Intraperitoneally displaced intrauterine device.

Intra-abdominal displacement of an intrauterine device (IUD) is a rare but serious complication. This is a case report of a 44-year-old woman who was referred to a surgical department with intermittent abdominal pain. Gynaecological examination and ultrasound failed to identify the patient's IUD. An abdominal CT scan confirmed the diagnosis of the intra-abdominally migrated IUD and the device was extracted by laparoscopy. Surgical removal of the migrating IUD is recommended to prevent long-term complications such as intra-abdominal adhesions, organ perforation, and fistula formation.

Impact of suboptimal tandem implantation on local control and complications in intracavitary brachytherapy for cervix cancer.

PURPOSE: Correct tandem implantation for cervix cancer intracavitary brachytherapy may be challenging. We investigated whether suboptimal implantation can be related to patient and disease characteristics and may result in subsequent underutilization of brachytherapy in cervical cancer. METHODS AND MATERIALS: Consecutive cervix cancer patients referred for intracavitary brachytherapy after external beam radiation therapy performed in several general hospitals from 2013 to 2017 were included. RESULTS: In 172 patients having 301 procedures, 95 implantations were suboptimal (15% inadequate tandem insertions, 10% subserosal insertion, and 6% uterine perforation on postimplant CT scan). Risk factors were age, myometrium invasion, and uterine retroversion. Median followup was 21 months. Three-year local control and survival rates were 72% and 85%, respectively. Forty-seven patients (27%) failed to receive brachytherapy. Failure to perform brachytherapy was associated with poorer local control (OR = 0.34 [0.17-0.67], p = 0.001). By contrast, suboptimal implantation did not increase local failure or toxicity rates in patients undergoing brachytherapy. No peritoneal carcinomatosis occurred after uterine perforation in our cohort. CONCLUSIONS: Suboptimal implantation was frequent. In the absence of image guidance during implantation, conversion to other treatment modalities (including external beam radiation therapy) due to insertion difficulties resulted in worse local control. With optimization, however, suboptimal brachytherapy implantation did not result in suboptimal dose coverage or poorer local control. Failure to perform a brachytherapy boost correlates with increased local failure risk in patients with cervix cancer, whereas tandem malposition does not. Real-time intraoperative ultrasound guidance may be useful to reduce uterine perforation rates and thus increase brachytherapy use.

Rectal perforation in a 42-year-old woman due to Henoch-Schönlein purpura: a case report.

Henoch-Schönlein purpura (HSP) is caused by deposition of IgA-containing immune complexes within the blood vessels. HSP mostly occurs in children and is less common in adults. In addition to palpable purpura, arthritis or arthralgia, renal disease and abdominal pain, gastrointestinal symptoms occur in 50% of children. These can be caused by gastrointestinal hemorrhage, bowel ischemia and necrosis, intussusception, and bowel perforation. In adults, intussusception is less frequent than in children. We report a 42-year-old woman referred to our hospital with acute abdominal pain. After laboratory and radiologic examinations, laparatomy was performed which revealed rectal perforation due to HSP. HSP is a multisystem disorder. Abdominal pain in patients with HSP may herald a serious gastrointestinal problem also in adult patients.

Laparoscopic removal of migrated intrauterine device.

Intrauterine device (IUD) is a popular long-acting reversible contraceptive device with an estimated rate of use of about 5.3%. It is highly effective but not without complications, one of which is uterine perforation. The patient was a 32-year-old female who presented with nausea, vomiting and right upper quadrant abdominal pain that was tender on palpation. CT scan was performed and they found signs of acute calculous cholecystitis with incidental finding of a migrated IUD in the left lateral mid-abdomen within the peritoneal cavity. She underwent a laparoscopic cholecystectomy followed by a successful IUD retrieval. Most uterine perforations occur at the time of insertion; however, partial perforation with subsequent delayed complete perforation may also occur. This case emphasises the importance of a full workup for a missing IUD and that, if incidentally found, IUDs can be removed safely laparoscopically in conjunction with another procedure.

Pseudolipomatosis in Endometrial Specimens Does Not Represent Uterine Perforation.

BACKGROUND: Specimens of endometrial biopsies can sometimes present with an artifact within blood, composed of optically clear vacuoles mimicking adipose tissue, pseudolipomatosis. This artifact can be mistaken for adipose tissue and lead to an overdiagnosis of uterine perforation. CASE: We describe the case of pseudolipomatosis seen within the evacuated products of conception from a missed abortion. RESULTS: Areas of vacuolization in the blood clot mimicked adipose tissue. However, the vacuoles varied in size and did not contain adipocytes. CONCLUSION: Familiarity with this artifact will lead to avoidance of overdiagnosis of adipose tissue and uterine perforation in curettage specimens.

Laparoscopic Removal of a Retroperitoneal Hysteroscopic Microinsert Using Fluoroscopy.

Perforation during placement of hysteroscopic microinserts for permanent sterilization occurs in approximately .9% to 2.6% of women undergoing the procedure. Most of the time perforation results in intraperitoneal placement of the hysteroscopic microinsert requiring laparoscopy or laparotomy for removal of the device. Herein we present a case of hysteroscopic microinsert perforation with subsequent retroperitoneal identification of the device. This is the first such case to our knowledge of retroperitoneal identification and retrieval of a perforated device that required real-time fluoroscopy during laparoscopy.

Uterine arteriovenous fistula after perforation during the placement of an intrauterine device - Minimally invasive treatment using uterine artery embolization.

Uterine arteriovenous fistula (AVF) is a rare, but potentially life-threatening condition. Acquired fistulae may occur as a result of trauma or instrumentation, endometrial carcinoma, gestational trophoblastic disease, and intrauterine devices (IUDs). Herein the authors present the case of a 33-year-old woman with a uterine AVF developing after uterine perforation during the placement of a levonorgestrel IUD. The fistula was diagnosed using color Doppler ultrasonography and angiography and the treatment was conducted by minimally invasive approach using uterine artery embolization.

Complications of Hysteroscopic and Uterine Resectoscopic Surgery.

Adverse events associated with hysteroscopic procedures are generally rare, but, with increasing operative complexity, it is now apparent that they are experienced more often. There exists a spectrum of complications that relate to generic components of procedures, such as patient positioning, anesthesia, and analgesia, to a number that are specific to intraluminal endoscopic surgery that largely comprise perforation and injuries to surrounding structures and blood vessels. Whereas a number of endoscopic procedures require the use of distending media, the response of premenopausal women to excessive absorption of nonionic fluids used for hysteroscopy is somewhat unique, and deserves special attention on the part the surgeon. There is also an increasing awareness of uncommon but problematic sequelae related to the use of monopolar radiofrequency uterine resectoscopes that involve thermal injury to the vulva and vagina. Furthermore, the uterus that has previously undergone hysteroscopic surgery may behave in unusual ways, at least in premenopausal women who experience menstruation or who become pregnant. Fortunately, better understanding of the mechanisms involved in these adverse events, as well as the use or development of a number of innovative devices, have collectively provided the opportunity to perform hysteroscopic and resectoscopic surgery in a manner that minimizes risk to the patient.

IUD String Perforation Through Anterior Cervix: A Case Report.

BACKGROUND: Intrauterine devices are increasingly the preferred method of contraception chosen by Canadian women. IUD strings are commonly not visible at follow-up, but rarely are visible yet not located within the endocervical canal. We report a case of IUD strings perforating the ectocervix. CASE: An asymptomatic, 26-year-old woman presented for removal of her levonorgestrel-releasing intrauterine system, over a year following insertion of the device. Upon examination the IUD strings were found to be emerging from within the cervical tissue, 10 mm above the external os. CONCLUSION: We discuss removal techniques, review the literature, and examine possible reasons for this presentation. These techniques may interest a range of practitioners managing contraceptive care for women.

Contexte : Les dispositifs intra-utérins constituent de plus en plus le mode de contraception privilégié par les Canadiennes. Les fils de DIU ne sont fréquemment pas visibles au moment du suivi; toutefois, lorsqu'ils sont visibles, il est rare que l'on ne soit pas en mesure de les localiser dans le canal endocervical. Nous signalons un cas de fils de DIU ayant perforé l'exocol. Cas : Une femme asymptomatique de 26 ans a sollicité nos services pour le retrait de son système intra-utérin à libération de lévonorgestrel, plus d'un an à la suite de l'insertion de ce dernier. Au moment de l'examen, nous avons constaté que les fils du DIU émergeaient du tissu cervical (10 mm au-dessus de l'orifice externe). Conclusion : Nous discutons des techniques de retrait, nous passons en revue la littérature et nous examinons les raisons possibles d'une telle présentation. Ces techniques pourraient intéresser un certain nombre de praticiens offrant des soins contraceptifs aux femmes.

Spontaneous rupture of pyometra manifesting as an acute abdomen: a case report.

Spontaneous perforation of pyometra is a rare entity with a reported incidence in the range of 0.01-0.05%. The clinical picture is similar to peritonitis arising from intestinal perforation and commonly the correct diagnosis is only made perioperatively. We report a case in an elderly postmenopausal woman presenting with an acute abdomen.

[COMPLICATIONS OF DIAGNOSTIC AND OPERATIVE HYSTEROSCOPY--REVIEW].

Hysteroscopy is a diagnostic or surgical mini-Invasive gynecologic operating procedure. The complications of this standard procedure are relatively rare. According to retrospective studies they are 0.95-13.6%. They occur more often by an operative rather than a diagnostic hysteroscopy. These complications could be divided into two groups of an approximately equal occurrence--due to a dilation and passing through the cervix uteri (cervical laceration, creative a false cervix uteri, perforation, bleeding, impossibility to pass through the inner orifice of the cervical canal, insufficiency of the cervix uteri) and due to the operative technique itself (uterine perforation, fluid overload, thermal or mechanical trauma of the inner urinaiy and gastrointestinal tract, infection, rupture of the uterus during a subsequent pregnancy). The most occurring complication is namely the uterine perforation--1-9%, the most severe could indeed be the fluid overload--0.01-11%. The gynecologist performing the hysteroscopy should be well grounded in the typical complications. Unveiling and performing a quick intervention of the latter could prevent unwanted consequences for the patient and the legal issues that could follow occur.

Perforated intraperitoneal intrauterine contraceptive devices: diagnosis, management, and clinical outcomes.

STUDY OBJECTIVE: To describe a series of intraperitoneal perforated intrauterine contraception devices (IUDs) and to discuss associated findings, methods for diagnosis, and management of this complication. DESIGN: Retrospective review of surgical database between 1998 and 2012 (Canadian Task Force classification II-2). SETTING: University medical center. PATIENTS: Thirty-seven women with a perforated IUD in the intraperitoneal cavity. MEASUREMENTS AND MAIN RESULTS: Nineteen copper IUDs (51%), 17 levonorgestrel-releasing IUDs (LNG-IUDs) (46%), and 1 Lippes loop (3%) were identified. Twenty women (54%) had abdominal pain, 16 (43%) had no symptoms, and 1 (3%) was found to have strings protruding from her anus. Twenty-six women (70%) underwent laparoscopy to remove the IUD, and 6 (16%) underwent hysteroscopy along with laparoscopy. Conversion to laparotomy was required in 4 patients (11%). Two IUDs (5%) caused full-thickness rectouterine fistulas that required laparotomy for repair. Dense adhesions were found in 21 women (57%); and of those, 15 (71%) were associated with a copper IUD. Copper IUDs were significantly more likely than LNG-IUDs to be associated with dense adhesions (p = .02). CONCLUSIONS: Perforated IUDs can be asymptomatic or cause short-term and long-term symptoms. Long-term complications include abscess and fistula formation. Copper IUDs cause a greater inflammatory process than do LNG-IUDs. Even if asymptomatic, we advocate prompt removal of all IUDs that perforate into the peritoneal cavity once they are identified. Laparoscopic surgical removal of an intraperitoneal IUD is a safe and preferred method.

[Rare complication of a late abortion: a case report]. / Complication rare d'une interruption volontaire de grossesse tardive.

We report the case of a young woman who presented with acute abdomen at our hospital. The control revealed the presence of fetal parts in extra-uterin and intra-abdominal place after a late abortion. The patient was succesfully operated by celioscopy.

Meconial peritonitis in a rare association of partial ileal apple-peel atresia with small abdominal wall defect.

Intestinal atresia type III B (apple peel) and gastroschisis are both congenital malformations who require early surgical correction in neonatal age. Their association is very rare. We present the case of a full term infant with partial apple peel ileal atresia and a small defect of the anterior abdominal wall, complicated by in utero intestinal perforation and subsequent meconial peritonitis. We observed a partial atresia of small intestine, with involvement of terminal ileus savings of jejunum and a large part of the proximal ileum, small anterior abdominal wall defect with herniation of few bowel loops, intestinal malrotation. Paralytic ileus and infections are the main causes of morbidity and mortality at neonatal age. In our case, in spite of the mild phenotype, prognosis has been complicated by the onset of functional bowel obstruction, caused by chemical peritonitis resulting from contact with either amniotic fluid and meconium.

Uterine perforation caused by intrauterine devices: clinical course and treatment.

STUDY QUESTIONS: What are the symptoms of uterine perforation caused by modern copper intrauterine devices (Cu-IUDs) and the levonorgestrel-releasing intrauterine system (LNG-IUS); how is perforation detected and what are the findings in abdominal surgery? SUMMARY ANSWER: Symptoms are mostly mild and ∼30% of women are asymptomatic. Surgical findings are mainly minimal; no visceral complications were found in this study. However, adhesions as well as pregnancies seem to be more common among women using Cu-IUDs. WHAT IS KNOWN ALREADY: Prior studies and case reports have suggested that uterine perforation by modern IUDs/IUSs is rarely serious. STUDY DESIGN, SIZE, DURATION: A retrospective study of 75 patients (54 LNG-IUS and 21 Cu-IUD) treated surgically for uterine perforation between 1996 and 2009. PARTICIPANTS/MATERIALS, SETTING, METHODS: The patients treated for uterine perforation by an IUD/IUS at clinics of the Helsinki and Uusimaa Hospital District were identified using the National Care Register for Health Institutions in Finland. The clinical data were collected from individual patient records. MAIN RESULTS AND THE ROLE OF CHANCE: The majority of patients (n = 53; 71%) had mild symptoms of abnormal bleeding or abdominal pain or both, in combination with missing IUD/IUS threads. Asymptomatic patients (n = 22; 29%) were examined because of missing threads or pregnancy. Failure to remove the IUD/IUS by pulling visible threads was the reason for referral in seven women (9%) requesting removal of the device. Eleven women (15%) were pregnant. Misplaced IUDs/IUSs were localized by a combination of vaginal ultrasonography (US) and X-ray, hysteroscopy or curettage. Only after this were patients treated by means of laparoscopy. The majority (n = 44; 65%) of the 68 intra-abdominal devices were located in the omentum, the remaining 24 (35%) around the uterus. Partial perforation or myometrial embedding was diagnosed in all seven cases (9%) with visible threads, but unsuccessful removal by pulling. During laparoscopy, filmy adhesions were found in 21 patients (30%). Pregnancy (33 versus 7%, P = 0.009) and intra-abdominal adhesions (58 versus 20%, P = 0.002) were significantly more common in the Cu-IUD group. Infections were rare; one non-specific acute abdominal infection, later found to be unrelated to the IUD, led to laparoscopy and in four cases the IUD was surrounded by pus, but there were no symptoms of infection. LIMITATIONS, REASONS FOR CAUTION: The study setting revealed only surgically treated symptomatic patients and asymptomatic women attending regular follow-up. Women not treated, but only followed or not attending follow-up, were not identified, excluding the possibility to analyse missed undiagnosed perforations, or conservative follow-up as a treatment option. WIDER IMPLICATIONS OF THE FINDINGS: As surgical findings are minimal, asymptomatic women may need no treatment at all. An alternative form of contraception is, however, important as pregnancies do occur. If a woman plans a pregnancy, a misplaced LNG-IUS should be removed, as it may act as a contraceptive.

Uterine perforation as a complication of surgical abortion causing small bowel obstruction: a review.

OBJECTIVE: Small bowel obstruction after unrecognized or conservatively treated uterine perforation is extremely rare. It is a surgical emergency and the delay in diagnosis and treatment has deleterious consequences for the mother. The purpose of this study is to critically review the available literature and ascertain the level of evidence for the mechanisms, diagnosis and management of small bowel obstruction after uterine perforation due to surgical abortion. METHODS: Systematic literature search was conducted in Pubmed (1946 to 2012) and Pubmedcentral (1900 to 2012) including all available English and French language fulltext articles. Three evaluators reviewed and selected all available case reports and case series. Search terms included small bowel obstruction, bowel obstruction, bowel incarceration, bowel entrapment, vaginal evisceration, uterine perforation, uterine rupture, and abortion. The exclusion criteria were (1) complex injuries where small bowel incarceration was present but with bleeding and/or bowel perforation as the leading symptomatology; (2) articles only numbering the patients without details on the topic. Analyses of incidence, risk factors, mechanisms of the disease, time of clinical presentation, diagnostic modalities, treatment, and maternal outcome were included. RESULTS: Of the 73 articles screened 30 cases of small bowel obstruction were included in the review forming incidence, risk factors, and mechanisms of the disease, diagnosis, therapy, and maternal outcome. CONCLUSIONS: A systematic review defined four mechanisms of small bowel obstruction after transvaginal instrumental uterine perforation with significant variations in clinical presentation and time of presentation. Duration of symptoms depend on the mechanism of small bowel obstruction. Vaginal evisceration is surgical emergency and treatment is mandatory without diagnostic workup. Survival rate during last century is 93 %. Multicentric trials and publication of all such cases are needed to determine algorithms for diagnosis and management of small bowel obstruction caused by instrumental uterine perforation.

Iatrogenic uterine perforation with abdominal extrusion of fetal parts: a rare radiological diagnosis.

BACKGROUND: Failure to detect uterine perforation during surgical abortion may result in adverse patient outcome besides having medicolegal implications. This rare case of uterine perforation was diagnosed seven days after abortion and underscores the importance of remaining vigilant for this complication during and after the procedure. CASE: A female underwent surgical abortion at sixteen weeks gestation and was discharged after the procedure, assuming no complication. She presented with abdominal pain seven days after the event. Ultrasound and CT revealed uterine perforation with abdominal expulsion of fetal parts. CONCLUSION: A patient complaining of abdominal pain following recent abortion related instrumentation should alert the clinician regarding possibility of perforation. Secondary signs on ultrasound may reveal the diagnosis even if rent is not identified. CT is valuable in emergent situations.