True Mirena failure: Twin pregnancy with Mirena in situ
A 36-year-old parous lady presented with complaints of severe epigastric pain for last 25 days, which was increasing in severity and worse after taking meals. She also gave a past history of acid peptic disease for which she used to take an antacid on and off. So, she consulted the gastroenterologist for epigastric pain and was advised to undergo few blood tests, Ultrasonography (USG) whole abdomen and pelvis and then accordingly planned to go for upper gastrointestinal (GI) endoscopy. Her blood test and upper abdomen scan was normal. Incidentally on the pelvic ultrasound two gestational sac corresponding to 6 weeks days and 6 weeks 3 days with Mirena in uterine cavity were detected. Sacs were irregular without fetal node and yolk sac. Urine for pregnancy test was positive. On retrospection, she gave a history of Mirena insertion 2 year back. Mirena was inserted 3 month following normal vaginal delivery without any problems. She always had irregular periods following the insertion of Mirena intrauterine device (IUD) lasting 2-3 days at an interval of 45-50 days. From past 2 month patient had amenorrhea, which she had been explained can occur with Mirena at the time of insertion. Before Mirena insertion she was having regular periods at an interval of 30-35 days lasting for 4-5 days. Speculum examination showed Mirena intrauterine system (IUS) threads in place, but no evidence of active bleeding. Bimanual examination revealed a gravid uterus enlarged to 10 weeks size.\nShe was taken up for suction and evacuation under USG guidance under sedation along with upper GI endoscopy. The Mirena IUD was removed at the same time. She was discharged home on the same day with a follow-up appointment to discuss various options for contraception.