AN UNUSUAL CASE OF A MISPLACED INTRAUTERINE CONTRACEPTIVE DEVICE
Ajita J Nawale*, Suleman A Merchant**,Shyam Sunder R Koteyar*, Anagha R Joshi***
*Lecturer; **Professor and Head; ***Assoc. Professor; Department of Radiology, LTM Municipal Medical College and LTM General Hospital, Sion, Mumbai 400 022.
We wish to report a case of a misplaced Lippe’s loop in an elderly woman with a pelvic mass that was erroneously diagnosed as an ovarian cyst. We have discussed the role the misplaced Lippe’s loop has played in arriving at the correct diagnosis and other USG features that pointed to the correct diagnosis. We have also discussed at length the imaging features of the case and provided a brief review of the literature.
A seventy year old woman, (fourth gravida) came with the complaint of a lump in the pelvis, noticed since four months, associated with dribbling of urine. She was postmenopausal since twenty-five years and was diagnosed as a case of an ovarian cyst on USG done at a private centre.
We performed a transabdominal ultrasound (Fig. 2) on the patient, which revealed a cystic well defined midline pelvic “mass” with low level internal echoes. The ovaries were not appreciated on this modality. The spiral turns of the Lippe’s loop were noted attached to the right lateral wall of the “mass” and was adherent to it in all positions. The rim of tissue outlining the “mass” had characteristics of the uterine wall. The left kidney revealed a mildly dilated pelvicalyceal system and ureter and was significantly smaller in size than the right kidney. A bladder calculus was also seen along with a normal right kidney.
This findings of a “rim” of uterine tissue along with that of the Lippe’s loop inside the “mass lesion” enabled us to arrive at a conclusion that the “mass” was a fluid filled uterine cavity. A cause of obstruction to the outflow of uterine contents was looked for. The cervix was not well delineated on TA study. On the basis of these findings a diagnosis of hydrometra was made.
As the patient refused a transvaginal ultrasound, transperineal ultrasound (Fig. 3) was performed to find the cause of the hydrometra was made. This was confirmed later on cervical biopsy.
A CT scan (Fig. 1) of the patient showed the “mass” as being a hypodense (HU : 12) pelvic lesion with intra-abdominal extension, however as the ovaries were not seen separately from the “mass” (which is not unusual at this age) an ovarian origin of the “mass” could not be ruled out. It measured 16.3 x 15 cm in size. It showed a radio-opaque linear density (which was confirmed to be the Lippe’s loop) adherent to the inner aspect of the right lateral wall of this “mass”.
Here again the presence of the Lippe’s loop within the “mass” suggested that it was a fluid filled uterine cavity, which was grossly distended. Ultrasound in this case enabled the correct diagnosis to be made with much greater confidence on account of the uterine “rim” being very well seen (along with the presence of the Lippe’s loop within the “mass”), which was more clearly visualised on this modality than CT.
Fig. 1 : CT scan image revealing a large cystic lesion with a linear radiodensity adjacent to the right lateral wall.
Fig. 2 : USG : same cystic lesion evaluated by USG. the individual limbs of the lippe's loop are clearly visualised (arrow ) and so is the thin rim of the uterine wall which is seen as a hypoechoic layer outlining the periphery of the cystic "mass".
Obstruction of the female genital tract may occur at different levels. In the adult, obstruction is usually at the cervical level, whatever the cause. Obstruction leads to an accumulation of fluid, which may be serous, due to mucus, secretion by cervical or vaginal glands, menstrual blood, or pus. Fluid collections are significantly associated with carcinoma of the uterus. Such hydrometra or haematometra are usually caused by obstruction from cervical carcinoma.[1-3]
In this case an endocervical growth was the cause of the hydrometra, with chronically inspissated mucus or blood giving the low-level internal echoes within the fluid collection on ultrasound. The Lippe’s loop had as a result migrated upward and got adherent to the right lateral wall of the uterus.
The interesting part of this case was that the patient was referred as a case of an ovarian cyst diagnosed on USG done at a private centre, (which was possible considering her age and the cystic pelvic lesion). Ultrasound guided us to the fact that (due to the rim of uterine tissue noted around the cystic “mass”, which was in the shape of the uterus), the “mass” was indeed a hydrometra. In this case the Lippe’s loop had its own role to play. Though extrauterine locations are known, it would be impossible for the Lippe’s loop to have got within an ovarian cyst. The presence of the Lippe’s loop within the “mass” guided us to the fact that the collection was intrauterine. The subsequent transperineal USG pinpointed the cause of obstruction as being an endocervical growth, which is the commonest cause of hydrometra, at this age.
Fig. 3 : Transperineal USG revealing the cervical growth.
Though USG is an often overlooked modality as compared to CT, in this case USG proved to be the prime modality in leading to the diagnosis. The Lippe’s loop was an additional aid by its sheer presence within the collection which proved it to be a hydrometra.
To conclude, pelvic USG though often underutilized, is a primary investigation of choice in arriving at a diagnosis. Transperineal USG helps in those patients where transvaginal USG cannot be performed. In our present case the presence of the Lippe’s loop within the “mass” proved to be tremendously useful in excluding this “mass” to be of ovarian origin and confirming the uterine origin of the “mass”, with its obvious implications to the further management of the patient.
1. Healther S Andrews. Uterine pathology. In : Keith Dewbury, Hylton Meire, David Cosgrove, Barry B Goldberg eds. Clinical ultrasound : a comprehensive text : Ultrasound in Obstetrics and Gynaecology.Churchill Livingstone pub. Edinburgh. 1993; 3 : 35-36.
2 Breckenridge JW, Kurtz AB, Ritchie WGM, Macht EL. Postmenopausal uterine fluid collections : indicator of carcinoma. AJR 1982; 139 : 529-34.
3. Carol M Rumack, Stephanie R Wilson, J William Charboneau. The uterus and adnexa - Shia Salem. Diagnostic ultrasound. 1991; 1 (16) : 383-412.