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Perforation

STOP, Stabilize, and Scan

Perforation is a rare complication of IUC placement, and occurs in one in a 700-1000 placements. Recognizing perforation at the time of placement reduces the risk of inadvertent migration or intraabdominal placement of a device.

Symptoms of perforation:

  • Excessive pain
  • Sudden loss of resistance
  • Excessive measurement with sound or IUC insertion tube
  • IUC inserter does not follow expected path of uterine axis
  • Do not continue with IUC placement if a sound has perforated the uterus

Most are fundal perforations and require no further management.

  • Monitor the woman:
    • Vital signs including blood pressure, oxygen saturation, abdominal exam and bimanual examination to assess pain and bleeding.
    • Consider CBC if concerned about hemodynamic status.
    • Ultrasound as clinically indicated.
    • If the woman is stable: inform her of signs and symptoms to observe and let her go home.
    • If the woman is unstable, initiate resuscitation and obtain an emergent gynaecology consultation.
    • Women with vaso-vagal reactions may look unstable, but the symptoms are usually self-limiting.
    • If an IUC is found to be placed in the abdomen (a very rare event), refer to gynecologist. Laparoscopic surgery may be required.

Costescu D. and Guilbert E. et al. Preceptorship Program - Module 4
Heinemann K et al. Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European Active Surveillance Study on Intrauterine Devices. Contraception 2015; 91(4): 274-279.

Perforation Incidence

The EURAS-IUD (European Active Surveillance Study for Intrauterine Devices) was a large, prospective, comparative, non-interventional, cohort study (n = 61,448) in parous women using LNG-20 (Mirena) and copper IUD the incidence of perforation was 1.3 (95% CI: 1.1 - 1.6) per 1000 insertions in 1 year.
Specifically:

  • 61 perforations occurred for LNG-IUS (n=43,078; 1.4 per 1,000 insertions; 95% CI: 1.1-1.8)
  • 20 for copper IUDs (n=18,370; 1.1 per 1,000 insertions; 95% CI: 0.7-1.7)
  • Current breastfeeding and postpartum insertion up to 36 weeks were associated with increased risk of perforation
  • There were no serious complications in any of the women who experienced a perforation, nor in any woman who required laparoscopic removal.

Risk Factors for Perforation

Certain clinical scenarios increase the risk of perforation. While in most cases this should not preclude an attempt at IUC placement, some clinicians will prefer to refer to a more experienced provider.

Risk Factors for Uterine Perforation

  • Postpartum state
  • Breastfeeding
  • Grand multiparity
  • Lack experience of health care professional (HCP) performing placement
  • Fixed and/or retroverted uterus
  • Uterine anomaly

Nulliparous women are not at increased risk of perforation.

In a large post-marketing study, no difference between the rates of perforation in nulliparous and multiparous women was observed. This is also true for mode of delivery (caesarean vs. vaginal).

Recognizing Perforation at Follow-up

Partial perforation (uterine embedment) or complete perforation of the uterine wall or cervix may occur during or following placement. The vast majority of perforations occur at the time of placement, though it may not be detected. As such, a follow-up visit is important. A delay in detection may result in a partially perforated IUC migrating to a complete perforation (a missed opportunity to remove the IUC in the office before a complication arose), increased risk of laparoscopic removal, and, very rarely, intraabdominal injury. Thankfully, the risk of major complication following IUC placement, even in the setting of perforation, is very rare. A woman should be informed of the small risk of perforation, and the importance of prompt diagnosis.

  • Women with an embedded device or unrecognised perforation may present with:
    • Persistent abnormal bleeding and/or abdominal pain
    • Acute episodes of pelvic pain (often unilateral), which can be provoked with intercourse. Typically, a correctly-placed IUC does not cause dyspareunia.
    • Asymptomatic or incidental ultrasound findings
    • Shortened or missing IUC strings
    • Pregnancy
    • Difficult removal attempt
    • Some are asymptomatic
  • This may decrease contraceptive effectiveness and result in pregnancy, especially for Cu IUDs. Some women with a migrated IUS will remain amenorrheic.
  • Usually diagnosed by ultrasound, although x-ray or CT scan can be useful adjuncts. MRI is not ideal as the IUD may affect image quality.
  • An embedded or perforated device should be removed on a semi-urgent basis.
    • For an embedded device, an office removal with or without paracervical block may be sufficient.
    • An examination under anaesthesia, hysteroscopy, and/or curettage may be needed for a difficult removal.
    • For an intraabdominal device, operative laparoscopy is the preferred approach. Most often, the device is in the posterior cul de sac, or adherent to the omentum. As a result, the IUC may be located in the upper abdomen during a laparoscopy (as the omentum is moved superiorly to visualize the pelvis)