unusual Presentation of Perforated Intrauterine Contraceptive Device
Mrs SA was a 35-year-old housewife with three living children, who was referred from a peripheral hospital to the accident and emergency department of Abuja Clinics Ltd. on the 5th of July 2010 with a 6-h history of lower abdominal pain. The pain was of sudden onset, sharp and radiated to the anal region. It was aggravated by movement but relieved by lying still. There was associated weakness and dizziness, but there was no fainting sensation. There was no bleeding per vaginum and no constitutional or urinary symptoms. Her last menstrual period was about 5 weeks prior to presentation. She claimed to have had a regular 28-day cycle with 4 days menstrual flow. She had right ectopic pregnancy and salpingectomy in 1997 and a miscarriage in 1998. She had spontaneous vaginal deliveries in 1999, 2001 and 2005. She wore an IUCD in between the pregnancies for an average of 13 months. She had Cu T IUCD in June 2005, about 6 weeks after her last confinement. She experienced pain during the Cu T IUCD insertion, which prompted an ultrasound scan to be done the same day. The ultrasound scan suggested that the IUCD was in situ and normally placed. She was reassured and was given paracetamol tablets for 2 days and the pain stopped.\nExamination on presentation revealed a young woman in painful distress, pale, anicteric and not dehydrated. Her pulse rate was 88 bpm while her blood pressure was 120/80 mmHg. Her abdomen was generally tender, but the tenderness was more marked at the right iliac fossa. Vaginal speculum examination showed the tail of her IUCD protruding from the external cervical Os. There was cervical excitation, tenderness and a bulging pouch of Douglass on digital vaginal examination. Rectal examination revealed no abnormality. An impression of acute abdomen due to ectopic pregnancy or acute appendicitis was made. Her packed cell volume (PCV) was 34%, genotype AA and blood group A rhesus D positive. Blood beta-HCG test was negative. The emergency ultrasound scan report showed a normal sized, anteverted uterus containing only part of an IUCD, while the remaining part of the device protruded through the fundus of the uterus. There was a thick-walled complex cystic mass in the right adnexium that was difficult to differentiate from the right ovary. The mass had an irregular outline and was sonoluscent. It measured 2.1 cm in diameter. These features were in keeping with the “adnexal ring sign.” This complex cystic mass was surrounded by a hematoma. Probe tenderness was marked over this mass. The left adnexium showed normal sonographic features. Moderate echo-rich fluid was present in the pouch of Douglas. Impression: these features were in keeping with a right ruptured ectopic pregnancy and a displaced IUCD.\nEmergency exploratory laparotomy, adhesiolysis [], Cu T 360 IUCD removal [] and intestinal repair were performed through the previous sub-umbilical midline incision. Intraoperative findings included a hemoperitoneum (approximately 700 ml), a normal sized uterus, adhesions involving the intestines, omentum and the fundus of the uterus, tangential laceration of the omental surface of the terminal ileum about 2-3 inches from the ileocaecal junction, normal ovaries and left fallopian tube. The right fallopian tube was absent. The horizontal arm of the Cu T 360 IUCD was inside the terminal ileum while the vertical arm was inside the myometrium, with the string still protruding in the vagina. The skin was closed sub-cortically using braided, coated and absorbable polyglycolic acid suture. She did not receive any blood transfusion. She received antibiotics, intravenous fluids and analgesics. She commenced oral intake on the fifth day and was discharged the next day in a stable condition.