The Wandering Mirena: Laparoscopic Retrieval.

2011·0.2 MB·English

by  Erian, Mark

C R
ASE EPORT
The Wandering Mirena: Laparoscopic Retrieval
Mark Erian, FRANZCOG, FRCOG, DM,
Glenda McLaren, FRANZCOG, FRCOG, David Baartz, FRANZCOG
ABSTRACT SUMMARY OF CLINICAL FEATURES
Levonorgestrel-containing intrauterine contraceptive de-
Patient One
vices,marketedasMirena(BayerHealthCarePharmaceu-
ticals, Inc. Australia) are widely used in contemporary
CM is a 44-year-old multiparous lady, with children 19 and
gynecology, primarily as an effective method for contra-
17 years of age. She delivered both of her children by
ception and for control of menstrual disorders like men-
spontaneous vaginal deliveries. About 15 months ago, she
orrhagia and dysmenorrhea. In this article, the authors
was fitted with a Mirena for contraception. Regular vaginal
report 2 cases of Mirena migration following intrauterine
examinations by her family physician confirmed that the
insertion by general practitioners (family physicians). In threads of Mirena were coming off the uterine cervix. She
the first case, the contraceptive device had moved to the was totally asymptomatic when she went for a periodic
patient’srightiliacfossajustanteriortothececumand,in cervicalsmear,atwhichpointthisproblemwiththeMirena
the second, within the peritoneal cavity close to the left device was detected. Ultrasound scan confirmed that the
leaf of the diaphragm. Both patients underwent unevent- devicewasnotpresentwithintheuterinecavity.Acomput-
ful laparoscopic retrieval of the devices. erized tomography scan showed that the device had at-
tached to the posterior aspect of the patient’s right rectus
Key Words: Mirena, Laparoscopic removal.
sheath. Laparoscopy was performed by using the “triple
port”ofentry,andthedevicewasfoundinthepatient’sright
iliac fossa just above her cecum and was surrounded by
omental adhesions. Laparoscopic adhesiolysis was affected
to free the device off the omental and cecal adhesions and
that was followed by laparoscopic retrieval of the Mirena
(Figures 1 and 2). The procedure was uneventful, and
there was no sign of uterine perforation. The patient was
dischargedaftertheoutpatientprocedure.
Patient Two
NG is a 19-year-old single lady. She underwent an unre-
markable vaginal suction termination of her first preg-
nancy (STOP) at about 8 week’s gestation and was fitted
withaMirena,atthesametime,bythetreatingphysician.
Shewasadmittedtothehospital10daysaftertheMirena
insertion with a history of acute severe pelvic pain that
required administration of narcotic analgesic injections.
HighDoctorateofMedicine,UniversityofQueensland,RoyalBrisbaneandWom-
en’sHospital,Brisbane,Queensland,Australia(DrErian). Ultrasoundscanningshowedthattheuteruswas“empty.”
SeniorConsultantObstetricianandGynaecologist,MaterMother’sHospital,Bris- PlainX-rayoftheabdomenshowedthattheMirenawasin
bane,Queensland,Australia(DrMcLaren). theperitonealcavityclosetothepouchofDouglas.Emer-
SeniorConsultantObstetricianandGynaecologist,RoyalBrisbaneandWomen’s gencylaparoscopy(“tripleport”ofentry)wasperformed,
Hospital,Brisbane,Queensland,Australia(DrBaartz).
and the peritoneal cavity was carefully inspected. The
Address correspondence to: A/Professor Mark Erian, 6th Floor, Teaching and Mirena was spotted within approximately 3cm of the left
Research,NedHanlonBuilding,RoyalBrisbaneandWomen’sHospital,Herston,
leaf of the diaphragm (Figures 3 and 4). There was no
Queensland4029,Australia.Email:[email protected]
sign of uterine perforation. Laparoscopic removal of the
DOI:10.4293/108680811X13022985131732
device was carried out smoothly, and the patient was
©2011byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. discharged after the outpatient procedure.
JSLS(2011)15:127–130 127
TheWanderingMirena®:LaparoscopicRemovalofaMigratedMirena®ContraceptiveDevice,ErianMetal.
Figure 1. Migrated Mirena® lying within abdominal cavity on Figure 3. Migrated Mirena® is close to the left leaf of the
topofthececum,surroundedbyomentaladhesions. patient’sdiaphragm.
Figure 2. Laparoscopic retrieval of the migrated Mirena® de- Figure 4. Laparoscopic retrieval of the migrated Mirena® de-
vice,followinganadhesiolysisprocedure. vice.
As a contraceptive, Mirena is probably the most effective
DISCUSSION reversiblemethodofcontraception8andwithouttheneed
totakedailyoralmedication,asisthecasewithcombined
The levonorgestrel-releasing intrauterine system (LNG-
oral contraceptive or progesterone-only pills.9 It is well
IUS, Mirena) is the most widely used contraceptive
tolerated,longacting,reversible,andadequatelyretained
method,withprevalenceratesrangingamongcountries
within the uterine cavity. Patient satisfaction is high with
from 2% to 80% of contraceptive users.1 It releases
acceptance among parous and nulliparous women alike,
20(cid:1)gm of levonorgestrel/day2 and is used as an effec-
asintheabove2patients,anditalsoprovidesreassuring
tive and reliable method of contraception, to manage
results for clinicians and adolescents considering use of
menstrual disorders as in menorrhagia3 and dysmenor-
Mirena.10
rhoea,4 as an endometrial protective agent in women
usinghormonalreplacementtherapy(HRT),5andinthe Inaddition,Mirenaisusuallyrecommendedasameansof
management of select cases of endometrial carcinoma6 contraception in “high risk” patients as in those with a
andprecancerousconditions,suchasatypicalendome- historyofdeepvenousthrombosis,11type1diabetesmel-
trial hyperplasia.7 litus,12 liver disease,13 epileptic seizures,14 and immuno-
128 JSLS(2011)15:127–130
compromised conditions including HIV.15 Nevertheless, nician and the patient that an unwanted pregnancy in
likemanytherapeuticsincontemporarymedicine,Mirena the future is very unlikely with the Mirena device in-
has some side effects. Continuing pain and discomfort as sertedonthesameoccasionastheterminationofpreg-
wellasirregularvaginalbleedingaremostlikelythemain nancy is to be carried out.27
reasons for patients’ requests to discontinue the Mirena
device therapy.16 Discontinuation is accompanied by re- CONCLUSION
turn of fertility.17 Contrary to old views, the device does
Because Mirena is gaining in popularity among clinicians
not increase the incidence of pelvic inflammatory dis-
and enjoys a wide range of candidacy among gynecolog-
ease18 and infertility, nor does it enhance tubal ectopic
icalpatients,itisimperativethathealthcareprovidersare
pregnanciesinwomenwithnosexuallytransmittedinfec-
fully informed of the value as well as the possible side
tions.19 In fact, Mirena may be considered protective
effects of the device, notably uterine perforation. An ex-
against infection, especially in nulliparous women.20
perienced gynecological endoscopist should be able to
Uterineperforationrelatedtotheinsertionofthisdeviceis safelyremoveamissedMirenaoutoftheperitonealcavity
one of the recognized side effects of Mirena. The inci- without any complications.
dence of such perforations varies from 0 to 2.6 per 1000
insertions and is largely related to the experience of the References:
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