RESUMO
The current literature suggests that serious complications after intrauterine contraceptive device (IUCD) insertion are rare. We present a rare case of a migrated IUCD into the rectosigmoid colon. A 33-year-old woman (parity one) presented to the emergency department with a three-day history of flank pain, upper urinary tract infection symptoms, and a low-grade fever. Differentials initially included renal colic or pyelonephritis. However, subsequent computed tomography of the kidneys, ureters, and bladder (CT-KUB) and magnetic resonance imaging of the pelvis (MRI-pelvis) showed a migrated IUCD posterior to the uterine body, with both ends closely abutting onto the adjacent proximal rectum. During further history-taking, she reported a past surgical history of an emergency caesarean section five years ago and the insertion of a copper-IUCD six weeks postnatally. She was subsequently referred to the gynaecologists. In view of the involvement of the bowels, the colorectal surgeons were consulted, and the patient was managed by a multidisciplinary team. The patient subsequently underwent diagnostic hysteroscopy, flexible sigmoidoscopy, diagnostic laparoscopy, removal of impacted IUCD, and repair of the rectum. Intraoperatively, her hysteroscopy noted a normal uterus with an intact cavity. Flexible sigmoidoscopy noted the horizontal arm of the IUCD abutting into the lumen of the rectosigmoid region; however, attempted removal with traction was unsuccessful. A partial rectotomy was done eventually to remove the IUCD. Migration of an IUCD is rare, with uterine perforation rates ranging from 0.04% to 0.2%. Albeit a rare complication, this case highlights the need for clinicians to be cognizant of complications arising from IUCD insertion, as symptoms are often non-specific and mild. This case also highlights the importance of a multidisciplinary discussion in the management of a migrated IUCD, which may include gynaecologists, colorectal surgeons, radiologists, and more. Many innovative ways were also discussed regarding the assessment of it, which includes preoperative imaging or endoscopic evaluation. Novel methods of removal of migrated IUCD in the rectosigmoid colon have also been proposed, including manual traction, proctoscopy, rigid sigmoidoscopy, and removal via a snare. They provide an alternative to the traditional diagnostic laparoscopy or laparotomy, thus reducing the need for general anaesthesia or operative intervention. Looking forward, long-term studies can be done to evaluate the need for intervention for asymptomatic patients where the risk of surgery may outweigh the benefits.
RESUMO
INTRODUCTION: Pregnancies in women with thrombophilia are associated with a higher risk of obstetric complications. We systematically reviewed the findings of relevant randomised controlled trials (RCTs) with the aim of investigating the effectiveness of low-molecular-weight heparins (LMWHs) in pregnant women with inherited thrombophilic disorders and its effect on the incidence of live births in these patients. METHODS: The MEDLINE-PubMed and Cochrane CENTRAL databases from 2000 to 2010 were searched using a combination of keywords, including low-molecular-weight heparin, enoxaparin, pregnancy, live birth and thrombophilia. Studies were included if they were RCTs assessing the effect of anticoagulant treatment on live birth rates in women with a history of miscarriage without apparent causes other than thrombophilic disorder. Interventions included LMWH, with or without aspirin, aspirin alone or placebo controlled for the prevention of adverse pregnancy outcome. RESULTS: 43 articles with seven RCTs were retrieved following the initial search, of which four studies had to be excluded as they assessed thromboembolic events as the final outcome (n = 1), focused on idiopathic recurrent miscarriages (n = 1), compared efficacy and safety of two doses of enoxaparin (n = 1), and examined patients with or without thrombophilic disorder (n = 1). Pooled data from the remaining three RCTs showed no significant difference in the improvement of live birth rates following LMWH interventions (p = 0.15). CONCLUSION: At present, the use of LMWH in women with inherited thrombophilia with recurrent pregnancy loss is not indicated. Large randomised placebo-controlled trials are further needed to prove the effectiveness of LMWH in these patients.