Contraception
45:541-546,
1992
REMOVAL OF INTRAUTERINE DEVICES WITH MISSING TAILS DURING EARLY PREGNANCY A. Assaf, M. Gohar, S. Saad, A. El-Nashar and A. Abdel Aziz Departments of Gynecology and Obstetrics, Benha University Hospital, Egypt
ABSTRACT During a 70-month period, CO2 hysteroscopy was carried out on 52 pregnant women wearing IUDs with retracted
tails. UItrasonography
was done prior to hysteroscopy
determine the size of the gestational sac and the site of the device. Successful
to
removal of the
device occurred in 46 cases. The technique, the findings of the study, and the limitations of the procedure are described.
INTRODUCTION In cases of pregnancy in a woman wearing an IUD, the general rule is to remove the IUD if the woman wishes to continue pregnancy and if the tail is not retracted. In the case of a missing tail, hysteroscopy or ultrasonic guidance may play an important role by allowing the device to be removed without injuring the fetus. The advantages of removal of the devices during pregnancy are: lowering the rate of spontaneous abortion, decreasing the incidence of septic abortion, thus increasing the chance of having a full-term pregnacy (l), and avoidance of anxiety in the patient (2). Submitted Accepted
Copyright
for publication for publication
0
1992
January 13, 1992 April 6, 1992
Butterworth-Heinemann
542
Contraception
MATERIAL AND METHODS PATIENTS Between December 1985 and November 1991,81 pregnant women with a history of IUD use were examined at the out-patient department or referred to us on a private basis; 52 patients underwent hysteroscopic removal of the device and 29 were excluded from the study. After history taking and clinical examination, a vaginal speculum was placed to confirm that the tails were retracted and ultrasonic examination was done to determine the size of the gestational sac, to confirm viability of the fetus, and to locate the device and determine its relation to the fetus (3,4). In three of the 28 patients excluded from the study, the tail was not retracted, in 12 women ultrasonography did not show an intrauterine device. In 8 women, the pregnancy was of more than 12 weeks’duration.
A history of threatened abortion was given by 5 women.
Before the procedure, a full explanation about the technique and its possible hazards was given to the patient.
TECHNIQUE Hysteroscopy was done under aseptic conditions using pamcervical block or short-acting intravenous anesthesia. Antiprostaglandin
in the form of endomethasin
suppository was given
one night before and after the procedure. The 7 mm sheath of the hysteroscope
(Karl Storz, Tuttlinge,
West Germany)
was
introduced into the cervical canal just in front of the internal OS.Dilatation was carried out only if required. CO2 gas was introduced to create a microcavity, which in turn, dilated the internal OS. The maximum Hysteroflator
volume of CO2 used to distend the uterine cavity was 200 ml, using a with an indicator
for CO2 volume (Wiest, Berlin, West Germany).
The
hysteroscope was then gradually passed through the internal OSto allow for visual inspection of the gestational sac and the device. Using a grasping forceps, the operator then gradually withdrew the device, taking care not to injure the fetus. Patients remained in the hospital for 5 days for complete rest and observation.
Ultrasonography was performed 2 weeks later to confirm viability of the fetus.
Contraception
543
RESULT The IUD was succesfully removed from 46 out of 52 women (F&.1). In 13 of these women, the IUD was covered by decidua parietalis and could be detected either by the raised de&dual covering or by tracing parts of the tails (Fig.2). Our procedure did not succeed in 6 women; in two cases due to immediate injury to the gestational sac, in 2 cases disturbance occurred a few days later. In the other 2 women. the devices were lying behind the gestational
sac, making their removal impossible
without
disturbing the pregnancy; we did not try to remove these IUDs. In the last 2 years we had no failure. The outcome of pregnancy in relation to the type of the IUD is shown in Table I.
Table
I : Outcome
of
pregnancy
Immediate abortion
Total
Abortion after few days
in
relation
On-going pregnancy
to
type
of
Full-term pregnancy
the
IUD
Total
2
DISCUSSION In cases of IUDs with missing tails during pregnancy, removal of the device is not possible without disturbing the gestational sac, unless hysteroscopy or ultrasonic guidance is used [6,7]. Wagner hysteroscopy.
successfully
removed
the IUD from 14 out of 18 women,
using CO2
Injury of the gestational sac occurred in 4 cases [7] .
Hucke et al. used hysteroscopy or ultrasonic guidance for removal of the IUD from 11 out of 13 pregnant women; no injury to the gestational sac was reported [6]. Helem [3] and
Contraception
Fig.
Fig.
l.Hysteroscopic
2,Hysteroscopic sac and
view
view
IUD covered
during
showing
pulling
an
by decldua.
intact
an IUD.
gestatiq ma1
545
Contraception
Bartfai et al. (8) remored the IUD in pregnant women who were scheduled for termination both reported not a single injury to the gestational sac. In a previous study, we restricted our work to the copper-containing
IUDs. We were
afraid of the larger surface area of the Lippes loop which would predispose to more injury to the gestational sac [2]. However, with more experience and with proper handling of the device during pregnancy,welwere able successfully to remove 24 Lippes loop out of 26 cases. Since Helem had used a 1.7 mm diameter hysteroscope
[3] and Bartfai used 4 mm
diameter [8], we were concerned that the 7 mm sheath might require cervical dilatation, which in turn might induce abortion.
Our results showed that cervical dilatation to Hegar No. 7 in
some cases with the use antiprostaglandins’pre-
and post-operatively,
did not predispose to
abortion.
CONCLUSION Either hysteroscopy or ultrasonographic
guidance can be used for removal of the IUD
during pregnancy; the choice depends on the experience of the gynecologist.
We propose the
use of hysteroscopy during pregnancy under the following circumstances. - The operator should have experience in the use of hysteroscopy during pregnancy.
This can
be gained by training on women scheduled for therapeutic termination of pregnancy. - A Iimited volume of CO2 gas should be used, with good control maintained.
REFERENCES 1. Tatum, H.J. (1979): Copper-bearing intrauterine devices. Clin. Obstet. Gynecol. 17, 73. 2. Assaf, A., El Tagy, A., El Kady, A. and El Agezy, H. (1988): Hysteroscopic removal of copper-containing
intraulterine
devices with missing tails during pregnancy.
Adv.
Contracept. 4, 131. 3. Helem, D. (1984). Hysteroscopic removal of missed IUD during early pregnancy. Am. J. Obstet. Gynecol. 304, 561. 4. Nemes, G. and Kerenyi, T.D. (1971). Ultrasonic localisation of the IUD. Am. J. Obstet. Gynecol. 109, 1919.
546
Contraception
5. Wagner,
H., Schweppe,
extraktion
K.W.
von intrauterin
and Krouholz.
pessaren
H.L. et al., (1980).
bei eingetretener
Moglichkeiten
schwangerschaft,
der
Med. Welt.
31,
1317. 6.
Hucke,
J., Campo,
bysteroskopischen sichtbaren 7. Wagner, devices.
RL., Kozlowski,
oder sonographisch
faden in der fruhschwangers
H. (1983). Diagnosis
P. and Bruyna, gesteuerten
entfemung
chaft. Geburtshilfe
and treatment
MTP Press, Boston.,
einer intrauterin
spiral ohne
16, 5751.
of intrauterine
D. van Lith
urit ser
contraceptive
and L. Keith
(eds).
p. 185.
8. Bartfai, G., Barad, DH., Kalli, SG. and Feinman, of “lost” intrauterine
Erfarungen
Frauenheilkd
of complications
In : H. van der Pas, 8. van Herendael,
Hysteroscopy.
F. (1991).
M, (1988). Video hysteroscopic
devices during first trimester of pregnancy.
removal
J. Reprod Med, 33, 877.
45:541-546,
1992
REMOVAL OF INTRAUTERINE DEVICES WITH MISSING TAILS DURING EARLY PREGNANCY A. Assaf, M. Gohar, S. Saad, A. El-Nashar and A. Abdel Aziz Departments of Gynecology and Obstetrics, Benha University Hospital, Egypt
ABSTRACT During a 70-month period, CO2 hysteroscopy was carried out on 52 pregnant women wearing IUDs with retracted
tails. UItrasonography
was done prior to hysteroscopy
determine the size of the gestational sac and the site of the device. Successful
to
removal of the
device occurred in 46 cases. The technique, the findings of the study, and the limitations of the procedure are described.
INTRODUCTION In cases of pregnancy in a woman wearing an IUD, the general rule is to remove the IUD if the woman wishes to continue pregnancy and if the tail is not retracted. In the case of a missing tail, hysteroscopy or ultrasonic guidance may play an important role by allowing the device to be removed without injuring the fetus. The advantages of removal of the devices during pregnancy are: lowering the rate of spontaneous abortion, decreasing the incidence of septic abortion, thus increasing the chance of having a full-term pregnacy (l), and avoidance of anxiety in the patient (2). Submitted Accepted
Copyright
for publication for publication
0
1992
January 13, 1992 April 6, 1992
Butterworth-Heinemann
542
Contraception
MATERIAL AND METHODS PATIENTS Between December 1985 and November 1991,81 pregnant women with a history of IUD use were examined at the out-patient department or referred to us on a private basis; 52 patients underwent hysteroscopic removal of the device and 29 were excluded from the study. After history taking and clinical examination, a vaginal speculum was placed to confirm that the tails were retracted and ultrasonic examination was done to determine the size of the gestational sac, to confirm viability of the fetus, and to locate the device and determine its relation to the fetus (3,4). In three of the 28 patients excluded from the study, the tail was not retracted, in 12 women ultrasonography did not show an intrauterine device. In 8 women, the pregnancy was of more than 12 weeks’duration.
A history of threatened abortion was given by 5 women.
Before the procedure, a full explanation about the technique and its possible hazards was given to the patient.
TECHNIQUE Hysteroscopy was done under aseptic conditions using pamcervical block or short-acting intravenous anesthesia. Antiprostaglandin
in the form of endomethasin
suppository was given
one night before and after the procedure. The 7 mm sheath of the hysteroscope
(Karl Storz, Tuttlinge,
West Germany)
was
introduced into the cervical canal just in front of the internal OS.Dilatation was carried out only if required. CO2 gas was introduced to create a microcavity, which in turn, dilated the internal OS. The maximum Hysteroflator
volume of CO2 used to distend the uterine cavity was 200 ml, using a with an indicator
for CO2 volume (Wiest, Berlin, West Germany).
The
hysteroscope was then gradually passed through the internal OSto allow for visual inspection of the gestational sac and the device. Using a grasping forceps, the operator then gradually withdrew the device, taking care not to injure the fetus. Patients remained in the hospital for 5 days for complete rest and observation.
Ultrasonography was performed 2 weeks later to confirm viability of the fetus.
Contraception
543
RESULT The IUD was succesfully removed from 46 out of 52 women (F&.1). In 13 of these women, the IUD was covered by decidua parietalis and could be detected either by the raised de&dual covering or by tracing parts of the tails (Fig.2). Our procedure did not succeed in 6 women; in two cases due to immediate injury to the gestational sac, in 2 cases disturbance occurred a few days later. In the other 2 women. the devices were lying behind the gestational
sac, making their removal impossible
without
disturbing the pregnancy; we did not try to remove these IUDs. In the last 2 years we had no failure. The outcome of pregnancy in relation to the type of the IUD is shown in Table I.
Table
I : Outcome
of
pregnancy
Immediate abortion
Total
Abortion after few days
in
relation
On-going pregnancy
to
type
of
Full-term pregnancy
the
IUD
Total
2
DISCUSSION In cases of IUDs with missing tails during pregnancy, removal of the device is not possible without disturbing the gestational sac, unless hysteroscopy or ultrasonic guidance is used [6,7]. Wagner hysteroscopy.
successfully
removed
the IUD from 14 out of 18 women,
using CO2
Injury of the gestational sac occurred in 4 cases [7] .
Hucke et al. used hysteroscopy or ultrasonic guidance for removal of the IUD from 11 out of 13 pregnant women; no injury to the gestational sac was reported [6]. Helem [3] and
Contraception
Fig.
Fig.
l.Hysteroscopic
2,Hysteroscopic sac and
view
view
IUD covered
during
showing
pulling
an
by decldua.
intact
an IUD.
gestatiq ma1
545
Contraception
Bartfai et al. (8) remored the IUD in pregnant women who were scheduled for termination both reported not a single injury to the gestational sac. In a previous study, we restricted our work to the copper-containing
IUDs. We were
afraid of the larger surface area of the Lippes loop which would predispose to more injury to the gestational sac [2]. However, with more experience and with proper handling of the device during pregnancy,welwere able successfully to remove 24 Lippes loop out of 26 cases. Since Helem had used a 1.7 mm diameter hysteroscope
[3] and Bartfai used 4 mm
diameter [8], we were concerned that the 7 mm sheath might require cervical dilatation, which in turn might induce abortion.
Our results showed that cervical dilatation to Hegar No. 7 in
some cases with the use antiprostaglandins’pre-
and post-operatively,
did not predispose to
abortion.
CONCLUSION Either hysteroscopy or ultrasonographic
guidance can be used for removal of the IUD
during pregnancy; the choice depends on the experience of the gynecologist.
We propose the
use of hysteroscopy during pregnancy under the following circumstances. - The operator should have experience in the use of hysteroscopy during pregnancy.
This can
be gained by training on women scheduled for therapeutic termination of pregnancy. - A Iimited volume of CO2 gas should be used, with good control maintained.
REFERENCES 1. Tatum, H.J. (1979): Copper-bearing intrauterine devices. Clin. Obstet. Gynecol. 17, 73. 2. Assaf, A., El Tagy, A., El Kady, A. and El Agezy, H. (1988): Hysteroscopic removal of copper-containing
intraulterine
devices with missing tails during pregnancy.
Adv.
Contracept. 4, 131. 3. Helem, D. (1984). Hysteroscopic removal of missed IUD during early pregnancy. Am. J. Obstet. Gynecol. 304, 561. 4. Nemes, G. and Kerenyi, T.D. (1971). Ultrasonic localisation of the IUD. Am. J. Obstet. Gynecol. 109, 1919.
546
Contraception
5. Wagner,
H., Schweppe,
extraktion
K.W.
von intrauterin
and Krouholz.
pessaren
H.L. et al., (1980).
bei eingetretener
Moglichkeiten
schwangerschaft,
der
Med. Welt.
31,
1317. 6.
Hucke,
J., Campo,
bysteroskopischen sichtbaren 7. Wagner, devices.
RL., Kozlowski,
oder sonographisch
faden in der fruhschwangers
H. (1983). Diagnosis
P. and Bruyna, gesteuerten
entfemung
chaft. Geburtshilfe
and treatment
MTP Press, Boston.,
einer intrauterin
spiral ohne
16, 5751.
of intrauterine
D. van Lith
urit ser
contraceptive
and L. Keith
(eds).
p. 185.
8. Bartfai, G., Barad, DH., Kalli, SG. and Feinman, of “lost” intrauterine
Erfarungen
Frauenheilkd
of complications
In : H. van der Pas, 8. van Herendael,
Hysteroscopy.
F. (1991).
M, (1988). Video hysteroscopic
devices during first trimester of pregnancy.
removal
J. Reprod Med, 33, 877.
