Intrauterine device penetrates gastric wall: Case describes rare complication

Zhao et al reported a novel case of an IUD penetrating the gastric wall with symptoms resembling a peptic ulcer, requiring a laparoscopic partial gastric resection in Contraception Journal.

The patient, a 31-year-old gravida 2 para 2 woman, presented with complaints of intermittent epigastric pain for 2 years. Eleven years prior, she underwent a "pi"-shaped copper bearing IUD placement 14 months after her first full-term delivery while still lactating; during and after the process, she denied severe or persistent pelvic pain or any other complaints.

One month after placement, her doctor performed an ultrasound examination during her well-women exam which demonstrated no IUD and a normal 2 weeks intrauterine pregnancy; the doctor diagnosed IUD expulsion.

She delivered vaginally at 41 weeks 3 days gestation and had another IUD of the same type placed postpartum.

Two years prior to the team's evaluation, she reported new onset epigastric pain and was treated with amoxicillin, omeprazole and metronidazole for presumed peptic ulcer complicated with Helicobacter pylori infection.

Six months prior, the patient again experienced severe pain in the left upper abdomen.

One month prior, a "pi"-shaped radio-opaque object in the upper abdomen was incidentally found by X-ray examination for a lumbar lesion and the patient was transferred to Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China.

• Abdominal computed tomography showed the object penetrating the gastric wall .
• Gastroscopy revealed a local protuberance of the gastric wall at the same site.
• The findings represented a perforated and displaced IUD with gastric wall penetration.

The team performed a laparoscopic partial gastrectomy which included the IUD as suspected. Additionally, a weak area at the uterine fundus was found. The patient had an uneventful postoperative course.

"A known but rare complication of IUD placement includes uterine perforation and migration to adjacent organs like bladder, lower urinary tract, and rectum; however, penetration of the gastric wall and symptoms resembling a peptic ulcer have not yet been reported. The incidence of uterine perforation in lactating women within 36 weeks after delivery of 4.8/1000 is approximately 4-fold higher than the overall perforation risk, which may be related to low estrogen levels during the lactation period.

In this case, the originally suspected uterine expulsion was actually a uterine perforation. Although IUDs have been reported in the upper abdomen following perforation, it was suspected that the elevation of the uterine fundus during the ensuing pregnancy may have also elevated the perforated IUD to the upper abdomen.

Notably, the patient lacked any symptoms for many years, which implies that gastric wall penetration occurred gradually over time. It is possible that the unique structure of this IUD may have contributed to penetration of the gastric wall, causing symptoms resembling a peptic ulcer.

In this case, the initial assumption of expulsion was never fully evaluated to exclude perforation. Even if radiological examination is not suitable during pregnancy, abdominal ultrasound can be an appropriate choice and abdominal X- ray can be performed after delivery. A completed evaluation after delivery in this patient may have allowed for simple laparoscopic retrieval years earlier and avoided the need for partial gastrectomy."

Source: https://doi.org/10.1016/j.contraception.2021.01.006 0010-7824/© 2021