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SUMMARY OBJECTIVE: Intraoperative complications of hysteroscopy, such as the creation of a false passage, cervix dilatation failure, and uterine perforation, may require suspension of the procedure. Some patients refuse a new procedure, which delays the diagnosis of a possible serious uterine pathology. For this reason, it is essential to develop strategies to increase the success rate of hysteroscopy. Some authors suggest preoperative use of topical estrogen for postmenopausal patients. This strategy is common in clinical practice, but studies demonstrating its effectiveness are scarce. The aim of this study was to evaluate the effect of cervical preparation with promestriene on the incidence of complications in postmenopausal women undergoing surgical hysteroscopy. METHODS: This is a double-blind clinical trial involving 37 postmenopausal patients undergoing surgical hysteroscopy. Participants used promestriene or placebo vaginally daily for 2 weeks and then twice a week for another 2 weeks until surgery. RESULTS: There were 2 out of 14 (14.3%) participants with complications in the promestriene group and 4 out of 23 (17.4%) participants in the placebo group (p=0.593). The complications were difficult cervical dilation, cervical laceration, and vaginal laceration. CONCLUSION: Cervical preparation with promestriene did not reduce intraoperative complications in postmenopausal patients undergoing surgical hysteroscopy.
ABSTRACT
Resumen ANTECEDENTES: Los dispositivos intrauterinos son anticonceptivos seguros y eficaces, aunque con un riesgo de perforación uterina si quienes los aplican no tienen el suficiente cuidado y experiencia. La incidencia de perforación es de 1 a 2 casos por cada mil inserciones. OBJETIVO: Exponer un caso de perforación uterina completa por dispositivo intrauterino. CASO CLÍNICO: Paciente de 27 años, con antecedentes de: dos cesáreas, inserción de dispositivo intrauterino liberador de levonorgestrel tres meses posteriores a la última cesárea. En la consulta externa refirió dolor pélvico, sangrados intermenstruales y dos intentos fallidos de extracción del dispositivo. En la histeroscopia se observó una probable falsa vía y no se encontró el dispositivo en la cavidad uterina. La TAC abdominopélvica lo ubicó en la salpinge izquierda; ante la sospecha de DIU traslocado se decidió el procedimiento laparoscópico en el que se documentó al útero con perforación en la cara anterior derecha, con tejido de granulación y cubierto por peritoneo parietal; el DIU en el fondo de saco, orientado hacia la izquierda, fijo, con adherencias laxas. Se extrajo y, por solicitud de la paciente, se practicó la salpigectomía bilateral. Reporte del estudio histopatológico: salpingitis crónica moderada, con fibrosis y quistes simples serosos paratubáricos CONCLUSIONES: Los dispositivos intrauterinos son anticonceptivos extraordinariamente simples, seguros y de larga duración. En general, hay una baja morbilidad asociada con su implantación, incluso cuando se produce una perforación uterina la mayoría de las pacientes experimenta síntomas leves: sangrado transvaginal y dolor abdominal inferior.
Abstract BACKGROUND: Intrauterine devices are safe and effective contraceptives, although with a risk of uterine perforation if the user is not sufficiently careful and experienced. The incidence of perforation is 1 to 2 cases per thousand insertions. OBJECTIVE: Presentation of a case of complete uterine perforation by intrauterine device. CLINICAL CASE: 27-year-old patient, with a history of two cesarean sections, insertion of levonorgestrel-releasing intrauterine device three months after the last one. At the outpatient clinic she reported pelvic pain, intermenstrual bleeding and two unsuccessful attempts to remove the device. Hysteroscopy showed a probable false pathway and the device was not found in the uterine cavity. The abdominopelvic CT scan located it in the left salpingeal cavity; given the suspicion of a translocated IUD, a laparoscopic procedure was decided, in which the uterus was documented with perforation on the right anterior aspect, with granulation tissue and covered by parietal peritoneum, the IUD in the cul-de-sac, oriented to the left, fixed, with lax adhesions. It was removed and, at the patient's request, bilateral salpigectomy was performed. Histopathological study report: moderate chronic salpingitis, with fibrosis and simple paratubal serous cysts. CONCLUSIONS: Intrauterine devices are remarkably simple, safe and long-lasting contraceptives. In general, there is low morbidity associated with their implantation, even when uterine perforation occurs most patients experience mild symptoms: transvaginal bleeding, lower abdominal pain.
ABSTRACT
RESUMEN Fundamento: El dispositivo intrauterino ha sido utilizado durante muchos años como método anticonceptivo; una complicación infrecuente posterior a su inserción es la migración fuera del útero. La localización vesical y la formación de vesicolitiasis, son complicaciones asociadas a la migración. Objetivo: Presentar un caso de migración de un dispositivo intrauterino a vejiga con litiasis sobreañadida como inusual etiología de una cistitis recurrente. Presentación del caso: Caso clínico de un dispositivo intrauterino en vejiga en una paciente de 43 años, cuyo diagnóstico se realizó incidentalmente en estudio de cistitis recurrente; se diagnosticó imagenológica y endoscópicamente en consulta de Urología; se decidió tratamiento quirúrgico mediante cistolitotomía a cielo abierto y se extrajo un cálculo de 4x5 cm de diámetro. La paciente evolucionó satisfactoriamente. Conclusiones: Considérese la posibilidad de migración del dispositivo intrauterino a la vejiga con litiasis sobreañadida como causa de cistitis recurrente, en pacientes femeninas que tengan antecedente de uso de este método anticonceptivo, lo que constituye un elemento importante en el diagnóstico y tratamiento de la infección urinaria baja.
ABSTRACT Background: The intrauterine device has been used for years as a contraceptive method; a non-frequent complication after its insertion is migration out of the uterus. The bladder location and the formation of vesicolithiasis are complications associated with migration. Objective: To present a migration case from an intrauterine device to the bladder with overadded lithiasis as an unusual etiology of recurrent cystitis. Case report: Clinical case of an intrauterine device in the bladder in a 43-year-old patient, whose diagnosis was made incidentally in a recurrent cystitis study, it was diagnosed by imaging and endoscopy in the Urology consultation; surgical treatment was decided by means of open cystolithotomy and a stone 4x5 cm in diameter was extracted. The patient evolved satisfactorily. Conclusions: To consider the possibility of migration of the intrauterine device to the bladder with overadded lithiasis as a cause of recurrent cystitis in female patients who have a preceding use of this contraceptive method, thus it constitutes an important element in the diagnosis and treatment of urinary lower infection.
Subject(s)
Uterine Perforation , Urinary Bladder Calculi , Cystitis/epidemiology , Intrauterine Device Migration , Intrauterine DevicesABSTRACT
Introducción: La litiasis vesical secundaria se forma en el reservorio vesical y requiere la existencia de condiciones patológicas previas como lo son los cuerpos extraños. Objetivo: Describir dos casos clínicos de litiasis vesical secundaria a migración de un dispositivo intrauterino. Caso clínico: Se presentan dos casos de migración intravesical de dispositivo intrauterino con litiasis vesical secundaria. Se diagnosticaron años después de su inserción, ante la aparición de dolor pélvico, cistitis a repetición y hematuria. La laparoscopia no fue útil para su diagnóstico. En consulta de Urología la ultrasonografía y la radiografía de pelvis fueron herramientas diagnósticas útiles ante la sospecha inicial de esta patología. Presentaron buena evolución y regresión total de los síntomas tras cistolitotomía suprapúbica. Conclusión: Se debe pensar en la posibilidad de migración de un dispositivo intrauterino a vejiga ante la cronicidad de síntomas urinarios irritativos bajos en toda mujer que emplee este método anticonceptivo y desconozca su paradero(AU)
Introduction: Secondary bladder lithiasis is formed in the bladder reservoir and requires the existence of previous pathological conditions such as foreign bodies. Objective: To describe two clinical cases of bladder lithiasis secondary to intrauterine device migration. Clinical case report: Two cases of intravesical migration of an intrauterine device with secondary bladder stones are reported. They were diagnosed years after insertion, due to the appearance of pelvic pain, recurrent cystitis and hematuria. Laparoscopy was not helpful for its diagnosis. In Urology consultation, ultrasound and pelvic radiography were useful diagnostic tools in the event of the initial suspicion of this pathology. They showed good evolution and total regression of symptoms after suprapubic cystolithotomy. Conclusion: The possibility of an intrauterine device migration to the bladder should be considered when chronicity of irritative low urinary symptoms in every woman who uses this contraceptive method and which locations are unknown(AU)
Subject(s)
Humans , Female , Uterine Perforation/epidemiology , Laparoscopy/methods , Cystitis/epidemiology , Intrauterine Device Migration/etiologyABSTRACT
Resumen ANTECEDENTES La perforación es la complicación más temida durante la aplicación de un dispositivo intrauterino; cuando esto sucede debe retirarse el dispositivo debido al potencial riesgo de perforación y obstrucción intestinal. CASO CLÍNICO Paciente de 26 años, con trastorno del ciclo menstrual y dispareunia. La radiografía abdominal mostró el dispositivo intrauterino en posición anómala. La tomografía simple de abdomen evidenció el dispositivo en la zona intraluminal del recto, en la pared anterior, a 10 cm del esfínter anal. Se extrajo el dispositivo mediante colonoscopia. Los hallazgos intraoperatorios fueron: migración del dispositivo intrauterino, a 12 cm del margen anal, con adecuada exposición del brazo vertical. La extracción del dispositivo fue exitosa, con evolución satisfactoria de la paciente pues no hubo dolor ni alteraciones intestinales. CONCLUSIÓN La colonoscopia es una técnica diagnóstica y terapéutica efectiva en pacientes con migración del dispositivo intrauterino y afectación intestinal sin perforación, incluso puede considerarse antes de recurrir a la laparoscopia o laparotomía.
Abstract BACKGROUND Perforation is the most important complication during the application of an intrauterine device, which should be removed because of the potential risk of perforation and intestinal obstruction. CASE REPORT Female patient of 26 years of age, who presents menstrual rhythm disorders as well as dyspareunia. The tomography revealed the intrauterine device in the rectum, in the anterior wall, intraluminal, and 10 cm from the anal sphincter. It was scheduled for colonoscopy and device removal. The intraoperative findings were: migration of the intrauterine device, 12 cm from the anal margin, with adequate exposure of the vertical arm. The extraction of the device was successful. The patient had a satisfactory evolution, showed no pain or intestinal alterations. CONCLUSION Colonoscopy is a study of great help in all patients in whom migration of IUD with bowel disease without perforation and related complications is suspected, since it provides diagnostic and even therapeutic support, prior to considering a laparoscopy or laparotomy.
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ABSTRACT We report a rare case of a 67-year-old postmenopausal woman presenting diffuse peritonitis secondary to spontaneous perforation of pyometra with obstructive acute abdomen. During laparotomy was performed subtotal abdominal hysterectomy with bilateral salpingo-oophorectomy. The histopathology found the presence of moderately differentiated uterine squamous cell carcinoma. Despite intensive care, the patient died due to multiple organ failure resulting from sepsis on postoperative day 1. This case shows the importance of clinical suspicion on the acute gynecological diseases presenting as a systemic disease in the emergency room.
RESUMO Relatamos um caso raro de uma mulher pós-menopausa com 67 anos de idade, a qual apresentou como peritonite difusa secundária a perfuração espontânea de piometra com abdômen agudo obstrutivo. Durante a laparotomia foi realizada histerectomia abdominal subtotal com salpingo-ooforectomia bilateral. A histopatologia determinou a existência de carcinoma de células escamosas moderadamente diferenciado do útero. Apesar dos cuidados intensivos, a paciente veio a óbito por falência múltipla de órgãos decorrente de sepse no primeiro dia do pós-operatório. Este caso mostra a importância da suspeita clínica sobre as doenças ginecológicas agudas que se apresentam como doenças sistêmicas na sala de emergência.
ABSTRACT
Secondary abdominal ectopic pregnancy is rare in clinical practice, but may lead to an increased maternal mortality. We present the case of a patient with an abdominal pregnancy secondary to a uterine perforation caused by a voluntary attempt to interrupt pregnancy that presented with nine weeks of abdominal pain and minimal vaginal bleeding which was mistakenly diagnosed as acute pelvic inflammatory disease, urinary tract infection, and post-abortion products of conception. Finally, the abdominal ultrasound test found an abdominal ectopic pregnancy. An exploratory laparotomy was performed and the fetus and placenta were removed without difficulties with a favorable postoperative course. It was concluded that uterine perforation during curettage of the cavity went unnoticed, leading to secondary abdominal implantation of pregnancy with a inconclusive clinical presentation, where ultrasound plays a fundamental diagnostic role. Laparotomy is indicated in most of these cases.
El embarazo ectópico abdominal secundario tiene una baja frecuencia de presentación en la práctica clínica, pero puede llevar al incremento de la mortalidad materna. Se presenta el caso de una paciente con embarazo abdominal secundario a una perforación uterina, causada por una interrupción voluntaria del embarazo. Este evolucionó durante nueve semanas con dolor abdominal y sangramiento vaginal escaso. A la paciente se le realizaron diagnósticos como enfermedad inflamatoria pélvica aguda, infección del tracto urinario, restos ovulares post aborto y definitivamente se concluyó como embarazo ectópico abdominal mediante ecografía abdominal. Se le realizó laparotomía exploradora y se extrajo el feto y la placenta sin dificultades con una evolución postoperatoria favorable hacia la curación. Se concluyó que la perforación uterina durante el curetaje de la cavidad pudo pasar inadvertida, llevando a implantación abdominal secundaria del embarazo con un cuadro clínico variable. En dicho cuadro, el ultrasonido juega un papel fundamental para su diagnóstico, siendo el manejo laparotómico el más apropiado en estos casos.
Subject(s)
Abdominal Pain/etiology , Abortion, Induced/adverse effects , Pregnancy, Abdominal/diagnosis , Uterine Perforation/etiology , Adult , Diagnostic Errors , Female , Humans , Laparotomy/methods , Pregnancy , Pregnancy, Abdominal/etiology , Ultrasonography/methods , Uterine Perforation/complicationsABSTRACT
La migración de un dispositivo intrauterino a la cavidad abdominal es una complicación poco frecuente de este eficaz método contraceptivo, sin embargo debe sospecharse ante la imposibilidad de visualizar los hilos del dispositivo vía vaginal y la ausencia intrauterina del mismo por ecografía. Si bien la migración abdominal puede ser asintomática, algunos casos pueden producir clínica de severidad variable incluyendo dolor abdominal y complicaciones derivadas de la formación de adherencias o la perforación de vísceras pélvicas y abdominales. Su detección intraabdominal debe sospecharse en primer lugar por ecografía y confirmarse mediante radiología simple de abdomen. Una vez localizado el dispositivo migrado, se recomienda su extracción inmediata, incluso en casos asintomáticos, con el fin de evitar las complicaciones derivadas de su desplazamiento. La laparoscopia será de primera elección en estos casos para la extracción. Presentamos un caso de migración intraabdominal de dispositivo intrauterino concurrente a un embarazo intrauterino no evolutivo.
Migration of an intrauterine device to the abdominal cavity is a rare complication of this effective contraceptive method, however, it must be suspected upon the inability to visualize the wires vaginally and the absence of intrauterine device by ultrasound. While its abdominal migration can be asymptomatic, some cases may produce variable clinical severity including abdominal pain and complications resulting from the formation of adhesions or perforation of pelvic and abdominal viscera. Its intraabdominal detection should be suspected first by ultrasound and confirmed by plain abdominal X-ray. Once the migrated device is located, immediate removal is recommended, even in asymptomatic cases, in order to avoid complications arising from its displacement. Laparoscopy will be the first choice in these cases for extraction. We report a case of intraabdominal migration of intrauterine device concurrent with a non-evolutive intrauterine pregnancy.
Subject(s)
Humans , Female , Pregnancy , Adult , Foreign-Body Migration/surgery , Abdominal Cavity , Intrauterine Device Migration/adverse effects , Uterine Perforation/surgery , Uterine Perforation/etiology , Foreign-Body Migration/diagnostic imaging , Laparoscopy , Device RemovalABSTRACT
The rare condition of strings of a missing intrauterine contraceptive device presenting at the anus is described. Partial removal was achieved via the rectum and this was followed by a normal uncomplicated pregnancy and delivery.
PIP: Uterine perforation by an IUD has an incidence of .3-.6/1000 insertions and reported by the International Planned Parenthood Federation in 1991. A 23-year old housewife with parity of 2+0 was referred to the gynecology clinic in Trinidad with a diagnosis of a misplaced IUD that had been inserted 3 years before after the 2nd childbirth. She felt for the strings in the vagina at regular intervals but they were missing at the last check, and she indicated that they were felt at the anus. Vaginal examination showed normal vagina and cervix, a normal size retroverted and mobile uterus without adnexal masses. During rectal examination neither the strings nor the IUD could be palpated. X-ray examination confirmed the presence of a copper-7 device in the pelvis, and ultrasound showed it lying posterior to the uterus. Proctoscopy under general anesthesia identified the strings and the long arm of the Cu-7 IUD at about 6 cm from the anal margin. The transverse arm of the IUD was embedded in the rectovaginal septum. Pulling the strings did not succeed in retrieving the device whose transverse arm remained embedded after breakage following scissor dissection at the rectal mucosa. Dilatation and curettage as well as laparoscopy failed to locate the remnant arm. She was instructed about the low likelihood of any problem resulting from it. Post delivery X-ray examination after an uneventful pregnancy confirmed the presence of the retained fragment in the same position as before without displacement during pregnancy. It is probable that the route of retrograde travel of the IUD was via the cervix uteri caused by repetitive uterine contractions which pushed it though the cervix and rectovaginal septum into the rectum.
Subject(s)
Foreign-Body Migration/complications , Intestinal Perforation/etiology , Intrauterine Devices, Copper/adverse effects , Uterine Perforation/etiology , Adult , Anal Canal , Female , Humans , PregnancyABSTRACT
PIP: The article reports on the case of a 21-year old patient whose Lippes Loop D had translocated into the abdominal cavity causing uterine perforation and amenorrhea. The device was easily removed by culdoscopy, and amenorrhea, caused by the partial distruction of the endometrium, treated with hormonal therapy.^ieng
Subject(s)
Intrauterine Devices/adverse effects , Uterine Perforation/etiology , Uterine Rupture/etiology , Adult , Culdoscopy , Female , Foreign Bodies/diagnostic imaging , Humans , Pregnancy , Radiography , Uterine Perforation/surgeryABSTRACT
PIP: 2139 women wearers of IUDs were examined for a period of 3 months-10 years. Of these 480, or 22.4%, received a genital damage from the device, mostly, i.e. 97%, because of infection, and/or because of serious menstrual disorders. However, only 10.2% of the 480 cases were considered clinically important, and surgical intervention was needed in only 1.5% of cases. 39 patients, i.e. 44% became pregnant with the device in situ. Results obtained with IUDs depend in great measure on the selection of acceptors, on the exact knowledge of contraindications, on the results of a thorough gynecological examination, and on a very precise technique of insertion.^ieng
Subject(s)
Intrauterine Devices/adverse effects , Female , Genital Diseases, Female/etiology , Humans , Iatrogenic Disease , PregnancyABSTRACT
PIP: A 25 year old patient, wearer of a Lippes Loop, required removal of the device 10 months after insertion complaining of pain. Endouterine exploration, hysterometry and laparosocpy failed to detect the device. Finally laparotomy was performed and the IUD, which had perforated the uterus and the urinary bladder, was found in the vesical cavity. This occurrence is very rare; it might, however, be avoided by choosing a different IUD type.^ieng
Subject(s)
Intrauterine Devices/adverse effects , Urinary Bladder/injuries , Uterine Perforation/etiology , Uterine Rupture/etiology , Adult , Female , Humans , PregnancyABSTRACT
PIP: This study evaluates the safety of female sterilization done by laparoscopy in the postabortion, postpartum, or interval period. The study was conducted by the International Fertility Research Program in collaboration with 3 medical institutions on 833 women sterilized in the interval period, 108 women sterilized postabortion, and 161 women sterilized postpartum. Average age in the 3 groups was 29.6, 31.8, and 33.1, respectively; average number of live children was 3.9, 3.3, and 5.6, respectively. The large majority of women were married, and most returned for follow-up 7-21 days after the operation. The group of women sterilized in the interval period had the lowest percentage of complications, about 5%, followed by women sterilized postabortion, 10%, and by women sterilized postpartum, 11%. A group of women undergoing abortion without sterilization had a complication rate of 7%. More importantly, in the interval sterilization group there were no important complications, such as uterine perforations, cervical lacerations, or burns. The 4 cases of uterine perforation were all in the postabortion sterilization group. None of the patients in the interval sterilization group required hospitalization, as compared to 4.7% in the postabortion group, and to 61.5% in the postpartum group. Studies are needed to ascertain whether the risk of complications after postpartum or postabortion sterilization are greater than those after simple abortion or simple term delivery.^ieng
Subject(s)
Laparoscopy/methods , Sterilization, Tubal/methods , Abortion, Spontaneous , Adult , Female , Humans , Laparoscopy/adverse effects , Postpartum Period , Pregnancy , Sterilization, Tubal/adverse effectsABSTRACT
PIP: 1265 cases of emergency peritonoscopy were performed in Havana from 1966-1971, including 54.5% gynecology, 17.6% gall gladder, 7.9% appendicitis, 2.6% liver abcess, and about 1% each hemoperitoneum, pancreatitis, and peptic ulcer cases. There were 4.7% normal abdomens and 2.5% incorrect diagnoses. In gynecology, 230 were ectopic pregnancies, of which 32 were diagnosed before tubal rupture. Other common findings were ovarian cysts, perforated uterus, and infections. The gall bladder, appendicitis, and pancreatitis cases are described in detail, but the remaining categories are only summarized briefly. Emergency peritonoscopy is not usually dangerous, and can often avoid exploratory laparotomy.^ieng
Subject(s)
Diagnosis , Evaluation Studies as Topic , Infections , Laparoscopy , Pregnancy, Ectopic , Uterine Perforation , Americas , Caribbean Region , Cuba , Developing Countries , Disease , Endoscopy , Latin America , North America , Physical Examination , Pregnancy ComplicationsABSTRACT
PIP: Statistics on the indicence of ectopia (displacement) of Lippes loop vary significantly by author; from .5/1000 to 6.81/1000 insertions. It is not clear whether ectopia occurs as a result of uterine perforation or of progressive migration. In all reported cases, however, hysterography was used to investigate. 50 patients from a control group of 1064 active Lippes D users chosen from the Family Planning Center of the San Camilo Hospital in San Felipe were studied between 1965-1969. Observations were made using x-ray and hysterography at 10 days, 1 month, 3 months, 6 months, and 1 year or more after insertion. Also studied were some of the characteristics of the loop and techniques for its insertion. In the 50 patients the device was found to be out of place in 6 (an ectopia rate of 5.6/1000 insertions), in a normal position in 30, and in an abnormal one in 14 (the distal part near or across the neck). All the ectopia was observed in patients between 20-34 years who had had 2-5 births. Those with 7-13 births did not seem to be prone to the complication. 8 of the 50 had a retroflexed uterus and 2 of those were displacement cases, suggesting that anomaly of position could be a predisposition for ectopia. Incidence of displacement was not found to vary significantly with doctor. None of the ectopic cases had severe side effects (pain or heavy bleeding) after insertion. In each case displacement was found to have occurred between 1 week and 6 months postinsertion, 2 of them within 2 weeks. It is probably that the later diagnosis of the others was due to the patient not having noticed the disappearance of the threads. It is concluded that ectopia is due to uterine perforation and not to progressive migration. The different positions in which the device was found when it was removed by laparotomy indicated that such perforation was due to the structure of the device and the resistance of the uterine cavity. Through modification of the loop this complication could be avoided. Disappearance of the threads did not necessarily mean that ectopia had occurred, but it was an important sign, especially if it occurred early on after insertion. With respect to abnormally positioned devices, it was not thought to be a reason for IUD removal, espcially since the abnormal positioning was found to have occurred in every case in an abnormally positioned uterus.^ieng