The art of plain radiography is disappearing fast, with the advent of ultrasonography, CT and MRI. However doctors still continue to ask for and perform these studies. One such study is plain radiograph of the pelvis with a sound in the uterine cavity, to localize missing IUDs. Actually ultrasonography localizes all of these in the uterine cavity and most of these outside it, unless bowel gas shadows obscure the IUD.
One of my old colleagues had a patient who presented with missing threads of an IUD. This patient used to menstruate regularly and had not missed a period. There was no abnormal finding on pelvic examination. Someone had obtained AP and lateral radiographs of her pelvis. They looked as follows.
"Where do you think is the IUD?" she asked.
"If the sound is in the uterine cavity, the IUD has probably perforated the uterus, at least partially" I said. "The lateral view shows the IUD going perpendicular and away from the tip of the sound. But there is no vulsellum on the cervix, which if held together with the sound would have prevented slipping of the sound.
If the sound has slipped out of the uterus when the patient was moved from supine to lateral position, the IUD could still be in the uterine cavity. Did you obtain a pelvic ultrasonogram?"
"Yes. It shows the IUD within the uterine cavity. But we don't believe it. We are going to perform a laparoscopy and hysteroscopy on her and remove the IUD. If it is a partial perforation, the tip could be in the peritoneal cavity and there is no knowing what it might have perforated, say bowel?"
"Let me know what the outcome is" I said.
I scanned the radiographs and took opinions of my staff members and exam-going residents on those images. I showed them only the AP plate and asked their expert opinion, checking various parameters discussed by them, their diagnosis and recommendations for management. The results are in the following table, the figures indicating percentage.
I offer no discussion or conclusion. I leave it for my readers to do.
When they operated on the case, the IUD was found within the uterine cavity. The vulsellum had been removed after placing the sound in place. It just goes to show the importance of holding the vulsellum and sound together.
One of my old colleagues had a patient who presented with missing threads of an IUD. This patient used to menstruate regularly and had not missed a period. There was no abnormal finding on pelvic examination. Someone had obtained AP and lateral radiographs of her pelvis. They looked as follows.
"If the sound is in the uterine cavity, the IUD has probably perforated the uterus, at least partially" I said. "The lateral view shows the IUD going perpendicular and away from the tip of the sound. But there is no vulsellum on the cervix, which if held together with the sound would have prevented slipping of the sound.
If the sound has slipped out of the uterus when the patient was moved from supine to lateral position, the IUD could still be in the uterine cavity. Did you obtain a pelvic ultrasonogram?"
"Yes. It shows the IUD within the uterine cavity. But we don't believe it. We are going to perform a laparoscopy and hysteroscopy on her and remove the IUD. If it is a partial perforation, the tip could be in the peritoneal cavity and there is no knowing what it might have perforated, say bowel?"
"Let me know what the outcome is" I said.
I scanned the radiographs and took opinions of my staff members and exam-going residents on those images. I showed them only the AP plate and asked their expert opinion, checking various parameters discussed by them, their diagnosis and recommendations for management. The results are in the following table, the figures indicating percentage.
Residents
|
Assistant Professors
|
Senior Faculty
| |
Asked for lateral radiograph
|
55.56
|
80
|
100
|
Asked for ultrasonogram
|
7.41
|
20
|
0
|
Comment on absence of Vulsellum on cervix
|
0
|
0
|
0
|
Perforation by sound
|
0
|
0
|
0
|
Downward displacement
|
0
|
0
|
0
|
Correct diagnosis, assuming sound was in the uterine cavity
|
40.74
|
30
|
80
|
I offer no discussion or conclusion. I leave it for my readers to do.
When they operated on the case, the IUD was found within the uterine cavity. The vulsellum had been removed after placing the sound in place. It just goes to show the importance of holding the vulsellum and sound together.
