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.