Delayed presentation of uterine and bowel perforation following insertion of an intrauterine device

Introduction Insertion of intrauterine methods of contraception (IUC) carries an inherent but small risk of perforation of the uterus, usually quoted at 2 in 1000. If perforation occurs, it is usually discovered either when a patient presents with 'missing threads' or with an unplanned pregnancy. Rarely, if the IUC has perforated bowel, patients can present acutely unwell although this sometimes occurs years after insertion. Asymptomatic perforation of the bowel (with IUC insertion or otherwise) is not common. Case history In January 2018, a 41-year-old woman attended our community sexual and reproductive health service requesting removal of her intrauterine system (IUS). The clinic nurse performed this and during the consultation the patient revealed that several days earlier she had passed a previous 'lost' intrauterine device (IUD) when she opened her bowels. She came to believe this was an IUD inserted in 2006 that had been 'lost' and resulted in a pregnancy with her third child. We counselled her about her options and she had the IUS removed as she was worried this could happen again and opted to use condoms. Conclusion This case reports an unusual presentation of a delayed and importantly 'silent' perforation of the uterus and bowel on insertion of IUC. The case highlights the importance of cross-specialty communication when an IUD has perforated or expelled resulting in a continuing pregnancy, so that appropriate imaging can be arranged following delivery of the baby.