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Migrated intra-uterine device to infra-umbilical skin: a rare case report

BMC Women's Health volume 24, Article number: 672 (2024) Cite this article

Abstract

Introduction

IUDs are effective, reversible and safe methods of contraception. The mechanism of action of IUDs as a group is inducing endometrial atrophy, apoptosis, altering tubal motility; preventing sperm permeability, fertilization, and implantation. Complications of IUD include menstrual disturbance, pelvic pain, and increased risk of ectopic pregnancy with contraceptive failure, device expulsion, uterine perforation or transmural migration with misplacement of the device. Pregnancies and IUD migration are uncommon complications, occurring in 1 to 2 from 1,000 users. The clinical presentation of migrated IUDs depends on the final anatomic location at diagnosis. Migration can be asymptomatic and incidentally found while imaging for any other diagnosis or may have various acute clinical presentations.

Case Presentation

We present the case of a 38-years-old Ethiopian woman with unusual migration of IUD to the infra-umbilical skin. She had infra-umbilical skin discoloration associated with intermittent itching for two months duration. On physical examination, there was diffuse violaceous patch over the infra-umbilical skin measuring 7 centimeters on its longest dimension and visible foreign body (IUD) with tiny sinus tract formation. Visible stem of copper-containing IUD was grasped by ring forceps and removed with gentle traction without complication during or following extraction. Removal of misplaced IUD with completely non-invasive manner makes this case special in addition to the unique site of migration to the infra-umbilical skin.

Conclusion and recommendation

To our knowledge, this is what likely to be the first reported case of IUD migration to the infra-umbilical skin which bestows a new finding to the existing literatures. Despite rare occurrence, possible IUD complications should be included in the informed consent process before insertion. Self-examination of the strings and vigilant evaluation at regular checkup is recommended for early detection of migrated IUDs.

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Introduction

Intrauterine devices (IUDs) are effective, relatively safe and long acting reversible contraceptives (LARCs) [1]. The two most commonly used types of IUDs are levonorgestrel-releasing intra-uterine system (LNG-IUS) and copper-containing intra-uterine devices (IUDs). These contraceptive methods have several advantages including ease of use, patient satisfaction, relatively affordable cost in addition with the long-term use, and reversible nature [2].

Levonorgestrel-containing IUDs act by thickening the cervical mucus (thereby preventing sperm permeability), promoting endometrial decidualization followed by atrophy, and altering the motility of the tube. This results in oocyte and blastocyst apoptosis due to induced inflammatory response by the presence of an intrauterine foreign body [3]. Copper-containing IUDs work by inhibition of fertilization and inducing endometrial inflammatory reaction which hinders implantation [4].

Complications of IUDs include menstrual disturbance, pelvic pain mostly related to copper-containing IUDs, expulsion, increased risk of ectopic pregnancy if method fails, and uterine perforation or trans-mural migration with resultant device misplacement [4, 5]. Conception and migration of IUDs are very rare complications occurring in 1 to 2 per 1,000 users reported [6, 7]. Migrated IUDs may be found in any pelvic or abdominal organs following uterine perforation. Misplaced devices may not necessarily always follow uterine perforation at the time of insertion as it could be with later trans-mural migration [8].

Risk factors for possible uterine perforation and trans-mural migration are insertion by less experienced clinicians, having lower parity and multiple previous abortions, insertion during lactation, and postpartum period within 6 months following delivery [9].

Patients with migrated IUDs have varied clinical pictures. The clinical presentation of misplaced devices depends on the final anatomical location at diagnosis. Misplaced devices may be first incidentally detected with radiography being ordered for other medical illness [10, 11]. Migration of IUDs may cause urolithiasis [12], anterior abdominal wall abscess [13], pelvic abscess [14], bowel perforation [15, 16], and acute appendicitis [17]. Several cases have been reported with the IUDs extracted within the peritoneum [18,19,20], from the urinary tract [10, 21,22,23,24], broad ligament [25], any segment of the gastrointestinal tract [15, 26,27,28], omentum [29], ovary [30], pouch of Douglas [31], and anterior abdominal wall [32].

Evaluation to look for the misplaced device is necessary once lost IUD is confirmed. Hysteroscopy as an initial workup helps confirm the absence of intrauterine location of IUDs after lost strings confirmed on physical examination [33]. X-ray is commonly used in search for the location of misplaced IUDs [5]. Laparoscopy can help in the diagnosis and removal of ectopically located devices [21, 34,35,36]. There are cases reported with robot assisted removal of misplaced IUDs [37]. Open surgery under general anesthesia can be used to remove migrated IUD causing anterior abdominal wall abscess [13].

We present an unusual case of IUD migration to the infra-umbilical skin which is likely to be the first case reported. Unlike those previous cases reported, this will help explain the potential migration sites of IUD are not limited to the pelvis, abdomen, and anterior abdominal wall. Therefore, this report will help the scientific community recognize that IUD migration to other body parts not previously reported could potentially occur.

Case presentation

We report the case of a 38-year-old Ethiopian woman. She had a reproductive history of six vaginal deliveries, and all were uncomplicated. Over the past 18 months, she had regular monthly menstrual cycles that lasted 3 to 5 days, with moderate amount of fluid, and minimal discomfort. She is a housewife in the countryside part of Ethiopia and had no history of smoking, pelvic inflammatory disease (PID) or chronic medical illness. After 7 weeks of her last delivery she had copper T-380 A-IUD inserted two years ago by the attending registered professional midwife at the michu clinic of university of Gondar comprehensive specialized referral hospital. Negative urine HCG test was confirmed before IUD insertion. She had no symptoms since insertion of IUD and before the current presentation. She neither had follow-up visits onwards nor tried to palpate IUD strings. The reason for missed follow up was due to geographic constraints as she was residing in the countryside.

The patient presented to outpatient department (OPD) with the complaint of infra-umbilical skin discoloration associated with intermittent itching for the past 2 months. She had no history of fever, abdominal pain, pelvic pain, and bladder or bowel complaints. She was applying emollients over the discolored skin but didn’t improve. She was breastfeeding exclusively for the first 5 months following delivery, and intermittently for the past 19 months until her current presentation.

On physical examination, her vital signs were normal with blood pressure 120/75 mmHg, pulse rate 74 beats per minute, respiratory rate 16 breaths per minute, and temperature of 36.6 degree centigrade. Her height was 160 centimeters, weight at time of presentation was 59 kg and her BMI was 23.05 kg per square meter. On abdominal examination, there was discolored infra-umbilical skin, which was diffuse violaceous patch measuring 7 centimeters on its longest dimension, and visible foreign body (one of the arms of IUD) with tiny sinus tract formation (Fig. 1). The abdomen was soft with no area of tenderness. There was no organomegaly or palpable mass. IUD strings were not visualized on pelvic examination. There was no pelvic mass, cervical motion tenderness or adnexal tenderness.

Fig. 1
figure 1

Diffuse violaceous patch over the infra-umbilical skin and visible foreign body (IUD) with sinus tract formation (pointed by the black arrow)

Full size image

On ultrasound examination, there was normal sized and empty uterus with visible tri-laminar pattern (Fig. 2). Bilateral ovaries were normal and there was no free peritoneal fluid collection.

Fig. 2
figure 2

Empty uterus with trilaminar pattern seen on trans-abdominal ultrasound in sagittal plane

Full size image

Visible arm of copper-containing IUD (copper T-380 A) was grasped with ring forceps and removed completely with gentle traction (Fig. 3). The patient was comfortable, and there was no need of analgesia or local anesthesia at time of migrated IUD removal which helped to remove the device in such completely non-invasive manner. There was no active bleeding or drainage of pus from the extraction site during, and after removal of the device. In addition, there was no fistulous tract which could be seen by the naked eye.

Fig. 3
figure 3

Copper T-380 A IUD removed completely with ring forceps

Full size image

She was counseled, but refused to use any form of contraceptive after IUD removal and was sent home without any complication. The patient was also advised to visit our hospital early in case of pain, fever, bowel, and bladder complaint or any other symptoms. After IUD removal she did not appear to follow-up clinics, but reported no symptom or complication on phone call interview.

Trajectory path of IUD migration to the infra-umbilical skin

Typically, an IUD is expected to stay in the uterus, anchored within the uterine cavity by its shape, and size. Here are the possible alternative paths of IUD migration from intrauterine cavity to the Infra-umbilical skin:

  1. 1.

    Perforation/trans-mural migration at the cervico-uterine junction below the Vesico-uterine peritoneal reflection → Further wandering of the device in the retro-peritoneal space → Erosion through the anterior abdominal Wall → Infra-umbilical skin (Fig. 4A).

  2. 2.

    Exit of IUD from intra-uterine cavity following uterine perforation or gradual trans-mural migration. This may occur on anterior body of the uterus in the case of retro-verted uterus (Fig. 4B) or posterior body in an ante-verted uterus (Fig. 4C) → The IUD transmigrated into and through peritoneal cavity until it adhered and eroded through the anterior parietal peritoneal layer → Further transmigration through the anterior abdominal wall until it arrived to the infra-umbilical skin.

Fig. 4
figure 4

Cartoon drawing showing presumed trajectory paths of IUD migration to the Infra-umbilical skin

Full size image

Discussion

IUDs are reversible, safe, and effective contraceptive methods. Type of IUDs to be used depends on clients’ choice, and type of available contraceptive device. Some women prefer to avoid hormone-containing devices and prefer copper-containing IUDs [4]. Device insertion can be made anytime with the negative pregnancy test [4, 38]. For this patient, copper T-380 A was inserted on the 7th week postpartum period following vaginal delivery while she was breast feeding exclusively.

Misplacement of IUDs may happen due to un-noticed perforation at time of insertion or due to gradual trans-mural migration [8, 39]. The device may be misplaced in any pelvic or abdominal organs including the urinary tract [10], gastrointestinal tract [27], peritoneum [20], omentum [29], anterior abdominal wall [32], and ovarian neoplastic mass [30] following trans-mural migration. One systematic review showed common sites of migration are bladder, the intestine, and omentum [7]. We presented a case of IUD migration to the infra-umbilical skin which is unusual and likely not ever reported before. Though this patient had IUD inserted in the postpartum period while she was lactating, the temporal relation of device migration and misplacement cannot be clearly defined.

Migrated devices may cause a secondary complication which depends on the organ where the IUDs are misplaced. These includes urolithiasis [12], acute appendicitis [17], bowel ischemia with perforation [16, 40], pelvic abscess [14], and anterior abdominal wall abscess [13]. Whereas, our finding reported the presence of diffuse violaceous patch and intermittent itching on the overlying skin which is less grave complication than other reported cases. Migrated IUDs are rare in occurrence, which is about 1 to 2 among 1,000 users [6, 7]. After IUD migration, it may remain asymptomatic for longer period of time. However, any free foreign body should be removed due to possibility of injuries to adjacent organs though there is no complication at the time of detection [11]. It is recommended to visit the care provider when the woman fails to palpate the IUD strings. The American College of Obstetricians and Gynecologists (ACOG) recommend IUD removal should not be attempted when the strings are not palpable until its final anatomic location is known [2].

Removal of misplaced IUDs depends on the location it resides. One systematic review showed that the preferred method for removing migrated IUD was laparoscopy [7]. Devices misplaced to and causing anterior abdominal wall abscess can be removed with open surgery under general anesthesia [13].

Removal of IUD with ring forceps without the need of anesthesia makes our case special. This patient had copper-containing IUD migrated to the infra-umbilical skin and caused localized hyperpigmentation which is diffuse violaceous patch associated with intermittent itching (Fig. 1).

The potential mechanism could be through direct retro-peritoneal migration following uterine perforation or trans-mural migration until it resided under and visible through the infra-umbilical skin (Fig. 4A). Other alternative mechanism could be following uterine perforation or gradual trans-mural migration on the body of the uterus. After the IUD reached the peritoneal cavity, continued to transmigrate through peritoneal lining; with further attachment and erosion through the anterior abdominal wall until it became visible with sinus tract formation over the infra-umbilical skin (Fig. 4B and C).

In either of these mechanisms, early adhesion and erosion of the IUD through the peritoneal lining might have contributed for this unique site of migration following probably silent PID for our case. In addition, Insertion of IUD by the 7th postpartum week while she was exclusively breastfeeding might have contributed for potential uterine perforation or delayed trans-mural migration and device misplacement.

The IUD was removed with ring forceps without any complication and need of anesthesia. Removal of IUD with completely noninvasive approach makes our case report special in addition to the unique site of migration as compared to the previously reported cases. This case report will uncover other possible sites of IUD migration.

Finally, in spite of rare occurrence, possible IUD complications should be included in the informed consent process before insertion [2].

Conclusion and recommendation

We present what is likely to be the first reported case of IUD migration to infra-umbilical skin which bestows a new finding to the existing literatures. Migrated IUD was grasped and removed by ring forceps with gentle traction. In this case, she had no emergency complaint and grave complications like in other case reports but misplaced IUD could have been detected earlier with vigilant examination and regular checkup. In spite of rare occurrence, possible IUD complications should be included in the informed consent process before insertion.

Women should have self-examination of the strings; regular checkups and vigilant examination even though they remain asymptomatic and comfortable after IUD insertion. It is prudent to have high index of suspicion for misplaced devices whenever there is missed IUD string. Removal should be attempted after the location of migrated IUD is confirmed with various diagnostic workups.

This is a unique case of IUD migration to infra-umbilical skin which is likely never had been reported before. Hence, this report will help the scientific community understand that IUD migration to other body parts not previously reported could potentially occur.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

ACOG:

American College of Obstetricians and Gynecologists

BMI:

Body Mass Index

HCG:

Human Chorionic Gonadotropin

IUD:

Intra uterine device

LARC:

Long Acting Reversible Contraceptive

LNG-IUS:

Levonorgestrel releasing intra uterine system

MD:

Medical Doctor

OPD:

Outpatient Department

PID:

Pelvic Inflammatory Disease

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Acknowledgements

We wish to express our profound appreciation to the editors, and reviewers for their invaluable comments, and recommendations. We extend our heartfelt gratitude to our patient for the informed consent which let us share this rare finding to the rest of the world.

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Nigat Amsalu Addis, Yared Alem Sibhat, Wasihun Nigdu Mengestu & Misganaw Abere Worku

  2. Department of Surgery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Yohannis Derbew Molla

  3. Department of Dermatovenereology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Abebe Sinknew Seid

  4. Medicos Art Club (MAC)-Ethiopia, Addis Ababa, Ethiopia

    Michael Argaw Damite

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Contributions

Nigat Amsalu Addis, MD contributed from inception of reporting the case, literature review, Submission and revision of images, and critically revised the final manuscript. Yared Alem Sibhat was involved in the patient management at the Outpatient Clinic. Yohannis Derbew Molla, MD wrote the original draft and contributed to the literature review. Wasihun Nigdu Mengestu, MD was involved in the management of the patient and revision of original draft. Abebe Sinknew Seid, MD was involved in the management of the patient and follow up. Michael Argaw Damite, MD Contributed in the submission and revision of images and cartoon drawing. Misganaw Abere Worku, MD was involved in the patient management, wrote the original draft of case presentation, and contributed to the submission of images. All authors agreed to be accountable for all aspects of this work.

Corresponding author

Correspondence to Nigat Amsalu Addis.

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This case report has been submitted to the school of medicine at University of Gondar College of medicine and health sciences for ethical board review and was approved as morally sound report. A written informed consent was obtained from the patient for publication of the case report and accompanying images. A copy of patient’s written consent is available for review for the editor-in-chief of this journal.

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Addis, N.A., Sibhat, Y.A., Molla, Y.D. et al. Migrated intra-uterine device to infra-umbilical skin: a rare case report. BMC Women's Health 24, 672 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12905-024-03522-0

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