Appendix perforation by an intrauterine contraceptive device

Perforation of the uterus by an intrauterine contraceptive device (IUD) is a rare, and serious complication, occurring in 1/350 to 1/2500 insertions. Perforation by IUDs can involve several neighboring organs such as the bladder and rectosigmoid. We report two cases of IUD perforations involving the appendix, both inserted during lactation. The first case is an asymptomatic patient in early pregnancy and the second is a woman whose original presentation was chronic lower abdominal pain. The presence of copper in the abdominal cavity can lead to adhesion formation and subsequent abdominal pain, bowel obstruction or infertility. Thus, we believe that when an IUD is located in the abdominal cavity it should be removed even in an asymptomatic patient. In addition, these cases might suggest postponing the use of this contraceptive method in lactating women.     

Perforation of uterus of Lippes loop (a case report)

Perforation of the uterus by the Lippes loop (a rare complication, frequency .6 per 1000) is described in 1 case where after repeated attempts at removal, the IUD was found in the abdomen embedded in the omentum and on the anterior surface of the uterus. Perforation usually occurs while introducing an IUD, but may also be due to improper removal or to erosion by the device and migration through the uterine wall. Patients usually complain of crampy pain with menorrhagia or spasmodic colicky pain with low backache, and may develop an acute abdominal emergency. However, in many cases where the loop has entered the peritoneal cavity, adhesions were minimal and neither peritonitis nor intestinal obstruction requiring immediate laparotomy were present; these facts support the advantages of the loop for mass programs.     

Surgical glove perforation in obstetrics

Perforation of surgical gloves places the obstetrician at risk for blood-borne infectious diseases. Seven hundred fifty-four surgical gloves used in vaginal and cesarean deliveries and postpartum tubal ligations were examined for evidence of perforation by the air inflation-water submersion technique. The overall glove perforation rate was 13.3%, with 62% of the perforations remaining unrecognized during the surgical procedure. The majority of perforations occurred on the fingers of the nondominant hand. Multivariate analysis with logistic regression indicated that cesarean delivery (odds ratio 3.52), any vaginal laceration or episiotomy (odds ratio 4.95), and chief resident status (odds ratio 3.00) were the major risk factors for surgical glove perforation. Surgical technique by assistants, especially in complex cases, is as important as that of the primary surgeon in regard to glove perforations.     

Vaginal removal of the pedunculated submucous myoma. Historical observations and development of a new procedure

A new method of vaginal removal of submucous fibroids was attempted on 151 patients. The procedure involves dilation of the cervix with Laminaria tents and removal of the submucous fibroid by grasping with appropriate instruments. Myomas were removed successfully in 92% of the patients; hysterectomy and abdominal myomectomy were avoided in all but four of them. Perforation occurred in two patients. Morbidity was minimal. The four patients who desired pregnancy conceived.     

Uterine perforation with intrauterine contraceptive devices. Review of the literature and cases reported to the National Committee on Maternal Health

The National Committee on Maternal Health reported on 28 cases of pe rforation of the uterus in a total of 16,338 first insertions of IUDs after confinement, an incidence of 1.7 perforations per 1000 insertions. 20 of the perforations followed the insertion of a bow. 16 of these occurred in patients less than 12 weeks postpartum. With the bow there is a highly significant correlation between the perforation rate and the number of weeks postpartum, especially if no menses have occurred. The perforation rate after 12 weeks postpartum for the bow is 2 per 1000 insertions. This is less than the perforation rate of 3.23 per 1000 found in a collected series of 77,903 curettages. The high perforation rate for the early postpartum insertions indicates that softness and friability of the uterus is a greater factor in the etiolog y of the perforations than the type of introducer employed. Perforation s with other devices are difficult to determine because of the lack of accompanying symptoms and the presence of a tail protruding through the cervix. Care in examining the patient, judicious timing of insertion, the use of a tenaculum, traction to straighten flexion deformities of the uterus, sounding the uterus, and gentleness during the introduction and ejection of the device into the uterus should greatly reduce the incidence of uterine perforation.     

Risk of uterine perforation during hysteroscopic surgery

STUDY OBJECTIVE: To evaluate the rate of uterine perforation during different operative hysteroscopy procedures. DESIGN: Observational study (Canadian Task Force classification II-2). SETTING: Department of Obstetrics and Gynecology, La Conception Hospital, Marseille, France. PATIENTS: One thousand nine hundred fifty-two women. INTERVENTION: Of 2116 operative hysteroscopies performed, there were 623 endometrectomies, 782 myoma resections, 422 polyp resections, 199 adhesiolyses, and 90 uterine septa sections. MEASUREMENTS AND MAIN RESULTS: Risk of perforation was evaluated according to hysteroscopic procedure. Severity of complications were also noted. In case of perforation, a management protocol was applied to prevent metabolic disorders and pelvic infections. Thirty-four perforations (1.61%) were reported. In 33 cases (97%) it was realized during the procedure and no complications occurred during follow-up. One perforation with hemorrhage was misdiagnosed during the intervention and required laparotomy. Perforation risk was higher during hysteroscopic adhesiolysis than during other procedures [endometrial ablation RR 9.39 (3.46-25.52), p <0.0001; uterine septa section RR 6.78 (0.91-50.6), p = 0.026; polyp RR 8.52 (2.60-30.80), p <0.0001 or myoma resection RR 7 (2.83-17.62), p <0.0001]. Perforation risk was comparable during endometrial ablation, uterine septa section, and polyp or myoma resection (p = 0.93). CONCLUSION: Perforation risk is higher during synechiolysis than in other indications for hysteroscopy. Severe complications are rare but may be avoided if precautions are taken.     

Perforation of uterus by Lippes loop (a case report)

A case report of a perforation by a Lippes Loop with pregnancy of 12 weeks duration is presented. A patient was presented with no pain, menstrual disturbances, or other symptoms; she had experienced severe brief epigastric pain at insertion, 8 months previously. At laparotomy the loop was visualized under the anterior leaf of the broad ligament; a hysterotomy, sterilization and removal of the IUD followed. Mechanism of action of IUD is reviewed. The incidence of loop perforation is not precisely known, although it occurs most often at insertion. The Birnberg Bow had the highest number of perforations. A list of references discussing perforation with each type of IUD is given. Perforation occurs more frequently in the soft recently pregnant uterus (this patient's youngest child was 2 1/2), with springed inflexible inserter, and if not discovered soon after it occurs, pregnancy rapidly follows. A review of cases of perforation is given. Removal of a loop which has been displaced into the peritoneal cavity is recommended.     

Frequency of glove perforation and the protective effect of double gloves in gynecological surgery

The purposes of this prospective study were to verify the frequency of glove perforation during gynecological operations and to evaluate the efficacy of double gloving in preventing damage to the inner glove. From May 2000 to May 2001, three house staff and 12 residents were asked to place their used gloves in bags labeled with the following information: procedure performed, presence of a recognized glove perforation, and role in operating team (surgeon, first or second assistant, and instrumentalist). All glove sets were tested using the method of water pression. Damaged gloves were excluded from that analysis. In all, 35 and 51 operations were utilized with single and double gloves, respectively. There were 240 single gloves and 792 double gloves tested. Perforation occurred in 10.4% of the single gloves and 9.8% of the outer double gloves. There were no cases of perforation in the inner double gloves. In cases of operating time that lasted more than 2 h, 56% of the surgeries that used single gloves had perforation vs 58.5% of the double gloves. The first assistant had the major risk for glove perforation with the use of single or double gloves. The indicator finger of the non-dominant hand was the major risk for perforation. In conclusion, we recommend double gloving in all gynecological surgery to reduce the risk of contracting blood-borne diseases.     

Diagnostic et prise en charge des perforations utérines par dispositif intra-utérin : à partir de 11 cas

ObjectiveIntrauterine device insertion is common. It is however not harmless and uterine perforation can be serious.Patients and methodsEleven cases of uterine perforation after intrauterine device insertion were listed at Tourcoing hospital between 2005 and 2009. They were analyzed to identify risk factors of uterine perforation and specify management.ResultsThe main symptom was pelvic pain (4 cases), pregnancy occurrence (3 cases) or unability to remove the IUD (2 cases). The intrauterine device was set during the first 9 months of post-partum in 7 cases, 2 patients were still breastfeeding. Seven patients underwent laparoscopy, 2 needed switch for laparotomy, one was treated by laparotomy only and one was lost of follow-up.Discussion and conclusionIncidence of uterine perforation after IUD insertion ranges from 0,1 to 3/1000. Pelvic pain is the most revealing symptom. Fifteen percent of perforations complicate with adjacent organ lesion. Perforation incidence seems greater if the intrauterine device is set during the 6 first weeks of post-partum and breastfeeding, but non influenced by operator practical experience. Ultrasound follow-up of patients carrying intrauterine device is controversial. Facing a suspicion of ectopic intrauterine device, pelvic ultrasound examination is the first step imaging modality and using 3D could be useful. If it fails to localize the intrauterine device, an abdominal X-ray must be performed. Ectopic intrauterine device removal is recommended.     

Adenocarcinoma of the appendix in pregnancy: a case report

BACKGROUND: Perforation of an adenocarcinoma of the appendix in a pregnant woman is rare and may present as a pelvic mass and acute appendicitis. CASE: A 30-year-old woman, gravida 3, para 2-0-0-2, presented at 26 weeks' gestation with an acute abdomen, right-sided pelvic mass and uterine contractions. Tocolysis and prompt surgical exploration revealed a perforated appendix. The patient underwent a right hemicolectomy with primary anastomosis, her postoperative course was benign, and she delivered a viable infant at term vaginally. Pathology revealed a perforated adenocarcinoma of the appendix. The patient was free of disease at 36 months. CONCLUSION: Adenocarcinoma of the appendix in pregnancy is rare, may present as an acute abdomen with a mass and is managed with right hemicolectomy.     

Urinary bladder perforation in a very low birth weight infant. A case report

Perforation of the urinary bladder is a rare complication with a considerable degree of morbidity and mortality in modern neonatal intensive care units. We report a case of urinary bladder perforation, which probably was triggered by prolonged urinary retention secondary to morphine infusion, using credé maneuver on an already over-distended bladder, and inserting an umbilical catheter as urethral catheterization in an extremely low birth weight infant.     

Urachal sinus perforation during laparoscopy. A case report

A patent urachal sinus, as well as other urachal anomalies, may complicate laparoscopy. Perforation of such a sinus occurred during laparoscopy. Laparotomy or repeat laparoscopy may be necessary to excise the urachal anomaly.     

Gastrointestinal perforations in the neonatal period

Forty-eight neonates were treated for gastrointestinal perforation during a 9-year period. In 30, perforation occurred within the first week of life. Thirty-six were preterm infants and many had a history of obstetric and postnatal complications. Perforation resulted from necrotizing enterocolitis in 26 patients, whereas in 14 neonates spontaneous perforation occurred in an apparently normal bowel, with no evident cause (idiopathic perforation). In 6 patients perforation was associated with meconium ileus. Primary closure was carried out for perforations of the duodenum and stomach. Intestinal perforations were usually treated by resection and enterostomies. The overall mortality rate in this series was 46%. The highest mortality rate was associated with necrotizing enterocolitis (62%). The mortality rate was only 14% in patients with idiopathic perforation. Despite improvement in the prognosis of neonatal gastrointestinal perforations in recent years, it is still discouraging, reflecting the difficulty in preventing and treating necrotizing enterocolitis.     

Uterine perforation by intrauterine contraceptive devices: diagnosis and treatment. Report of a case

The reported incidence of IUD perforation ranges from .05/1000-8.7/1000 insertions and probably occurs at the time of insertion. Perforation is more frequent in cases of extreme antiflexion or retroflexion of the cervical canal and is more likely to occur in the presence of a tight cervical os. In diagnosis it is necessary to distin guish between unnoticed expulsion, ascent of the tail into the cavity, and perforation. Pregnancy may exist in any of these conditions. Biman ual palpation may allow detection of the ectopic IUD. Exploration of the cavity with a uterine sound or electrical amplification is the next step. If the device is still undetected, radiography with a uterine sound in place following the instillation of radioopaque dyes, or following the insertion of a 2nd device, is recommended. Removal of the device may be done by colpotomy, laparotomy, or laparoscopy and may be accompanied by abortion or sterilization. A case report of a 30-year-old nulligravida inserted with a Lippes loop who had a subsequent pregnancy is reported. At the time of therapeutic abortion the IUD was absent from the uterine cavity. X-rays revealed the loop superior to the uterine corpus. Under general anesthesia a laparoscopy was performed and the IUD located lying on the fundus with the nylon tail buried in the myometrium.     

Laparoscopic Removal of a Retroperitoneal Hysteroscopic Microinsert Using Fluoroscopy

Perforation during placement of hysteroscopic microinserts for permanent sterilization occurs in approximately .9% to 2.6% of women undergoing the procedure. Most of the time perforation results in intraperitoneal placement of the hysteroscopic microinsert requiring laparoscopy or laparotomy for removal of the device. Herein we present a case of hysteroscopic microinsert perforation with subsequent retroperitoneal identification of the device. This is the first such case to our knowledge of retroperitoneal identification and retrieval of a perforated device that required real-time fluoroscopy during laparoscopy.     

Problems of peritoneal access in intraperitoneal treatment and monitoring of ovarian cancer

Summary. A total of 154 peritoneal lavages was attempted through either a permanent (17) or a temporary percutaneous cannula (137) in 59 ovarian cancer patients undergoing intraperitoneal treatment or monitoring. Seven of the eight permanent catheters were removed because of complications; intraperitoneal adhesions were a major problem in this group. Overall, 137 temporary catheters were inserted (14G Venflon i. v. cannula in 119, Verres needle in 15, and a Trocath peritoneal dialysis catheter in 3 instances) but it was not possible to perform a peritoneal lavage in 42 (30%). Access to the peritoneal cavity was unsatisfactory on 29 (34%) occasions when a Venflon cannula was used, either because there was inadequate flow of lavage fluid into the peritoneal cavity or this was limited by pain. Perforation of the bowel occurred in 12 (9%) cases but there was no significant morbidity. Problems with achieving reliable peritoneal access using either permanent or temporary catheters may limit the potential advantages of the intraperitoneal route for treatment and monitoring.     

Hepatic abscess due to gastric perforation by ingested fish bone demonstrated by computed tomography.

Perforation of the gastrointestinal tract by ingested foreign bodies is rare. Preoperative diagnosis of complications due to foreign bodies in the gastrointestinal tract can rarely be achieved because the conventional radiographic appearance is nonspecific. This report describes a 69-year-old woman who presented with vague clinical manifestations, intermittent abdominal pain, and low-grade fever. Hepatic abscess, secondary to a foreign body penetrating the gastric wall, was diagnosed preoperatively using computed tomography findings. On exploration, the foreign body turned out to be a fish bone. The abscess was confirmed and drained during surgery and a partial gastrectomy was performed. This case illustrates the value of CT in the evaluation of this condition.     

Perforation of the uterus

Perforation of the uterus following intrauterine manipulation usually occurs when pregnancy is the motivating factor for such manipulation, and is probably due to the extreme softness and bogginess of the gravid uterine wall. When it occurs accidentally under aseptic conditions, it does not appear to be a major complication providing extrauterine trauma has not occurred, and is treated expectantly with maximal antibiotic therapy to prevent spread of infection. When perforation occurs in the course of a criminal instrumentation, such perforation can usually be recognized and diagnosed at a later time by the presence of a small tender area close to the uterus which is coupled with tenderness on motion of the cervix. Patients with this diagnosis should not be subjected to curettage, but should be allowed to complete the abortion spontaneously. If extrauterine damage is suspected or diagnosed, laparotomy for the repair of such damage is essential at the earliest possible moment. If infection, other than parametritis, has developed as the result of perforation, antibiotic therapy is relatively useless, and gives a false sense of improvement. The procedure found most beneficial is the surgical removal of the infected genital tract together with splitting of the cervix for drainage.     

Anatomic and clinical correlates of uterine perforation.

We reviewed cases of uterine perforations which occurred at or were referred to the Boston Hospital for Women, Lying-In Division, over the 2 year period from mid-1975 to mid-1977. There were 25 uterine perforations; twenty patients were pregnant and five were not. In the pregnant patients, 16 perforations involved the cervix or the lower uterine segment, whereas only four were located in the uterine fundus; in the nonpregnant patients, all five were fundal perforations. In the pregnant patients, 12 required laparotomy, eight had serious lacerations of the uterine artery, and three had hysterectomy while none of the nonpregnant patients had lacerations or required subsequent procedures. Thus, there is a significant anatomic difference between those perforations which occurred in the pregnant patients and in the nonpregnant patients, the manner in which they presented clinically, and the need for intervention via laparotomy, subsequent morbidity, and outcome as reflected in future reproductive capability. Perforation at or near the cervix may be more common than previously assumed. Furthermore, two distinct clinical entities of cervical perforation exist in pregnant patients as based on the anatomic location of the defect. The anatomy of cervical perforations, their recognition, and their management are discussed.