{"paper_id":"f15ca12a-35ca-458a-8757-54bf6222dbd7","body_text":"47\nMDEDGE.COM/FAMILYMEDICINE\nPHOTO ROUNDS\nVOL 70, NO 1  |  JANUARY/FEBRUARY 2021  |  THE JOURNAL OF FAMILY PRACTICE\nPelvic pain\nWhen a complete metabolic panel offered no clues, we \nturned to imaging. And that’s when we had our diagnosis.\nWilliam Terrill, MD;  \nCassie Tran, MD;  \nDon Nguyen, MD, MHA \nAllegheny Health Network, \nPittsburgh, PA \n william.w.terrill@gmail.com\nDEPARTMENT EDITOR\nRichard P . Usatine, MD\nUniversity of Texas Health  \nat San Antonio\nThe authors reported no potential \nconflict of interest relevant to this \narticle.\ndoi: 10.12788/jfp.0129\na 34-year-old woman with no significant \npast medical history presented as a new \npatient to our family medicine clinic with  \n2 weeks of intermittent lower abdominal and \npelvic pain. She was sexually active with 1 part-\nner and denied abnormal vaginal discharge or \nbleeding. She mentioned she’d had an intra-\nuterine contraceptive device (IUD) placed a \nfew weeks ago. The patient was afebrile, and \nher pelvic examination was unremarkable. \nPhysical examination showed mild ten-\nderness to palpation over the lower abdomen \nwithout rebound tenderness or guarding.  \nA complete metabolic panel revealed no sig-\nnificant abnormalities, and her human chori-\nonic gonadotropin levels were normal. \nFindings from the physical exam and her \nclinical history prompted the need for imaging. \nAn abdominal radiograph (FIGURE 1) and non-\ncontrast computed tomography ( FIGURES 2A \nAND 2B) were subsequently ordered. \n●  WHAT IS YOUR DIAGNOSIS?\n●  HOW WOULD YOU TREAT THIS \nPATIENT?\nFIGURE 1\nAbdominal radiograph reveals  \na nonobstructive bowel gas pattern— \nand something else\nIMAGES COURTESY OF DON NGUYEN, MD, MHA\n\n48\nTHE JOURNAL OF FAMILY PRACTICE  |  JANUARY/FEBRUARY 2021  |  VOL 70, NO 1\nPHOTO ROUNDS\ngenerally well tolerated, with minimal adverse \neffects or complications. In a multicenter ret-\nrospective chart review of 2138 patients who \nhad IUDs, Aoun et al found that serious com-\nplications included pelvic inflammatory dis -\nease (2%), IUD expulsion (6%), and pregnancy \n(1%).1 In a retrospective cohort study examin-\ning complications among 90,489 women with \nIUDs, Berenson et al found ectopic pregnancy \nand uterine perforation affected < 1%.2 \nA less serious complication is IUD mal-\npositioning. Although it does seem to occur \nmore often than other, more serious compli-\ncations, the exact incidence is unknown. In a \nretrospective case-control study, Braaten et al \nreported the rate for IUD malpositioning was \n10.4% among 182 women. 3 Malpositioned \nIUDs may be more likely to occur in those \nwith suspected adenomyosis. 3 In a study by  \nde Kroon et al, the estimated prevalence rate \nfor an abnormal IUD position ranged from 4% \nto 7.7% among 195 patients.4\nThe clinical presentation  \nof IUD migration \nIdentification of a malpositioned IUD is \nneeded to avoid the possible increased risk \nfor uterine perforation, IUD expulsion, or \npregnancy.5\nIUDs that have perforated the uterus float \nfreely in the pelvis or abdomen and can re-\nDx: Intra-abdominal  \nIUD migration\nThe abdominal radiograph revealed a non-\nobstructive bowel gas pattern with an IUD \noverlaying the central lower abdomen and \npelvis at the L5-S1 level (FIGURE 1 ). Computed \ntomography (CT) of her abdomen and pelvis \nshowed that the IUD was outside the endome-\ntrial cavity (FIGURES 2A AND 2B ). There was no \nevidence of pneumoperitoneum or bowel per-\nforation. Based on the work-up and imaging, \nthe patient’s pain was due to intra-abdominal \nIUD malpositioning. \n❚ Diagnostic criteria for IUD malpo-\nsitioning include device migration into 1 of \nseveral locations, such as the lower uterine \nsegment or cervix. IUD malpositioning can in-\nvolve the rotation or protrusion of the device \ninto or through the myometrium. On imaging, \na well-positioned IUD should have a straight \nstem contained within the endometrial cavity, \nwith the arms of the IUD extending laterally at \nthe uterine fundus. \nFor our patient, an abdominal radiograph \nshowed that her IUD was superiorly displaced \noutside the expected region of the endome-\ntrial cavity. CT helped to confirm this. \nComplications with IUDs are few\nUsing an IUD is an increasingly popular meth-\nod of contraception because it is effective and \nFIGURE 2 \nCT scans of the abdomen (A) and pelvis (B) showed  \nan IUD outside the endometrial cavity\nBA\n\n49\nMDEDGE.COM/FAMILYMEDICINE VOL 70, NO 1  |  JANUARY/FEBRUARY 2021  |  THE JOURNAL OF FAMILY PRACTICE\nFor \nasymptomatic \npatients with an \nIUD in the lower \nuterine segment \nand above the \ninternal cervical \nos, consider \nleaving the IUD \nin place.\nsult in injury to adjacent structures as well as \nperitonitis, fistulas, and hemorrhage.5-7 In ad-\ndition, adhesion formation over the IUD can \nlead to intestinal obstruction, infertility, and \nchronic pain.6 \n❚ Common symptoms of IUD malposi-\ntioning include abdominal or pelvic pain and \nabnormal bleeding, although many patients \nmay be asymptomatic. 8 In a retrospective \nstudy of 167 patients with IUDs who under -\nwent pelvic ultrasound, 28 patients were \nfound to have an IUD in an abnormal posi-\ntion.8 Rates of bleeding and pain were higher \nin patients with malpositioned IUDs (35.7% \nand 39.3%, respectively) than in those with a \nnormally positioned IUD (15.1% and 19.4%, \nrespectively).8 \nThe differential Dx includes \nendometriosis and fibroids\nIUD malpositioning can be distinguished \nfrom other diagnoses that cause pelvic pain \nand have similar presentations—including \nendometriosis, ectopic pregnancy, and fi-\nbroids—through imaging study findings, clini-\ncal history, and presentation. \nOther conditions that may need to be \nruled out include pelvic inflammatory disease, \nacute appendicitis, and ovarian cysts.9 A thor-\nough history and physical examination can \nhelp rule out these conditions by organ sys -\ntem, and laboratory and imaging studies can \nhelp to confirm the diagnosis.\nWhich imaging tool  \nto use, and when\nAssessment of intrauterine contraception \nplacement requires evaluation of the uterine \ncavity; gynecologic examination alone is not \nsufficient to fully evaluate for IUD position. \nCertain imaging studies are particularly help-\nful for revealing possible IUD migration. \n❚ Ultrasound—a widely available, radi-\nation-free modality—is the first-line imag-\ning tool for evaluation of an IUD’s position. 10 \nIn addition, ultrasound can provide effective \nevaluation of other pelvic structures, which \nis helpful in identifying or eliminating other \ncauses of pain or abnormal bleeding. \n❚ Conventional radiography. If the IUD \nis not visualized on ultrasound, the American \nCollege of Obstetricians and Gynecologists \n(ACOG) recommends radiography to deter -\nmine if the IUD has been expelled or has mi-\ngrated to an extra-uterine position.6 \n❚ CT may be best suited for the evalua-\ntion of more severe complications of IUD mal-\npositioning, including visceral perforation, \nabscess formation, or bowel obstruction. CT \nshould be considered if the patient’s clinical \npresentation is suspicious for a more serious \nintra-abdominal pathology. \nManagement depends \non the IUD’s position\nFor patients whose IUD has an uncertain po-\nsition or nonvisualized intravaginal strings, \nACOG’s first-line recommendations include \nruling out pregnancy, using an alternative \nmethod for contraception, and ordering pelvic \nultrasonography.6 ACOG recommendations \nfor the management of IUD malpositioning \ndepend on the device’s location and the pa-\ntient’s symptomatology. \n❚ Management of low-lying IUDs  is \ncomplex. An IUD that is malpositioned in the \ncervix is considered partially expelled and \nshould be completely removed. 6 For asymp-\ntomatic patients with an IUD located in the \nlower uterine segment and above the inter -\nnal cervical os, there should be strong con-\nsideration given to leaving the IUD in place \nbecause removal is associated with higher \nrates of pregnancy given the low rates of ini-\ntiation of effective contraception following \nremoval.6 \nIUD malpositioning in the peritoneal cav-\nity requires surgical intervention. Although \nACOG’s first-line recommendation is laparo-\nscopic intervention, laparotomy can be con-\nsidered if laparoscopy does not result in the \nremoval of the IUD or the patient has more \nsevere complications (sepsis or bowel perfora-\ntion).6 At the time of IUD removal, the clinician \nshould also discuss and/or prescribe interim \ncontraception. \n❚ Treatment for our patient included \nuncomplicated laparoscopic surgical remov-\nal of the intra-abdominal IUD. The patient’s \nsymptoms went away following the procedure, \nand she was subsequently switched to an oral \ncontraceptive.                 JFP\nCONTINUED\n\nPHOTO ROUNDS\nReferences \n 1.   Aoun J, Dines VA, Stovall DW, et al. Effects of age, parity, and de-\nvice type on complications and discontinuation of intrauterine \ndevices. Obstet Gynecol. 2014;123:585-592.\n 2.   Berenson AB, Tan A, Hirth JM, et al. Complications and continu-\nation of intrauterine device use among commercially insured \nteenagers. Obstet Gynecol. 2013;121:951-958. \n 3.   Braaten KP , Benson CB, Maurer R, et al. Malpositioned intra-\nuterine contraceptive devices: risk factors, outcomes, and future \npregnancies. Obstet Gynecol. 2011;118:1014-1020.\n 4.   de Kroon CD, van Houwelingen JC, Trimbos JB, et al. The value of \ntransvaginal ultrasound to monitor the position of an intrauter-\nine device after insertion. A technology assessment study. Hum \nReprod. 2003;18:2323-2327.\n 5.   Thonneau P , Almont T , de La Rochebrochard E, et al. Risk factors \nfor IUD failure: results of a large multicentre case-control study. \nHum Reprod. 2006;21:2612-2616.\n 6.   ACOG Committee on Gynecologic Practice. Committee Opinion \nNo 672: clinical challenges of long-acting reversible contracep-\ntive methods. American College of Obstetricians and Gynecolo-\ngists. Obstet Gynecol. 2016;128:e69-e77.\n 7.   Heinemann K, Reed S, Moehner S, et al. Risk of uterine perfora-\ntion with levonorgestrel-releasing and copper intrauterine de-\nvices in the European Active Surveillance Study on Intrauterine \nDevices. Contraception. 2015;91:274-279. \n 8.   Benacerraf BR, Shipp TD, Bromley B. Three-dimensional ultra-\nsound detection of abnormally located intrauterine contracep-\ntive devices which are a source of pelvic pain and abnormal \nbleeding. Ultrasound Obstet Gynecol. 2009;34:110-115.\n 9.   Bhavasr AK, Felner EJ, Shorma T . Common questions about the \nevaluation of acute pelvic pain. Am Fam Physician. 2016;93:41-48. \n 10.   Peri N, Graham D, Levine D. Imaging of intrauterine contracep-\ntive devices. J Ultrasound Med. 2007;26:1389-1401.\n50 THE JOURNAL OF FAMILY PRACTICE  |  JANUARY/FEBRUARY 2021  |  VOL 70, NO 1\nPRACTICE  \nOPPORTUNITIES\n    Please contact Tim LaPella to inquire about classified advertising in The Journal of Family Practice (circulation: 95,000).  \nDisplay rates are available, with a discount for frequency. Per word rate for line ads is $5.25. Phone 484-921-5001. Fax 484-921-5005.  \nE-mail: tlapella@mdedge.com. Visit our Web site at mdedge.com/familymedicine; visit MedJobNetwork.com.\nPOSITIONS AVAILABLE\n309554\nJFP_0121_Classifieds_new.indd   50 1/19/21   9:48 AM\n50 THE JOURNAL OF FAMILY PRACTICE  |  JANUARY/FEBRUARY 2021  |  VOL 70, NO 1","source_license":"CC0","license_restricted":false}