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Obstet Gynecol Surv. 1981 Jul;36(7):335-53.

Complete and partial uterine perforation and embedding following insertion of intrauterine devices. I. Classification, complications, mechanism, incidence, and missing string.



This report of complete and partial uterine perforation and embedding following IUD insertion is based on a review of the pertinent literature of the past 15 years. An analysis of 356 cases reported in the literature during this time are included. A classification is proposed based on the distinction between complete and partial perforation. Of all perforations of the uterus, be they fundal, lower segmental, or upper cervical, the completely perforated IUD is the type most often encountered, most commonly described, most readily recognized, and most easily removed. To differentiate between perforated IUDs, 3 anatomical compartments are postulated. For the purposes of discussion, the endometrial and serosal layers of the uterus are disregarded, leaving only the myometrium as its truly essential feature. Compartment 1 is the uterine cavity; compartment 2, the myometrium; and compartment 3, the peritoneal cavity. Completely perforated and, less often, partially perforated IUDs may intrude upon neighboring viscera, particularly the intestinal tract, resulting frequently in seriously ill patients who require intensive treatment including intestinal surgery. In the review of 356 case reports, such special situations arose in 53 cases, or 15%. Of the 53 reported cases, 41 concerned the intestinal tract. There were 6 cases in which the IUD was in the bladder. In 1 case, the perforation had been partial (Lippes loop) and, in 5 cases, complete (4 Lippes loop and 1 Dalkon shield). There were 3 cases in which the uterus was involved under special circumstances. There were 5 cases in which death occurred in relation to uterine perforation by IUD. It is probable that, of the various factors responsible for uterine perforation by IUDs, the most important are the consistency and flexion of the uterus, the type and the rigidity of the IUD and its inserter, and the amount of force exerted at insertion, with the result that the IUD stops at a certain point rather than proceeding to complete perforation. If the IUD does not penetrate beyond the uterine wall, i.e., if it is type 1-2 or type-2 perforation, negative intraabdominal pressure does not obtain. If the IUD had penetrated beyond the uterine wall, the theoretical possibility exists for further progression to type 3 perforation more readily than in the type 1-2 or type 2 perforation. In this review of 356 cases, 352 cases were suitable for analysis. Of these there were 53 unusual complications involving the intestinal tract, bladder, and so forth. There were 299 cases of simple perforation involving the uterus only, of which 255 were complete and 44 were partial. The mechanism of cervical perforation appears to depend on the presence of an IUD with a dependent limb in its design. Embedding, diagnosis, and the problem of the missing string are reviewed.

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