Understanding Uterine Perforation Risks of Intrauterine Devices

Intrauterine devices (IUDs) comprise one of the largest shares in the long-term reversible contraception market. A recent survey, involving 3,901 women of reproductive age, found that 24% had used an IUD in the previous year.

Preferred for their effectiveness, IUDs are under intense scrutiny from a safety viewpoint. Potential risks abound, some of which can lead to serious complications.

Adverse events involving uterine perforation are a lot more common than the other complications of IUD insertion. This guide reviews the risk factors, clinical presentation, and diagnostic approaches with a focus on effective management and multidisciplinary coordination.

What is Uterine Perforation?

Uterine perforation is a serious complication in which an IUD punctures through the uterine wall. This may happen during insertion or due to migration through the myometrium over time.

It is a rare yet possible occurrence, with an incidence rate ranging between 0.006-0.012% in a healthy, unscarred uterus. The perforation may be partial, where the device is embedded yet not completely through the uterine serosa. It could also be complete, where the device enters the abdominal cavity.

Patients experiencing uterine perforation are at serious risk of internal bleeding, infections, and injuries to adjacent organs like the bladder or the intestines. The situation calls for prompt action to prevent the risks from turning into severe complications.

Risk Factors

A thorough understanding of the potential risk factors of uterine perforation helps guide clinical decisions and patient counseling. They are as follows:

Insertion technique and experience: The skills of an operator are a deciding factor. Nearly 75% of perforation cases in a study were associated with inexperienced surgeons. Gentle, controlled insertion is critical.
Insertion timing: The post-abortion and postpartum periods (primarily within six weeks following delivery) carry the highest risks. This is due to the thinning and softening of the uterine wall.
Uterus anatomy and anomalies: If the uterus is retroverted (tilting backwards towards the cervix), the risk of a perforation is high. The same goes for anomalies like uterine fibroids, scarring from previous surgeries, and congenital abnormalities.
Device characteristics: The risks are comparable between hormonal and non-hormonal IUDs. However, a case in point is the Paragard lawsuit, which involves claims of device breakage or migration during removal of a non-hormonal copper IUD. Such events further highlight the importance of proper insertion and follow-up care.
Patient-related factors: Those with a thin or small uterus and breastfeeding mothers face a higher risk of uterine perforation associated with IUDs.

Clinical Presentation

A high index of suspicion becomes important because symptoms vary widely among women. Let’s look at the different clinical scenarios:

During insertion: A sudden, sharp pain or resistance may point towards uterine perforation.
Post-insertion: If a vaginal examination reveals shortened or missing IUD strings, it’s most likely due to displacement and perforation.
Delayed symptoms: Some patients only experience symptoms of perforation days or weeks after insertion/removal. These include abdominal or pelvic pain, infection, and abnormal bleeding.
Rare complications: If the IUD migrates to adjacent organs, patients may experience other symptoms like peritonitis, urinary problems, and bowel issues.

Diagnosis

Early and accurate diagnosis is essential to prevent worsening of symptoms and risks. Uterine perforation can be detected using the following approaches:

Pelvic examination: It’s important to check the IUD strings. An absence or shortening is a sure sign of a perforation.
Ultrasound imaging: A transvaginal ultrasound is the preferred diagnostic tool to localize the device. The latter may be found embedded within the myometrium.
CT scan or X-ray: These imaging tools are beneficial if an ultrasound fails to identify the device. They are also used if an extrauterine migration is suspected.
Hysteroscopy or diagnostic laparoscopy: These two procedures are reserved for cases where imaging was inconclusive or when corrective surgeries are planned.

Management

The treatment or management strategies will depend on the symptoms, extent of perforation, and device location. Here’s how they may differ:

Prompt removal: This approach is recommended in most cases to prevent further complications like organ injury or infection.
Surgical options: Cases of serious infections and bleeding require surgical interventions. If the device is outside the uterus, the minimally invasive technique of laparoscopic retrieval is performed. Complex cases where laparoscopic retrieval is not possible require open surgery or laparotomy.
Conservative management: If the device is embedded partially but without any symptoms, close monitoring is required. In such cases, conservative management is considered, involving physical therapy and medications.
Antibiotics: They become necessary in cases where an infection is suspected.

Anesthesia Considerations

Professionals who administer anesthesia are typically needed during surgical retrieval procedures. Given their need to prepare for complications, the following come under their area of purview:

Preoperative assessment: This stage includes evaluation for bleeding, infection, and signs of organ involvement. The patient’s imaging results will be reviewed to guide the surgical plan.
Choice of anesthesia: General anesthesia is usually used for laparoscopic or open retrieval to ensure patient comfort. Regional or local anesthesia is an option for minimally invasive procedures, depending on the patient and the surgical requirements.
Intraoperative monitoring: During this stage, the professional must watch for signs of bleeding and instability. It’s crucial to manage ventilation, especially during laparoscopy.
Postoperative care: Anesthesia providers need to monitor for signs of delayed complications for prompt pain management. They must also collaborate with the surgical team on patient discharge and education.

Prevention Strategies

Prevention strategies play a key role in minimizing the risks of uterine perforation. They should involve the following:

Device insertion must be done only by trained and experienced clinicians.
IUD placement is best avoided during periods of heightened risk, such as post-abortion.
Ultrasound guidance is a must for patients with known anomalies or a history of challenging surgeries.
Patient education on serious complications should be prioritized.

Severe as the complications of uterine perforation are, prompt and accurate diagnostic response increases the chances of treatment success. A 2024 case study conducted on a 33-year-old patient with a history of multiple IUD insertions confirms this.

A retained IUD was found embedded in the broad ligament. The patient had been experiencing intermittent lower abdominal pain for six months with no other acute symptoms. A successful laparoscopic retrieval was performed.

Besides reassuring of successful recovery, this case highlights how uterine perforation can be asymptomatic. Healthcare providers must be vigilant in monitoring complications and diligent in patient education.