How will you manage a case of misplaced copper-T (Cu-T)?

Understanding Misplaced Cu-T

Misplaced Cu-T can manifest in various ways, ranging from partial displacement within the uterine cavity to complete migration into the peritoneal cavity or adjacent organs. This often presents as "lost strings" on routine examination or with symptoms like abdominal pain, abnormal bleeding, or even an unintended pregnancy.

Diagnosis of Misplaced Cu-T

The diagnostic process is sequential and aims to precisely locate the device.

• Clinical History and Examination:
  • Symptom Assessment: Inquire about symptoms such as absent IUD strings, abdominal or pelvic pain, abnormal vaginal bleeding, dyspareunia, or suspected pregnancy. Notably, approximately 31% of patients with migrated IUDs can be asymptomatic.
  • Per Speculum Examination: Inspect the cervix for the presence or absence of Cu-T strings. If strings are not visible, they might have retracted into the cervical canal or uterus, or the device might have been expelled or migrated.
  • Per Vaginal Examination: Palpate the uterus for size, position, and tenderness.
• Imaging Modalities:
  • Transvaginal Ultrasound (TVS): This is the primary imaging modality. It can confirm the presence of the IUD and its position within the uterine cavity, identify if it's embedded in the myometrium, or suggest extrauterine location.
  • Abdominal X-ray (AP and Lateral views): If the Cu-T is not visualized by ultrasound or is suspected to be extrauterine, X-rays of the abdomen and pelvis can confirm the presence of the radio-opaque device and its general location.
  • 3D Ultrasound: Offers a more detailed view of the uterine cavity and the IUD's relationship to the uterine walls, helping to differentiate between intra-uterine malposition and perforation.
  • Computed Tomography (CT) Scan or Magnetic Resonance Imaging (MRI): These advanced imaging techniques are reserved for cases where the IUD is suspected to be deeply embedded in the uterine wall or has migrated to distant extrauterine sites, especially when close to vital organs.

Management Strategies Based on Location

The management of a misplaced Cu-T is dictated by its exact location and the presence of symptoms or complications.

1. Cu-T within the Uterine Cavity (Lost Strings, Malpositioned, Embedded)

If the Cu-T is found within the uterine cavity but the strings are not visible, or it is malpositioned/partially embedded:

• Cervical Canal or Lower Uterine Segment: Often, the device can be retrieved with long artery forceps or an IUD hook under direct visualization using a speculum.
• Upper Uterine Cavity (Lost Strings):
  • Uterine Sound/IUD Hook: A uterine sound can be used to explore the cavity. If the device is felt, an IUD hook can be used for retrieval. This is often performed under ultrasound guidance to prevent uterine perforation.
  • Hysteroscopy: This is the preferred method for intrauterine misplaced or embedded IUDs. It allows for direct visualization of the uterine cavity, precise localization, and removal of the device using hysteroscopic graspers or forceps. It minimizes the risk of blind manipulation and associated trauma.

2. Cu-T with Uterine Perforation or Extrauterine Migration

Uterine perforation and migration into the abdominal or pelvic cavity are rare but serious complications. The incidence of uterine perforation is reported to be between 0.05 and 13 per 1000 insertions, with an average of 1.2 per 1000 insertions. Once outside the uterus, the IUD can migrate to various sites, including the omentum, bladder, intestine, or broad ligament. Approximately 80% of IUDs are found in the peritoneal cavity after perforation. Removal is generally recommended even if asymptomatic, due to the risk of adhesion formation, inflammatory reactions, and injury to vital organs.

• Laparoscopy: This is the gold standard for the removal of an extrauterine Cu-T. It is a minimally invasive surgical procedure that allows visualization and retrieval of the IUD from the peritoneal cavity or other accessible extrauterine locations. It offers better visualization, reduced recovery time, and less postoperative pain compared to laparotomy.
• Laparotomy: Reserved for complex cases where laparoscopy is technically difficult or contraindicated, such as extensive adhesions, bowel involvement, or if the IUD is deeply embedded in an inaccessible location. Assistance from a general surgeon or urologist may be required if the device has migrated into or caused injury to the bowel or bladder.
• Cystoscopy/Colonoscopy: If the IUD is found within the bladder or colon lumen, these endoscopic procedures can be used for retrieval, often in conjunction with other surgical approaches.

Potential Complications of Retained/Misplaced IUD

Retained or misplaced IUDs, especially if extrauterine, can lead to several complications:

• Loss of Contraceptive Efficacy: Increased risk of unintended pregnancy, including ectopic pregnancy.
• Pain and Bleeding: Persistent pelvic pain, dyspareunia, and abnormal uterine bleeding.
• Infection: Increased risk of pelvic inflammatory disease (PID).
• Adhesion Formation: Copper, being a foreign body, can trigger an inflammatory reaction leading to adhesion formation with surrounding organs like the bowel and omentum.
• Organ Injury: Perforation of the bowel, bladder, or other abdominal organs, potentially leading to obstruction, fistula formation, or peritonitis.
• Fragmented IUD: Rarely, the IUD can fracture, leaving fragments in situ, requiring more complex retrieval.

Prevention of Misplacement

Preventive measures are crucial to reduce the incidence of misplaced Cu-T:

• Proper Training: Healthcare providers should receive adequate training in IUD insertion techniques.
• Careful Patient Selection: Assess for risk factors such as uterine anomalies, recent childbirth (especially immediate postpartum insertion), and breastfeeding status.
• Correct Insertion Technique: Ensure proper uterine sounding and placement of the IUD at the fundus.
• Post-Insertion Counseling: Educate the patient on how to check their IUD strings and recognize signs of displacement (e.g., changes in string length, feeling the IUD itself, persistent pain, abnormal bleeding).
• Follow-up: A follow-up visit typically a month after insertion is recommended to confirm correct placement.

Location of Misplaced Cu-T	Preferred Management	Key Considerations
Intrauterine (lost strings, malpositioned, embedded)	Hysteroscopy, IUD hook under ultrasound guidance	Avoid blind manipulation; ensure complete removal.
Extrauterine (peritoneal cavity, omentum, bladder)	Laparoscopy	Minimally invasive; precise localization and retrieval; may require assistance from other surgeons.
Complex Extrauterine (extensive adhesions, bowel/bladder involvement)	Laparotomy	More invasive; necessary for complicated cases; higher risk of complications.