An Unusual Case of a Forgotten Intrauterine Contraceptive Device for 25 Years Presented with Ectopic Pregnancy at AMDA Hospital, Damak, Nepal

Intrauterine contraceptive device (IUCD), Copper T-380A, is widely used by more than one million women around the world. It is a long acting, reversible device with higher safety, low cost and low failure rate profile. Hereby, we reported a case of ectopic pregnancy with a forgotten IUCD. She was a 42 year woman who had forgotten the IUCD placed in her uterus 25 years back. She was totally unaware of the follow up visits, its removal and that IUCD was causing a problem to conceive for the second time. The inserted IUCD was incidentally discovered on ultrasonography, when she presented with history of lower abdominal pain and vaginal bleeding. On investgation, she had right tubal pregnancy with moderate fluid in pelvic cavity. So, emergency laparotomy was performed followed by right salphingectomy and removal of IUCD. Birat Journal of Health Sciences Vol.2/No.1/Issue 2/ Jan - April 2017, Page: 142-144


INTRODUCTION
The Intrauterine Contracep ve Device (IUCD), is one of the most commonly used method of contracep on with over 1 one million women accep ng it worldwide.IUCD is highly effec ve, reliable and long ac ng reversible contrac ve 2 device.The acceptability is high with this device.It is easy to insert and remove whenever pa ents prefer.It can be inserted in post menstrual, post abortal, post delivery or post puerperal period.Copper-T exhibits its contracep ve effects through the dissolu on of copper ions, which creates a spermicidal, sterile inflammatory response at the level of the endometrium and copper-rich cervical mucus that decreases 3 sperm mo lity.Its principal mechanism of ac on is to 2 prevent fer liza on by affec ng sperm mo lity.However rarely its unwanted effects are bleeding disorder, cramping pain, discharge per vaginum, pelvic inflammatory disease, perfora on of uterus on inser on, displacement of device in situ and in abdominal cavity and ectopic pregnancy.
The average annual failure rate of Cu-T 380A IUCD is 0.4 percent or less and a er 12 years of use, the cumula ve failure rate is 2.2 percent, which is comparable to that of

CASE REPORT
A lady of 42 years, P1L1 with last childbirth vaginally 25 years back presented at AMDA Emergency Department in morning with complains of minimal bleeding per vaginum since 6 days associated with lower abdomen pain for last 2 days.The pain was moderate type radia ng to epigastric region.Her last menstrual period was 18 days back but the flow was scanty.Her pa ern of menstrual flow had reduced to minimal and used to have dysmenorrhea since her last childbirth.A erwards she had planned for concep on but she had not consulted doctors for infer lity.
On examina on she was obese, pale but hemodynamically stable with mild elevated in blood pressure.Her abdomen was tender on palpa on, mostly on the right side.On per speculum, minimal altered bleeding was seen, cervix looked normal.On bimanual examina on, there was tenderness on right fornix, cervical mo on tenderness was present and size of uterus was difficult to delineate.Her pregnancy test was twice repeated and came out to be posi ve but she was not expec ng to be pregnant, as she had difficulty in concep on for such a long me since her last childbirth.Then she was advised to do an ultrasound of abdomen and pelvis.Her ultrasound report showed small fibroid in fundus with IUCD in uterine cavity, gesta onal sac of 10.4mm in right adnexa with moderate fluid in pelvic cavity.History regarding IUCD revealed that she had forgo en it a er which was inserted a er five months of her last childbirth on her first resump on of menstrua on at a near by health post.She had no proper knowledge of its dura on of use and when to remove.She assumed that the contracep ve effect of it would wear off on its own a er certain period of me and ignored its presence, as she had no serious effect.
A erwards she was admi ed in the hospital and planned for laparotomy.Her blood report showed hemoglobin of 8.0 gm/dl.Her pulse rate and abdominal pain was increasing, however her blood pressure was high.
Before star ng laparotomy, IUCD with missing thread was removed with forceps.Laparotomy was proceeded, and the findings were -hemoperitoneum of 1.5litres, right tube edematous, bulge at ampula, oozing from the fimbrial end.Right total salphingectomy with periteonal lavage was done.Pa ent was stable throughout and in postopera ve period.Pa ent did well and was discharged on third post-opera ve day.

DISCUSSION
Studies have shown that device may be less effec ve for ectopic pregnancy preven on then for intrauterine 5 pregnancy preven on.The risk of ectopic pregnancy resul ng from contracep ve failure varies according to the contracep ve method used.Condoms use show no increased risk, oral contracep ve pills show a slightly increased risk, but in contrast IUCD use and tubal steriliza on, both show 6 strongly increased risk.In IUCD users, risk of pregnancy is less but if pregnant, chance of being ectopic is more.This pa ent was not pregnant for 25 years but as she conceived it turned out to be ectopic.There are studies, which showed that extended use of IUCD would prevent pregnancy.So it is not copper only but the device itself plays role for preven on of pregnancy.As in this case, the copper was ge ng shed.So, regarding the lifespan of copper IUCD, the fact is that inert IUCDS (i.e.unmedicated IUCD such as lippes loop) has demonstrated contracep ve efficacy via the local inflammatory effect on endometrium, raising the theore cal possibility that medicated IUCD may exert some of contracep ve effect, even a er copper concentra on is 3 undetectable.
Hence, proper counseling of the contracep ve method being used should be done.One should focus on the need for follow up and examina on periodically and if any signs and symptom occurs.Long-term users are at risk of pelvic inflammatory disease, perfora on of uterus on heading to menopause and perimenopausal bleeding.

CONCLUSION
Family planning programs should aim to improve quality of services through proper counseling and follow-up services, which helps to support women's con nua on of effec ve methods.This case report showed that the quality and level of counseling to the pa ent was very poor.It may also be the possibility the pa ent was told but she may have forgo en, though she denied this fact.Though, IUCD in place for such a long me did not cause serious effect, it should not be le in situ for more than its dura on as complica ons can occur at any stage, mild or serious.So proper counseling of device and follow up mandatory even if no side effect of the device, should be stressed upon.

4 female
steriliza on.Ectopic pregnancy is a major cause of maternal morbidity and occasionally mortality.In recent decades, the incidence of ectopic pregnancy has increased; contracep ve failure has 5 been considered one of the factors.Ectopic pregnancy is simply a fer lized ovum implanted outside the uterine cavity, most common involvement being fallopian tube.Risk factor for ectopic pregnancy are PID, endometriosis, IUCD use, tubal surgery, pregnancy a er tubal liga on, progesterone only pills use, ovula on induc on and assisted reproduc ve 2 techniques.The incidence of pregnancy is less but the risk of ectopic is more if pregnant occur in IUCD users, risk being approximately 1 in 20.A WHO mul centric study found that IUCD users are 50% less likely to experience an ectopic 4 pregnancy than non-contracep ve users.