Computed Tomography for Localization of Intra- Abdominally Dislocated Intrauterine Devices

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1 Act Rdiologic ISSN: (Print) (Online) Journl homepge: Computed Tomogrphy for Locliztion of Intr- Adominlly Dislocted Intruterine Devices Esjörn Hederström, M. Ahlgren & H. Slminen To cite this rticle: Esjörn Hederström, M. Ahlgren & H. Slminen (1989) Computed Tomogrphy for Locliztion of Intr-Adominlly Dislocted Intruterine Devices, Act Rdiologic, 30:5, To link to this rticle: Pulished online: 07 Jn Sumit your rticle to this journl Article views: 69 Full Terms & Conditions of ccess nd use cn e found t

2 Acr Rdiologic 30 (1989) Fsc. 5 FROM THE DEPARTMENT OF DIAGNOSTIC RADIOLOGY AND THE DEPARTMENT OF OBSTETRICS AND GYNAECO- LOGY, UNIVERSITY HOSPITAL, S LUND, SWEDEN. COMPUTED TOMOGRAPHY FOR LOCALIZATION OF INTRA-ABDOMINALLY DISLOCATED INTRAUTERINE DEVICES E. HEDERSTROM, M. AHLGREN nd H. SALMINEN Astrct CT with scnogrm nd selected scns ws performed in 7 women ged 23 to 46 yers where n extruterine locliztion of intruterine devices (IUD) hd een considered present t ultrsonogrphy in 6 ptients nd questionle intruterine position of the device in one. Adominl rdiogrphy nd hysteroslpingogrphy gve conclusive evidence of extruterine device disloction in 5. CT provided good informtion out the reltion of the IUD to djcent orgns nd ws thus helpful when plnning for the mode of extrction. The gondl rdition exposure t CT ws not less thn tht given y the conventionl rdiologic methods ut my e reduced with slight chnge of technique. It is suggested tht CT exmintion should e the next step in the dignostic follow-up when US fils or is equivocl in demonstrting n IUD. Key words: Uterus, CT; contrceptive devices, disloction. Intruterine devices (IUD) my dislocte from the uterine cvity ut it is minor prolem considering the widespred use of such devices. The perfortion rte my rnge from to insertions (7) nd is most common when the insertion is mde post prtum or post ortum. Complete IUD perfortion defined s n extruterine loction of the device well seprted from the uterus ccounts for out 80 per cent of ll cses of uterine perfortion in some reported series (7). The IUD my then e locted nywhere in the domen. Aout 20 per cent of the perfortions re incomplete, i.e. mlposition of the IUD within the uterus with some component of it locted intrmurlly or prtly in the peritonel cvity (7). The extruterine locliztion of device hs hitherto required the employment of comined rdiologic methods: Adominl survey rdiogrphy, hysteroslpingogrphy (HSG) nd for the lst 15 yers lso ultrsonogrphy (US). Computed tomogrphy (CT) hs occsionlly een used (one cse report) (5) ut the role of this modlity hs not yet een defined (6). The im of this study is to present further experience with this method fter evluting smll group of ptients where the work-up of IUD disloction hd een initited y dominl pin, desire to ecome pregnnt, or pregnncy nd childirth in spite of n inserted IUD. Mteril nd Methods Seven women ged 23 to 46 yers (men 36 yers) were exmined with CT (Philips Tomoscn 300 nd 350) since clinicl exmintion hd filed to loclize the IUD (no strings seen). The different types of IUD used were: 4 Nov T, 2 Multilod Cu 250 nd 1 of unknown type. The men time for crrying the device ws 2 yers nd 3 months (1.5 months4 yers). US ws performed s the initil dignostic exmintion; the uterus ws empty in 6 cses indicting complete perfortion nd in one ptient incomplete perfortion ws considered possile. Adominl survey rdiogrphy followed fter US in ll ptients, eing conclusive of extruterine device locliztion in 5 nd inconclusive in 2 ptients. One ptient lso underwent HSG. CT ws performed in ll 7 ptients the dy efore the scheduled opertion for IUD removl. On n initil dominl scnogrm the IUD ws loclized nd 3 to 5 complementry scns (120 kv, 302 mas, slice thickness 9 mm, consecutive scns), were otined in order to define the exct IUD position. Accepted for puliction 29 My

3 532 E. HEDERSTROM, M. AHLGREN AND H. SALMINEN Results In one ptient the device ws locted in mrkedly retroverted uterus ut even on CT it could not e decided with certinty whether there ws prtil penetrtion of the uterine wll or not (Fig. 1). In 3 ptients IUDs were in the smll pelvis outside the uterus, in one of them (Fig. 2) the ldder wll lso seemed to e prtly perforted t CT ut the device ws emedded in omentl tissue t lproscopy. In 3 ptients the device ws found outside the smll pelvis: djcent to the nterior dominl wll (Fig. 3), etween the liver nd the kidney (Fig. 4) nd djcent to the sigmoid colon (Fig. 5). The IUD ws seen close to the nterior dominl wll in 3 of the 7 ptients (Fig. 3). In 6 ptients the IUD ws locted in ftty tissue. The locliztion suggested t CT ws correct in ll ptients operted upon, ut in one ptient the device prtly penetrted the sigmoid wll, which ws not suggested t CT (Fig. 5). The IUD ws extrcted trnscerviclly in the ptient in whom it ws oserved within the uterus. The device could e extrcted t lproscopy in 4 ptients, while in 2 lprotomy ws lso necessry. In one ptient the device ws seen on survey rdiogrm to the right in the pelvis ut not t the susequent CT performed immeditely fterwrds. The ptient left the deprtment efore CT ws completed. She ws sked to come for complete exmintion, which ws not performed until 5 weeks lter since the ptient hd only minor sujective symptoms. The IUD ws now seen t CT to the left of the midline, t the L4/L5 level. In retrospect the initilly missed IUD on the CT scnogrm could e explined y position nterior to the scrum which msked the device, while t dominl rdiogrphy (ldder projection) the crniocudl em direction mde the device pper in the pelvis. At the exmintion 5 weeks lter the IUD hd moved to more crnil position. Discussion Missing IUD strings on clinicl exmintion is most often due to retrction of the strings within the endocervicl cnl or the uterine cvity. Unnoted spontneous expulsion of device is fr more infrequent, nd lest frequent is prtil or complete uterine perfortion (3). US is consequently the method of choice s first step for loclizing n IUD where the string s re not seen on clinicl exmintion even fter endocervicl explortion with smll forceps (1, 3,4). An intruterine IUD position cn mostly e either confirmed or rejected even if the identifiction nd loction of the IUD my e difficult, depending on hitus of the ptient nd type of device (2). Possile incomplete perfortion is still n miguous US dignosis often requiring n dditionl HSG for definite dignosis (2, 6). Fig. 1. CT scnogrm showing IUD in the smll pelvis () (+), nd selected scn displying the device within the uterus (). Fig. 2. Scnogrm showing n IUD in the pelvis () nd CT () n IUD djcent to the ldder which seems prtly perforted. According to the lproscopist the device ws emedded in omentl tissue. Detecting n IUD outside the uterus y US my only occsionlly e possile since gs-contining owel loops often lurr the view of the lower domen. Adominl survey is helpful in confirming whether the ptient still crries the IUD or not. If the device still remins, conventionl rdiogrphy provides the est informtion in the presence of complete perfortion. It cn only offer n pproximte informtion out the IUD locliztion which is inferior to tht of CT. Consequently fter n inconclusive US, CT including scnogrm should e considered s the next step in the dignostic sequence. HSG ws previously the stndrd procedure for demonstrting the IUD s reltion to the uterus when US nd conventionl films were inconclusive (7). This method, though vlule in selected cses of incomplete uterine wll perfortion, does not provide informtion if the IUD is outside the uterine cvity. The clculted gondl rdition exposure t conventionl dominl rdiogrphy (one 35@43 cm frontl film nd one ldder projection, 24@30 cm frontl film, the tue tilted in crniocudl position) mounts to out 2 mgy. A single CT dominl scnogrm provides out

4 CT LOCALIZATION OF INTRAUTERINE DEVlCES 533 Fig. 3. HSG, lterl projection, of the IUD nterior nd crnil to the uterus ()(+). CT scnogrm shows IUD in the smll pelvis C () (+) nd CT (c) the device in the omentum, djcent to the nterior dominl wll (+). Fig. 4. CT scnogrm with IUD situted in the right domen t the level of the umilicus () nd CT () the device etween the liver nd the kidney. Fig. 5. Second CT exmintion. Device in left domen crnil to the pelvis () nd the device djcent to the left colon () (+). the sme informtion s conventionl rdiogrphy in the serch for n IUD ut t much lower gondl exposure (or mgy). In 6 of our ptients the IUD ws esily recognizle on the scnogrm nd selected scns over the IUD. Often, 3 to 5 slices were otined in order to visulize lso the lims of Copper T, t cost in gondl exposure dose of pproximtely 6 mgy per scn if the ovries were within the imged re. This exceeds the gondl exposure of dominl rdiogrphy with conventionl technique, nd my e equivlent to the comintion of the conventionl rdiogrphy nd HSG (gondl dose ws estimted to 6 mgy per exposure, minimum of 2 is needed; the fluoroscopy dose should, however, lso e dded). With modern rdiologic equipment including photofluorogrphy (log10 cm) the gondl exposure of HSG my e reduced y 40 to 50 per cent of given vlues. The min prt of the gondl dose t CT thus origintes from the selected scns nd cre must e tken to reduce their numer. Proly 2 to 3 non-consecutive scns should e sufficient. A CT scnogrm filed to demonstrte the IUD in the ptient in whom the sigmoid wll ws penetrted (the device, highly moile ecuse of the locliztion, ws oscured y pelvic ones) ut it ws esy to recognize t repet exmintion. It ws necessry to hve conventionl rdiogrph with tilted tue to verify the loction of the IUD. Since the gondl exposure of scnogrm is negligile, dditionl scnogrms in different projections including tilted gntry might hve solved the prolem. A repet exmintion (s in this cse) hs lso een recommended (7), if n IUD is not found. CT s employed in this limited group of ptients did not reduce the gondl dose ut hd other dvntges. It provided the lproscopist with vlule ntomic informtion especilly in the presence of complete IUD uterine perfortion. The ptient with n IUD etween the liver nd the right kidney could not hve een successfully treted t lproscopy without the detiled informtion given y CT. The vlue of this informtion is incresed if the rdiologist cn decide whether the IUD is locted in the omentum or not. This ws not stted in the primry reports ut loction in ftty tissue could in retrospect e concluded in 6 ptients. A precise description of the IUD loction should e given since it hs n impliction on the plnned mode of extrction: An IUD locted in the omentum fvours extrction y lproscopy. A demonstrtion

5 534 E. HEDERSTROM, M. AHLGREN AND H. SALMINEN of n entire IUD on selected consecutive scns my, however, increse the gondl dose, if performed over the ovries. The IUD penetrtion of the sigmoid wll in one ptient ws demonstrted y CT. A prtil volume effect nd n unfvourle scnning plne with respect to the site of penetrtion explin the shortcoming in this cse (Fig. 5). The dignostic vlue of the CT exmintion ws still superior to wht would hve een offered y conventionl rdiogrphy. The intestines would e etter visulized on CT y dding orl contrst medium efore the exmintion. This cnnot e recommended for routine use however, since it would most proly concel the IUD. In conclusion, neither conventionl dominl rdiogrphy nor HSG seem to e motivted for routine use ut the investigtion cn proceed directly with CT when the prolem of IUD locliztion cnnot e solved y US. HSG my then e employed only for selected cses of incomplete uterine perfortion, if CT is inconclusive. Conventionl rdiogrphs could e dded only if the IUD cnnot e oserved t CT. ACKNOWLEDGEMENT Thnks re due to Kerstin Lofvnder Thpper, Ph. D., Deprtment of Rdiophysics, University Hospitl, Lund, who mde the clcultions of gondl rdition exposure. Request for reprints: Dr Esjorn Hederstrom, Deprtment of Dignostic Rdiology, S Lund, Sweden. REFERENCES I. CALLEN P. W., FILLY R. A. nd MUNYER T. P.: Intruterine contrceptive devices. Evlution y sonogrphy. Amer. J. Roentgenol. 135 (1980) CARROLL R. nd GOMBERGH R.: Empty-ldder (hysterogrphic) view on US for evlution of intruterine devices. Rdiology 163 (1987), COCHRANE W. J.: Ultrsound nd the intruterine device. In: Ultrsound in ostetrics nd gynecology, p Edited y R. C. Snders nd A. E. Jmes. Appleton-Century-Crofts, Norwlk, Conn NAJARIAN K. E. nd KURTZ A. B.: New oservtions in the sonogrphic evlution of intruterine devices. J. Ultrsound Med. 5 (1986), RICHARDSON M. L., KINARD R. E. nd WATIERS D. H.: Loction of intruterine devices. Evlution y computed tomogrphy. Rdiology 142 (1982), ROSENBLATI R., ZAKIN D., STERN W. Z. nd KUTCHER.: Uterine perfortion nd emedding y intruterine device. Evlution y US nd hysterogrphy. Rdiology 157 (1985) ZAKIN D., STERN W. 2. nd ROSENBLATI R.: Complete nd prtil uterine perfortion nd emedding following insertion of intruterine devices. Ostet. Gynecol. Surv. 36 (1981). I:335 nd II:401.