Case Report

A 26-year-old had 4 term vaginal deliveries and 1 early spontaneous miscarriage. A levonorgestrel-releasing IUD was placed 3.5 years ago. At a 2-week follow-up the strings were not visualized and the IUD was not located at pelvic ultrasound. She was told the IUD had fallen out and was started on depot medroxyprogesterone acetate injections. A year ago during a workup for abdominal pain, a CT demonstrated the IUD in the left midabdomen near the left anterior abdominal wall. The patient refused laparoscopic removal. The patient presented with a viable 8-week pregnancy. Patient counseling included discussions of the theoretic effects of levonorgestrel on the fetus, risks of miscarriage from laparoscopy, and risks of bowel complications if left in situ. After obtaining a second opinion, she returned for removal.

At 12 weeks, a laparoscopy was scheduled. Although the patient was awake, brief fluoroscopy views with pelvic shielding showed the device was now on the right, lateral to the umbilicus, and directly under the anterior abdominal wall ( Figure ). The decision was made to attempt removal through a minilaparotomy under local anesthesia. A field block was created using a local anesthetic. A 3.5-cm incision was made over the IUD. After entering the peritoneum, the IUD was not visualized but could be felt. The finger was used to direct the device through the wound and it was dissected from the adherent omentum with the strings still attached. The abdomen was closed and fetal heart tones were demonstrated.

Spot fluoroscopy in the operating room

Intrauterine device is to the left of L3–4. A hemostat was placed on the abdomen.

Peleg. Intraabdominal IUD removal during pregnancy. Am J Obstet Gynecol 2013 .

A detailed anatomy of the fetus revealed normal anatomy at 20 weeks. The pregnancy continued and was unremarkable. The patient delivered a healthy baby boy at 39 weeks by spontaneous vaginal delivery.

Comment

Pregnancy with the levonorgestrel-releasing IUD is unusual. In a Finnish study of 17,360 users, there were a total of 64 pregnancies of which 31 were intrauterine and 33 were ectopic. The 5-year pregnancy rate was 0.5 per 100 users and the Pearl rate was 0.11.

The incidence of misplacement and uterine perforation is unknown because it is underreported and estimates range from 0.8 to 2.2 per 1000 insertions. Perforations are more common in breastfeeding women and in those postpartum less than 6 months. Only 8.5% of perforations are detected at the time of insertion.

When correctly placed, the levonorgestrel-releasing IUD releases 20 mcg/day and plasma concentrations plateau at 0.4–0.6 nmol/L. However, when located in the abdomen, the plasma level was 4.7 nmol/L. Fetal exposure to this level of levonorgestrel has not been shown to be teratogenic. However, a recent review of a 37 neonates exposed to the levonorgestrel-releasing IUD in the first trimester demonstrated a crude anomaly rate of 5.4%, arguing in favor of removal.

With a properly placed IUD and a viable uterine pregnancy, it is recommended to remove the IUD if possible to prevent complications such as septic abortion and preterm labor. Intraabdominal IUDs may cause adhesion formation, infection or organ injury. Removal can usually be accomplished via laparoscopy with fluoroscopy for localization. In our case, we successfully avoided general anesthesia and laparoscopy by removing the device through a minilaparotomy because the device was directly under the anterior abdominal wall.

In the 2 reported cases of an intraabdominal levonorgestrel-releasing IUDs, both were left in situ and removed at the time of cesarean. Both neonates were reported normal.

Laparoscopic surgery during pregnancy is safe as demonstrated by the use of this technique for appendectomy, but must be weighed against the risks of complications and miscarriage. In our case, it was unclear whether removal was necessary during pregnancy. Removal during pregnancy would prevent possible complications of hormone exposure and foreign body. Leaving it in situ and removal at the time of cesarean or thereafter would prevent the complications of surgery during pregnancy.