33) IUD Perforation/ Migration: A Very Rare Complication (Talking IUC With Dr. D, @dr_dervaitis)

hi i'm dr. christina der betas welcome back to my channel talking i you see with dr. d my youtube channel devoted to all things related to intrauterine contraception and answering questions about this method of contraception so in today's video i'm going to talk about the very rare complication so this isn't common but i'm going to talk about the very rare complication of something called IUD perforation sometimes also known as migration now in terms of other potentially more common side effects or risks of the IUD i'd refer you back to my video number three the need-to-know info in which i detailed the complete list of potential risks versus benefits using the IUD but in today we're specifically going to be talking about the situation of uterine perforation so what is this complication and what does it mean so uterine perforation refers to the situation in which the IUD actually goes through the uterine cavity so of course the IUD is intended to be within the uterine cavity just as this is sort of my little model here we're supposed to be here inside the uterine cavity but for various reasons which will describe the IUD actually ends up outside of the uterus where it's not supposed to be in terms of the incidence again this is very rare and although there's been a number of different studies the generally quoted rate of uterine perforation is about one in a thousand so again very very rare and I want my viewers to put that in the perspective of other risks as well so looking at the fact that all contraceptive methods almost all very effective contraceptive methods unfortunately do have some risks associated with them for example the birth control pill has a very very risk of blood clot or stroke applications but in any situation where we're using medications we're weighing potential risks versus benefits and of course the risk that we're up against is the potential risk for unplanned pregnancy and that's what this is all about is preventing unplanned pregnancy here and so keeping in mind that half of all pregnancies in North America are unplanned and of those around half are due to contraceptive failures so patients who have used a method and it has failed them and I'll remind viewers I know I'm a bit of a broken record about this but I'll remind viewers that the IUD has a less than 1% chance of pregnancy in terms of typical real-world use rates compared to the birth control pill for example which requires the user to remember to take a pill every day and has up to a nine percent chance of pregnancy typical youth rates for condoms up to 18 percent and fertility awareness or natural family planning has gotten a lot of press online recently and the typical use failure rates are actually in the range of about 24 percent according to the CDC so we want to keep all of that in mind so what actually occurs or how doesn't a leader in perforation happen so most uterine perforation actually occur at the time of insertion and what happens is that for various reasons which we'll discuss some of the risks but for various reasons the actual insertion device which normally would stop sort of just shy of the top of the uterus for whatever reason it actually penetrates and goes through the the wall of the uterus and in most instances could lead to the IUD actually existing outside of the uterus in the abdominal cavity now in some instances the IUD inserter may recognize prior to deploying the IUD may recognize that there's been a penetration or perforation rather and that they may stop the procedure and not actually deploy the IUD and in those situations nothing further may actually need to be done that healthcare practitioner would talk to the patient about what had just happened why they didn't deploy the IUD what signs and symptoms to look out for such as abdominal pain dizziness lightheadedness and so on and so forth and would give out patient instructions of where to go in the case of an emergency but most instances of that sort of a uterine perforation where the IUD is not deployed actually the defect in the uterine cavity that's created will heal spontaneously and nothing further may need to be done it would be very rare for there to need to be a surgical procedure in that situation so what are some of the potential causes and we're going to talk about the consequences and how we manage that situation but first let's talk about some of the potential reasons that this might happen so in some instances there may not be any risk factors for perforation but some of the more commonly mentioned risks are for example a patient who is in the postpartum state so postpartum patients because of certain characteristics of the actual uterus itself after it's healing from the pregnancy and delivery process that can potentially predispose to uterine perforation similarly because of some of the hormonal changes during breastfeeding and the effects on the uterus in breastfeeding patients there may be a slightly increased risk of uterine perforation now I that all is to say that those are potential risks but I want to emphasize that that does not mean that it is not an appropriate option for postpartum breastfeeding patients both the levonorgestrel and the copper IUD are both ideal options for postpartum patients and breastfeeding patients but it's just something that as a health care provider and as an IUD inserter that we are aware of when we're counseling patients and when we're actually performing the IUD insertion procedure itself another potential risk factor for uterine perforation would be potential features of uterine anatomy that make predisposed to perforation now everyone's Anatomy is a bit unique and prior to an IUD insertion the healthcare provider is doing an internal exam to feel for the uterine anatomy and to tell which direction the uterus uterus is facing and so on but in some situations for example DIF there's a quite a dramatically angled uterus in one direction or another or if there might be scar tissue for various other reasons that might fix the uterus in one position or another making it a little bit less flexible those situations might potentially predispose to uterine perforation another situation that's potent in the literature in terms of risk factors is potentially an inserter who might be less experienced at IUD insertion so like all things and all procedures the more procedures one does the more skillset that person might have and that can certainly factor into the equation but I want to mention that even in the hands of the most experienced inserter there is still this potential risk of uterine perforation it's not something that can be completely a risk that can be completely eliminated so so those are some of the situations where you might see a uterine perforation although as I mentioned it in some situations there may not actually be an identifiable risk factor what happens if there's a uterine perforation and how can we tell and how do we make the diagnosis now I will say that many or if not most uterine perforation ZAR actually ace and dramatic or the patient may not have any symptoms or potential discomfort part of the reason is that the IUD itself is really quite a soft flexible material and even when it's present outside of the uterus and within the intra-abdominal cavity as it might be pushing up against other structions with structures within the abdominal cavity it's really quite soft and in many situations or most situations will not cause any sort of damage or any sort of discomfort oftentimes the IUD may be found just sort of tucked behind the uterus where it's not really causing any harm or discomfort to the patient the other feature of our anatomy that I wanted to point out in this situation is that we have something called the omentum which is a big sort of layer of fat that hangs within the abdominal cavity it hangs from the bowel and it is designed to protect the peritoneal cavity or the abdominal cavity from any sort of process that may be causing harm or foreign bodies so that momentum is designed that if something is there that wouldn't typically be there within the abdominal cavity it latches on to it and this fatty labour layer encapsulate that and basically protecting the remaining abdominal structures from that foreign body so that potential protective mechanism also may attribute for the fact that really the there may be very few symptoms in the situations if the omentum has essentially grabbed on to and covered up the foreign body in this case the IUD and so it's it's not causing any harm or any symptoms or pain probably one of the commonest ways that we would diagnose a uterine perforation would be at a check-in the the office a subsequent check after the initial insertion appointment we do a check and find that where the strings aren't visible now I want to emphasize that that does not mean that in all situations where we're not able to see the strings that it means for sure a uterine perforation absolutely not and in other videos I sort of discussed this and the fact that sometimes the strings can sort of be hidden within the cervical canal but I would say that if I'm if a healthcare practitioner is seeing their patient after an IUD insertion and the strings are not visible then that would be one thing on their differential diagnosis or list of possibilities and further investigations would be necessary similarly if a patient previously was able to feel their own strings at home and now is not able to feel the strings then that might be a potential situation where we're concerned about possible uterine perforation and further investigation is required other situations that might alert us to a possible uterine perforation or uterine my or an IUD migration or an out-of-place IUD might be prolonged or unusual bleeding patterns or prolonged or unusual pain so in those situations we obviously want to do our due diligence and check on the position of the IUD and I just wanted to also add that given that in many situations the actual perforation does not have any symptoms and the patient doesn't necessarily notice anything or have any symptoms or know that anything's wrong this is part of why I think it's really important for you to followup with your healthcare provider as instructed and to go and see that your doctor for that checkup afterwards whether it be a month later or everyone practices a bit differently and I will also say that I'm because of this rare risk and because of the risk also of expulsion I actually tell my patients to just to be on the safe side to use backup contraception until we've done that check because of course one of the other potential complications of a uterine perforation or symptoms if you would be potential pregnancy that the IUD is outside of the uterus and obviously not doing its job or functioning properly and the patient who is not using any sort of other form of contraception ends up with an unintended pregnancy for that reason so just keeping that in mind and again to reinforce the importance of follow-up afterwards now if we're suspicious that there might be an IUD perforation for example let's say the situation where we've done an exam and the strings aren't visible what are the next steps for diagnosis so probably the very next step that most healthcare providers would take would be to order an ultrasound now after the ultrasound has been done obviously if the IUD is shown to be in good position then we're reassured if the IUD is not visualized within the uterus then we need to take next diagnostic steps because if the IUD is not visible within the uterus there are two possibilities that we need to sort out one possibility is that the IUD may have been exposed or may have come out of the uterus and the patient may not have been aware of that and there's overall on average about a 5% chance of expulsion so we need to sort of sort out that possibility and decide to the IUD fall out vaginally and was exposed or has the IUD gone through the uterus into the abdominal cavity so to do that or to sort that out usually the next step would be an abdominal x-ray or a flat plate x-ray and most are pretty much all common modern IUDs that are available currently or in Canada are what we call radio opaque opaque so that we can see them on an x-ray and so then obviously if we are able to see the IUD on that x-ray somewhere within the abdominal cavity and we weren't able to see it within the uterus on ultrasound then the conclusion is that the IUD has gone through the uterus and is no longer within the uterus in some situations it can be difficult to tell just based on ultrasound or based on flat plate x-ray sometimes depending on the patient's uterine anatomy or other factors such as fibroids or other things that may affect the ability to visualize the uterus and the uterine cavity on ultrasound and in some situations we may actually order a CT scan for better visualization so in this situation let's presume that so that we've made the diagnosis of the we haven't seen the IUD on ultrasound within the uterus but we've done a flat plate and we see that the IUD is still present in the abdominal somewhere in the abdominal cavity it has not been exposed vaginally it is there outside of the uterus within the peritoneal cavity so what what is the next step there so usually to remedy this situation we would next go on to add a surgery procedure called laparoscopy now before we talk about that I just want to emphasize a couple of things that patients are often confused about when we are in a situation where there's a uterine perforation when we need to go on to surgery to retrieve the IUD this does not have an impact on future fertility this does not necessarily mean that the patient is going to have difficulties conceiving so I just want to address that misconception right off the top now in terms of laparoscopy and having to do a day surgery to retrieve the IUD it all sounds very dramatic and I understand when we're in the situation in explaining to patients they're you know of course upset at the news and upset at the thought of having to undergo surgery but just keeping the big picture in mind again and the overall perspective of you know the goal here being to prevent unplanned pregnancy remember that in patients who unfortunately end up having an unplanned pregnancy whether they continue with the pregnancy or termini there is still the potential that they may end up with a surgical procedure or some sort of a procedure if you consider that a vaginal delivery even can sometimes require some manipulation or intervention and we would consider a procedure about 25% of deliveries currently or births currently in Canada are via c-section so that would be a surgery if you choose to terminate a pregnancy some are done medically some might require surgical termination so again it seems dramatic that this is a complication that might might require a surgery to correct the situation but keep in mind that unplanned pregnancy itself could sometimes result in a surge of surgical procedure as well and this is all about trying to permit unplanned pregnancy okay so that was just sort of a bit of perspective there and again I just want to again emphasize that this is a very manageable situation so it does not have an impact on future fertility and we can manage this situation by going on to laparoscopy so a laparoscopic surgery is usually a day surgery procedure which means you don't have to stay in the hospital over night if there were no complications with the procedure the entire procedure usually ends up taking around 30 minutes I would ask me again in an uncomplicated situation it does involve a general anaesthetic so you're asleep for the procedure and not aware of anything and not feeling anything generally what's involved in last laparoscopy so it's like a we would call it a video camera surgery so we would make an incision involves just very small incisions usually less than one centimeter usually a small incision beneath the bellybutton area and a small incision just above the pubic bone area beneath the belly button we would one practices to insert a needle what we call in saline or puff up the abdominal cavity with carbon dioxide gas which creates a protective layer between the abdominal wall and what lies beneath and through that small under the bellybutton incision we would insert what's called a trocar which allows us to place a video camera through to look around and then through the lower abdominal smaller incisions we would put in another instrument that allows us to manipulate things so that we can essentially look for the IUD and retrieve it through that small incision site in many instances the IUD is sort of tucked behind the uterus and what we call the cul-de-sac it may be encased in some omentum and we have to do a little bit of dissection work - to remove it there but in the vast majority of cases in the vast majority of cases it is easily retrievable being first via this day surgical procedure recovering from a laparoscopy although there is some discomfort and usually the surgeon would prescribe some sort of analgesic afterwards in terms of activity restrictions really the only activity restrictions would be based on the patient's own discomfort if they are feeling well and able to do the regular activities no restrictions there someone who's working would be theoretically entitled to one or two weeks off of work but that but most patients may find that their up and back to regular activity much sooner than that and I will mention this for anyone out there watching this video who might be in that situation where they are postpartum and breastfeeding I will say that having to have a laparoscopy and a general anaesthetic should not interfere with or dramatically interrupt your ability to breastfeed other than obviously the time that you need to spend at the hospital actually having the procedure done none of those medications mean cessation of breastfeeding at all now in terms of future contraception in someone who's have a uterine perforation because of an IUD I do want to note that some patients will actually elect to have a new I u D placed at the time of the laparoscopy because in that situation they are actually able to we are actually able to do the insertion in this situation where we can actually visualize the top of the uterus and ensure with our own two eyes that there's not any sort of a perforation situation so having a new IUD placed is a possibility and having one IUD perforation does not necessarily mean that a perforation will happen again per se if you choose to continue to use an IUD for contraception in some patients who are 100% definitive that they are not interested in any future pregnancies they may elect to have a tubal ligation or removal of the fallopian tubes there's different ways of tackling that procedure which I won't get into here but they may elect to have some sort of tubal occlusion or removal procedure as a permanent form of contraception but again that's a 100% permanent situation so that patient has to be 100% definitive that under no circumstances would they be interested in future pregnancies one thing that I wanted to mention here is that I've discussed the situation of complete uterine perforation or when the IUD has actually gone through the uterus I didn't spend a lot of time talking about partial migration or penetration or perforation because it's a bit of a different situation that would be where instead of being right center within the uterine cavity some portion of the IUD whether it be the actual IUD stem or some more commonly the arm of the of the IUD the T portion if you will sometimes a portion of that can penetrate a little bit into the deeper muscle layer of the uterus which is different from it going all the way through and partial penetration is a bit of a subtopic but I will say that each situation is individualized depending on the situation the type of IUD the imaging report and not necessarily every single partial penetration may require removal certainly these don't usually require surgical procedure to remove occasionally a history scopic procedure or video camera within the uterus but these don't usually require laparoscopy to remove and again it's sort of on a case-by-case basis if the arm is slightly penetrating the muscle layer it doesn't necessarily mean bad things are gonna happen or that the IUD isn't working and it may not always require removal of the I u D or e insertion of a new IUD but so that was just a little bit on that subheading so that was a bit of a long video but I just wanted to go in depth for any patient out there or viewer out there who may have experienced this complication and is looking for detailed information I also want to address that I know that there's a lot of horror stories out there on the Internet and unfortunately these sorts of very very rare but serious complications tend to be the ones that people are reporting online or that the press or the media are reporting on but keep in mind that this is still a very very rare incidence and keep in mind the overall goal that we're up against which is preventing unplanned pregnancy and remember that the IUD is one of our most effective ways of doing so so it's all about weighing risks versus benefits okay so that's all for today to view I'm gonna end as I always do by reminding you that in much less than the time that it took for me to took for you to watch this video you could have had an IUD inserted the whole process takes about five minutes and I can provide up to five years of worry free contraception thanks for watching we will see you in the next video take care

Channel: Dr. Kristina Dervaitis

Views: 26,031

Keywords: iud, intrauterine device, iud perforation, iud migration, iud complication, complication, perforation, migration, iud risks, contraception, unplanned preganacy, contraception failure, gynecologist, education, diu, the coil, dispositivo intrauterino, copper iud, hormonal iud, levonorgestrel iud, laparoscopy

Id: Y5J9NygBdds

Length: 26min 28sec (1588 seconds)

Published: Sun Mar 08 2020