Coronal Plane and 3D Imaging Key for IUD Complications

Case Presentation

Our patient was a 27-year-old gravida 1 para 1 female complaining of lower abdominal and pelvic pain. Ten days prior to this presentation, she was seen in the Emergency Department, where a CT scan suggested a small hemorrhagic ovarian cyst. She reports to us that she has been getting some relief with ibuprofen but still has persistent pain.

Her pelvic examination was unremarkable save for an IUD thread visible at the cervical os.[[{"type":"media","view_mode":"media_crop","fid":"27536","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6806895681656","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2697","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"325","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"Figure 1. This 2D image shows a displaced IUD.","typeof":"foaf:Image"}}]]

A transvaginal ultrasound with 3D volume (Voluson S8, GE Medical Systems) was performed. Both ovaries appeared normal, with apparent interval resolution of the hemorrhagic cyst that had been seen on the previous CT scan. A ParaGard IUD was seen displaced inferiorly into the uterine isthmus and upper cervix (Figure 1).

The 3D-rendered image demonstrated that the IUD not only was displaced but also was embedded (Figure 2).[[{"type":"media","view_mode":"media_crop","fid":"27537","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_8427162514999","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2698","media_crop_rotate":"0","media_crop_scale_h":"338","media_crop_scale_w":"325","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"Figure 2. This 3D image clearly shows the IUD is also embedded.","typeof":"foaf:Image"}}]]

Discussion

This case clearly highlights the utility of 3D ultrasound in the localization of intrauterine devices. While displacement was clear from the initial 2D image, the 3D-rendered image clearly demonstrated the extent of this patient’s problem.

It has been noted that 75% of patients presenting with pain or bleeding with an IUD in situ had a malpositioned IUD.¹ Moreover, the degree of malpositioning was often only seen in the coronal plane of the 3D volume.

As our case demonstrates, 3D volume ultrasonography should be the modality of first choice in monitoring patients with an IUD.

References:

1. Benacerraf BR, Shipp TD, Bromley B. Three-dimensional ultrasound detection of abnormally located intrauterine contraceptive devices which are a source of pelvic pain and abnormal bleeding. Ultrasound Obstet Gynecol. 2009;34(1):110-115. doi: 10.1002/uog.6421.