Uterine perforation by Lippes loop.

PIP: After a 32-year-old women was unable to locate a C Lippes Loop (inserted approximately 9 weeks postpartum) at any time during a four week period after insertion, the position of the device was shown by x-ray to be extrauterine. Removal of the IUD necessitated a colpotomy, resulting in bleeding which could not be controlled vaginally. Following laparotomy, grasping of the extremely friable uterus caused tearing of the Fallopian tubes from the uterus. A hysterectomy was performed. This case demonstrate the real, if rare, possibility of perforation of the uterus with the Lippes Loop.^ieng

Unilateral tubo-ovarian abscess and intrauterine contraceptive devices.

The association of unilateral tubo-ovarian abscess and the presence or use of an intrauterine contraceptive device (IUD) appears to be a definite clinical entity. Four cases of unilateral tubo-ovarian abscess in patients using the IUD are presented. Three patients had a Dalkon Shield IUD and one had a Lippes Loop. Two patients had unilateral salpingo-oophorectomy while the other 2 had total abdominal hysterectomy and bilateral salpingo-oophorectomy. The differential diagnosis, possible etiology, route and mode of infection, and management are discussed.

PIP: 4 cases of unilateral tuboovarian abscess in patients using an IUD are presented; 3 of the 4 patients had a Dalkon shield and 1 had a Lippes loop. These cases present the problem of diagnosis and treatment as the presence of pelvic mass in an IUD user may be due to an ectopic pregnancy, ovarian cyst, or a pelvic or tuboovarian abscess. Unruptured tuboovarian abscess requires conservative treatment with antibiotics initially and surgery if there is an unsatisfactory response. These patients display a high fever and purulent cervical discharge. An ascending infection is associated with IUD use and recent investigations implicate the tail, especially the compound variety. Trauma to the endometrium by the IUD may initiate the infection and the finlike projections of the IUD may cause further trauma. The connection of unilateral tubooovarian inflammatory mass with the IUD user should alert more clinicians to this possibility.

Ectopic endometrium in omentum. Uterine perforation by Lippes loop.

A case of ectopic endometrium in the omentum following perforation of the uterus by a Lippes Looptm is reported. Evidence is presented substantiating Sampson's theory of endometrial implantation.

PIP: This is a case report of a patient who had an IUD inserted the year following a spontaneous abortion. The next year she became pregnant and delivered a full-term infant. Another IUD was then inserted. After 2 years lower abdominal pain and vaginal bleeding of 2 months duration caused her to ask to have the IUD removed. The thread broke during the removal attempt so the patient was admitted to the hospital where a hysterogram revealed a Majzlin spring partially embedded in the uterine wall and a Lippes loop outside the uterine cavity. The Majzlin spring was removed through the vagina and curettage done. At laparotomy to remove the other IUD the Lippes loop was found embedded in a large mass of omentum. The loop and adherent omentum were removed. Histologic study revealed an area of well-preserved endometrium, an area of hemorrh agic endometrium with leukocytic infiltration, and dense fibrous tissue surrounding the endometriotic foci. These findings support the theory of endometrial transplantation rather than the theory of metaplasia.

Perforation of the uterus and partial extrusion of a Lippes loop. Report of a case.

PIP: This is a case report of a woman having an IUD which became partially extruded through the uterine wall and went undetected until the patient became pregnant. Severe metritis followed premature rupture of the membranes during the early part of the third trimester. Cesarean section hysterectomy led to a salutary outcome.^ieng

Intrauterine contraceptive devices: a comparison between their use in indigent and private patients.

PIP: Use of intrauterine contraception for an aggregate 8291 months in a group of 706 private patients (mean age 27.5 years, mean number of pregnancies 2.75, 9 nulligravidas) was analyzed and compared briefly with use in a group of 623 women from a lower socioeconomic level. Considering private patients only, 195 (27.6%) had intermenstrual bleeding after IUD insertion and 27 (3.8%) experienced an increase in the amount or duration of menstrual flow. All women had cramping after insertion of the Lippes loop (or Permaspiral in 2 patients); 43 (6.1%) expelled the device. Infection developed in 9 (1.3%), and perforation of the uterus during insertion of the loop occurred in 2 patients. The pregnancy rate for all users was 2.6 pregnancies per 100 years of use. Termination of intrauterine contraception in 216 (30.6%) was because of intermenstrual bleeding (89 women), increased menstrual flow (7), cramping (19), infection (8), spontaneous ejection (22), a sterilizing operation on either spouse (8), pregnancy when IUD inserted (2), pregnancy desired (37), and other personal reasons (6). The IUD continued to be acceptable to 535 (75.8%, including those sterilized or desiring pregnancy) of 706 upper and middle class women an aggregate of 6655 months of use. Private patients compared to clinic ones had a lower incidence of irregular bleeding (195 of 706 vs. 391 of 623), but more of them discontinued intrauterine contraception because of irregular or excessive bleeding (96 or 13.6% of private patients vs. 28 or 4.5% of clinic patients). The infection rate, total expulsion rate, and final rate for discontinuation due to expulsion were lower for private vs. clinic patients (1.3% vs. 8%, 6.1% vs. 15%, and 3% vs. 5.7%, respectively). It was found that the main advantage of the IUD, constant unburdensome protection against pregnancy, was important to both groups and that couples of any social class could effectively use intrauterine contraception. Differences in use are due to lesser dependence on the IUD among upper strata women, who can use other contraceptive methods successfully.^ieng

Effects of contraceptive pills and intrauterine devices on urinary bladder.

The incidence of bacteriuria and cystoscopic changes in women on oral contraceptives or users of IUD (intrauterine devices) were evaluated compared with a control group. Subjects with bacteriuria accounted for 40.5 per cent of pill users, 20 per cent of women fitted with IUD, and 16 per cent of the control group. Bladder trabeculations were found in 50.5 per cent of the pill group, 8.7 per cent of the IUD group, and 8 per cent of the controls. Congested bladder trigone was observed in 24.6 per cent of women fitted with an IUD. The mode of action of ovarian hormones and their possible side effects on the bladder are discussed. The relation of IUD to pelvic inflammatory disease and its effect on the urinary bladder are evaluated.

PIP: The incidence of bacteriuria and cystoscopic changes in 200 women using oral contraceptives from 1 month to 2 years and 150 users of IUD were compared with 50 women using neither method. Bacteriuria in midstrean urine samples of all subjects were identified qualitatively and quantitatively by the method of Stamey et al. Cystoscopy was performed on all subjects. Positive bacteriuria were found in 40.5% of patients on oral contraceptives, 20% of IUD users, and 16% of the control group. Positive pathogenic bacterial cultures in women using oral contraceptives were proportional to the length of time the pill had been used: 27% for 1 year users, 35% for 2 year users, and 50% for longer users. The potency and dosage is correlated with the pathogenic effects observed. Bladder trabeculations were found in 50.5% of oral contraceptive users, 8.7% of IUD users, and 8% of control subjects. The highest incidence was in subjects using pills for 2 years or more, and is correlated with the dosage used. Bladder trigone congestion was observed in 24.6% of IUD users; 56% of users from 1 to 3 months, 35% of users more than 2 years, and no users between these time extremes. The high incidence of bladder trabeculations might be explained by the effect of progestogens and estrogens on bladder tone; progestogens producing hypotonia and estrogens hypertonia. The IUD should not be used more than 2-3 years continuously to avoid urinary bladder effects and inflammatory pelvic disease.

Salpingitis: a frequent response to intrauterine contraception.

Nonbacterial, chronic salpingitis was found in less than 1% of non-IUD users undergoing elective tubal sterilization, Nonbacterial, chronic salpingitis was found in 47% of IUD users undergoing elective sterilization. Speculation about the influence of this finding on inflammatory morbidity is presented.

PIP: Histologic specimens from both IUD-wearing and non-IUD-wearing women undergoing translaparoscopic tubal sterilization were examined for inflammatory changes. Among 1500 non-IUD wearers salpingitis was noted histologically in 10, less than 1%. At laparoscopy 3 of these had signs of old gonococcal infection, including peritubal adhesions. In 1 case perihepatic adhesions were observed. In 49 patients undergoing simultaneous IUD removal and sterilization, 23 (47%) had chronic salpingitis histologically similar to the inflammatory response previously reported in the endometrium among IUD wearers. The majority of IUDs were Dalkon shields, a reflection of IUD use in the Seattle community. Infectious morbidity did not complicate the poststerilization convalescence. Bacteriological investigation gave negative results. It seems likely that chronic nonbacterial tubal inflammation explains some of the symptoms commonly associated with the IUD. This study also lends histologic support to the theory that decrea sed host resistance to bacterial infection is an explanation for IUD-rel ated inflammatory morbidity.

Intra-abdominal Lippes Loop removed at laparoscopy. A case report.

PIP: A case of abdominal Lippes loop removed by laparoscopy is reported and illustrated. Some diagnostic pitfalls are discussed. A 25 year old, gravida 1, para 1 was seen on April 17, 1970 stating that she had been fitted with an IUD 5 weeks earlier. No strings were visible, the uterus was of normal size, and a flat plate of the abdomen revealed a "Lippes loop" in the pelvis. On May 21, after a normal period, attempts at probing the uterus were made, but no IUD was felt. No IUD was obtained on July 20 when a D and C was performed. A hysterosalpingogram was subsequently performed and was interpreted by the radiologist as: "foreign body, IUD, within the uterus." When the films were requested and viewed, it was shown that the IUD was in the abdominal cavity. On September 13, the IUD was removed at laparoscopy. The patient had an uneventful postoperative course and was discharged the following day in good condition. It is noted that a report of a test must be accepted with caution by the clinician, particularly when there is discrepancy with the clinical diagnosis. In this case, the films were taken with a clearly improper technique which led to faulty readings. Laparoscopy was chosen in the removal of the IUD because it offers the chance of an accurate visual diagnosis and, circumstances permitting, avoiding laparotomy.^ieng

Silent uterine perforation with Lippes' loop and its management.

PIP: 14 cases of silent perforation of the uterus by the Lippes loop are presented. Loop perforations are usually asymptomatic and can be treated conservatively. If complications occur, they require surgical intervention with posterior colpotomy being the procedure of choice if the loop is in the pelvic cavity. Laparotomy is indicated if the loop is in the abdominal cavity. Perforation usually occurs for 3 reasons; lack of experience and unnecessary force at the time of insertion; a hyperkinetic uterus; or a loop larger than the cavity. The best treatment is prevention. The most important indication of perforation is an opening of the coils of the loop as seen by x-ray. Perforation is usually suspected by absence of the nylon thread in the vaginal cavity. The site of perforation usually heals in 1 month and can no longer be detected on examination. None of the 14 cases in this study became pregnant as a result of the perforation.^ieng

Uterine bleeding in rhesus monkeys after insertion of polyethylene and copper containing polyethylene intrauterine contraceptive devices.

PIP: The effect of polyethylene devices, with or without copper, on the incidence of postinsertion bleeding episodes in rhesus monkeys is reported. 24 rhesus monkeys were divided into 4 groups. Group 1 was fitted with the Lippes loop (No. 25). Group 2 was fitted with the loop with 2 cm copper wire (.2 mm diam.) wound around it. Group 3 was fitted with plain polyethylene T-device without copper, and Group 4 was fitted with copper-T (model TCu-200 L). Vaginal smears of all of the monkeys were examined every 12 hours for microscopic bleeding. 1 of the animals of each group showing frank uterine bleeding was sacrificed. The uterus was dissected out and processed for histological studies. The results showed that the incidence of postinsertion bleeding in rhesus monkeys varied according to the design and material of the devices. The severity of bleeding was markedly less with either the plain T-device or the T-device with copper, as compared to Lippes loop with or without this metal. The copper containing Lippes loop caused less bleeding in so far as duration and flow were concerned than the loop without copper. The severity of bleeding in animals fitted with plain T-device was less than that seen after insertion of the plain Lippes loop. This suggests that the design of the device is a crucial factor in bleeding. A comparison between plain T-devices and copper T-devices showed a beneficial action of copper in reducing the incidence of postinsertion bleeding.^ieng

[Experiences with newer types of intrauterine contraceptive devices of Czechoslovak origin]. / Skusenosti s novsimi typmi intrauterinnych teliesok domãceho põvodu.

PIP: 922 women were studied, half using the Dana Super IUD and half using the Dana Super Fix IUD. Of the half using the Dana Super, 1.3% were expelled, 3.7% became pregnant, and 19.7% experienced complications. Of the half using the Dana Super Fix, 1.1% were expelled, none became pregnant, and 9.2% experienced complications. Manipulation of the device was must easier, more efficient, and comfortable for the patient with the Dana Super Fix.^ieng

[IUD and nullipara]. / IUP och nulligravidae

PIP: 3 types of IUDs were inserted in 203 nulligravidae, and their effect iveness and side effects were compared. Gravigard was inserted in 54 women; there were no conceptions, 3 rejections, and 2 cases of salpingitis, with 83% of the patients continuing use of the IUD after 12 months. There were 2 conceptions with Copper-T 200 users, 11 rejections, and 3 cases of salpingitis, with a 67% continuation rate after 12 months. The Dalkon Shield Small, especially designed for nulligravidae, was used by 95 women, with 4 conceptions, 1 rejection, 3 cases of salpingitis, and an 86% continuation rate after 6 months. There were some difficulties in insertion as the cervical canal was small and dilation was not performed. Most of the rejections were probably due to the smallness of the uterus, which was not capable of accommodating the IUD. Abnormal bleeding was the most frequent reason for discontinuation of the IUD. The frequency of salpingitis was relatively high.^ieng

[Perforation of the uterus with a Lippe's loop]. / Uterusperforation med Lippe's loop.

PIP: A case of perforation of the uterus by a Lippes loop IUD in a 33-year-old woman is described. X-rays had shown the IUD in its characteristic intrauterine position after it had perforated the uterus and migrated extrauterinely. Hysterosalpingography was required to locate the IUD. Characteristic symptoms of these patients are discussed.^ieng

The Dalkon Shield in perspective.

PIP: When the Dalkon Shield IUD became clinically available in the early 1970s, it appeared that an ideal contraceptive had been developed, with essentially no adverse effects (very safe) and a very high degree of efficacy. Within a few years, however, it became apparent that the Dalkon Shield had not lived up to expectations. In fact, it caused very severe complications, not infrequently resulting in the loss of reproductive ability and in 17 cases, death. In addition, the pregnancy rate among women using this IUD was significantly high, with many resulting in mid-trimester abortion when the IUD remained in-place. The authors trace the legal consequences of this medical disaster, which has resulted in both the development of new and the extension of old legal theories and doctrines involving negligence and product liability. Dalkon Shield litigation is most likely to continue. Many women are assumed to wear the shield still, and neither the FDA or A.H. Robins, manufacturer of the shield, has issued a formal recall.^ieng

[Insertion of the Lippe's loop immediately after abrasio residuorum and interruptio graviditatis]. / Postaviane na spirala Lippes neposredstveno sled abrasio residuorum i interruptio graviditatis

PIP: 166 women experiencing abrasio residuorum after incomplete abortion and 68 experiencing interruptio graviditas were inserted with the Lippes Loop immediately after curettage. .85% of these were spontaneously expelled 15 days after insertion. 2.55% were expelled spontaneously after 15-60 days. Only 1.2% of the patients had complications before the 15th day and 3.5% between the 15th-60th day. These low percentages led to the conclusion that early complications and spontaneous expulsion are not higher in women using the IUD after curettage than in those without previous curettage.^ieng

[Extrauterine IUD localization (author's transl)]. / Mimodelozní lokalizace IUD

PIP: 3 cases of extrauterine localization of an IUD are described. The Dana Super IUD was used in all 3 cases. Extraction of the device was uncomplicated in all 3 cases and no postoperative complications arose. X-rays of the 3 localizations are examined. In discussing the possible mechanisms of the appearance of this disruption, it is considered incorrect to blame it on faulty insertion of the device by the physician. It is considered, and substantiated by other studies, that the spontaneous movement of the IUD is quite possible, although the mechanism of this action is not clear.^ieng

[Work incapacity on account of complications after insertion of IUD (author's transl)]. / Práceneschopnost pre komplikácie po zavedení IU.

PIP: Since the insertion of an IUD may involve many complications, it is apparent that many women will be unable to work should they occur. Between 1966-1972, 3723 Dana IUDs were inserted in a clinic in Kosice, Czechoslovakia. There were 176 complications (4.7%) requiring hospitalization. The most frequent reasons for inability to work were injuries to the uterus, extrauterine pregnancies, and infections.^ieng

[Spontaneous disintegration of the IUD in the uterus]. / Spontánní rozpad IUD in utero.

PIP: A 30 year old woman who had had 2 normal pregnancies and no abortions came to a clinic 4 years after the insertion of a DANA Super 2 IUD. During her last menstrual period, she found 2 pieces of plastic on her sanitary pad. She believed them to be pieces of her IUD, and X-ray examination of the lower abdomen confirmed that the IUD had fractured within her uterus. The remaining pieces of the IUD were removed, and the patient suffered no sustained damage or injury. The IUD probably shattered because of defects in the microstructure of the plastic used to make the device. The plastic is stressed during insertion and perhaps further stressed by uterine movements when in place. The suspected defects may have caused the device to shatter when exposed to these repeated stresses.^ieng

Complications following use of Lippes' Loop.

PIP: A critical analysis of 120 cases of complications occurring in 475 women who had been fitted with a Lippes' Loop (30 mm size) from Jan. 1, 1965 to May 31, 1967 at the Family Planning Clinic of S.S.G. Hospital, Baroda, India is presented. Another 100 cases of loop insertions with complications, referred from peripheral clinics is also included. All of the 220 cases wanted removal of the loop. Abnormal vaginal bleeding was present in 57.5% of the cases. In 21 cases, x-ray of the pelvis was required to confirm the presence of the loop as the thread was not seen. 5 cases had chronic endometritis and 2 cases showed intraperitoneal displacement of the loop. In 80% of the cases, removal of the loop was easy; 7 cases required dilation of the cervix under anesthesia and abdominal exploration was required in 6 cases. Laparotomy was mandatory in 2.72% of the cases. 24 cases were convinced to continue to use the loop as a contraceptive device.^ieng