Summary: The primary care physician performed a pelvic speculum
examination and noted no active bleeding. The IUCD string was not
visible in the uterine cervix or vaginal vault. A pelvic ultrasound
was requested to verify position of the IUCD.
Complete uterine perforation by an intrauterine contraceptive
The uterus was retroflexed. The endometrial complex was homogenous
and well demonstrated (Figure 1). A densely echogenic linear
structure characteristic of an IUCD was not present within the
This raised the possibilities of spontaneous expulsion or
uterine perforation. A supine abdominal plain radiograph to
evaluate the presence or absence of an IUCD in the pelvis showed a
"T"-shaped metallic structure midline in the pelvis, which is
characteristic of an IUCD (Figure 2). The IUCD was cephalad to the
expected position and was oriented with the vertical axis pointing
A more extensive ultrasound evaluation of the uterus and
adjacent structures documented a densely echogenic, linear foreign
body lying along the anterior-superior serosal surface of the
uterine body (Figure 3). The foreign body did not move with changes
in patient position. These findings were discussed with the
obstetrician. A preliminary diagnosis of complete perforation of
the uterus with the IUCD lying adjacent to the serosal surface of
the uterus was made. An incomplete perforation of the uterus with
subserosal placement of the IUCD could not be excluded.
The patient was then taken to the operating room, where a
laparoscopic removal of the IUCD was performed. Intraoperative
laparoscopic images showed a round perforation of the uterus with
the IUCD lying freely in the pelvis along the serosal surface of
the uterus (Figure 4).
A Copper-T IUCD is a mainstay method of contraception in developing
countries and is often used in the United States. An IUCD is often
an ideal contraceptive method for lactating women because it has no
effect on the quality or composition of breast milk.1
postpuerperal IUCD is often inserted 6 to 8 weeks after delivery at
a postpartum follow-up visit.
Ultrasound is commonly used to document the presence and
position of an IUCD within the uterus. A highly echogenic linear
structure, with a much greater echogenicity than the normal
endometrium, is characteristic of an IUCD. The sonographic
appearance of an IUCD is determined by its shape and composition.
Most IUCDs are now shaped like a "7" or a "T." Intrauterine
contraceptive devices are made of a combination of plastic and
metal (copper). The metal causes a "reverberation artifact," a
series of parallel lines that become progressively weaker
posteriorly, when the IUCD is parallel to the ultrasound beam.
Plastic tubing is displayed as 2 parallel lines representing an
entrance and an exit shadow. A normally positioned IUCD lies in the
midline of the endometrial canal, equidistant from the uterine
Intrauterine contraceptive device strings are used to monitor
and remove the IUCD. The primary diagnoses of a "lost string"
include: 1) IUCD in situ, 2) unrecognized expulsion, and 3)
perforation of the uterus. Rare possibilities include: 1)
fragmentation of the IUCD with expulsion of the fragment bearing
the string, and 2) migration of a linear IUCD into the uterotubal
Patients with misplaced IUCDs may present with pregnancy, "lost
string," vaginal bleeding, or pelvic pain, or may remain
asymptomatic for years. Approximately 80% of misplaced IUCDs are
found within the uterine cavity, 15% are found in the cervical
canal, and 5% perforate the uterus.3
A missing string is the first sign of perforation in
approximately 80% of cases.4 The incidence of uterine
perforation, the most dangerous complication of IUCD placement, is
as high as 2.2 per 1000 insertions.5
A multimodality approach is essential in the diagnosis of a lost
IUCD string. There is significant danger in making the diagnosis of
expulsion of the IUCD based solely upon ultrasound findings of
an empty endometrial cavity. The literature reports a case assumed
to be IUCD expulsion based only on ultrasound findings. Afterward,
that patient had persistent symptoms, became unintentionally
pregnant, and then an intra-abdominal IUCD was documented by
radiography.6 This underscores the importance of
utilizing a combination of clinical history, ultrasound, and
radiographic imaging, leading to the diagnosis of uterine
perforation by a misplaced IUCD.
- Bhalerao AR, Purandare MC. Post-puerperal Cu-T insertion: A
prospective study. J Postgrad Med. 1989;35:70-73.
- Guillebaud J. Scheme for management of lost IUD Threads.
IPPFMed Bull. 1980;14:1-3.
- Barsaul M, Sharma N, Sangwan K. 324 cases of misplaced
IUCD-A5-year study. Trop Doct.2003;33:11-12.
- Heinonen PK, Merikari M, Paavonen J. Uterine perforation by
copper intrauterine devices. Eur J Obstet Gynecol Reprod
- Caliskan E, Ozturk N, Dilbaz BO, Dilbaz S. Analysis of risk
factors associated with uterine perforation by intrauterine
devices. Eur J Contracept Reprod Health Care. 2003;8:150-155.
- Miranda L, Settembre A, Capassa P, et al. Laparoscopic removal
of an intraperitoneal translocated intrauterine contraceptive
device. Eur J Contracept Reprod Health Care. 2003;8:122-125.