DISCUSSION
Transmigration of IUCD, a rare catastrophic complication of IUCD insertion, usually occurs at the time of insertion, as might have happened with our case since the lady was not able to feel the strings the next day.7 Moreover, the incorrect positioning of the IUCD is the result of faulty technique and insertion by insufficiently trained staff.8
Copper-containing devices can cause massive inflammation and recurrent pregnancy losses following uterine perforation and peritoneal reaction.8 Similarly, the miscarriage seen in this patient could have been a result of a damaged, perforated uterus unable to sustain the pregnancy. The complete extrusion of a malpositioned IUCD through myometrium is facilitated by the uterine contractions and the pressure difference between the higher pressure uterus and the lower pressure peritoneal cavity. Contractions of the abdominal organs i.e. urinary bladder, intestine as well as the movement of the peritoneal fluid may further facilitate the migration of the IUCD in the peritoneal cavity which can explain how the IUCD in our patient ended up in the anterior parietal abdominal wall.9 The transmigration of the malpositioned IUCD could have started when the uterus was contracting violently to expel the miscarriage and further progressed due to bowel peristalsis and changes in patient position.
Ultrasound is the optimal modality in case of non-visualization of the IUCD thread, as it is both cost-effective and can accurately identify the misplaced device. A plain radiograph of the abdomen may also be done to detect the device. Also, to see the exact distance of the IUCD from the uterine cavity, uterine sound can also be used during radiographic examination.10 In our case, although ultrasound was done, the IUCD was not clearly visualized. If the initial post-miscarriage ultrasound had visualized the device, further complications like adhesions and abscess formation could have been prevented.
According to WHO, removal of the misplaced or malpositioned IUCD is mandated because of the risk of injury to the adjoining organs and medico legal issues, even if the patient is asymptomatic. Laparoscopy is the preferred modality for the removal of misplaced IUCDs, but laparotomy is rarely required in very complicated cases.11 A misplaced IUCD device can often mimic appendicitis if it is found embedded in the appendix, causing an abscess formation in the right iliac fossa. Features such as fever, leukocytosis, vomiting, and features such as right iliac fossa tenderness may further cause diagnostic confusion.8 A similar thing happened with our patient in which the laparoscopy was done with the provisional diagnosis of appendicitis, but IUCD was found accidentally.