Soper

but becomes negative once donor cells have been de­stroyed. An elevated unconjugated serum bilirubin and a relative decrease in serum haptoglobin may be helpful serologic tools. Demonstration of red blood cell alloan­tibodies, not present before transfusion, can confirm the diagnosis of delayed hemolytic transfusion reaction, when combined with the clinical and laboratory evi­dence of hemolysis mentioned above.

The morbidity associated with delayed hemolytic transfusion reaction is proportional to the amount of incompatible blood transfused. Persistent anemia and fever are the most common complications. Further transfusions in the affected patient may precipitate an acute hemolytic transfusion reaction. Repeat anti­body studies are essential, and subsequent transfusions should be considered dangerous until one can identify

September 15, 1985 Am J Obstet Gynecol

the offending antigens. These antigens are usually found in the Rh, Kidd, Duffy, and/or Kell systems.

Delayed hemolytic transfusion reaction is an uncom­mon complication of blood transfusion. The gynecol­ogist should be aware of this phenomenon in order to prevent further morbidity by subsequent blood trans­fusions as well as to avoid the inappropriate use of antibiotics in the therapy of a late postoperative fever not secondary to infection.

REFERENCES

I. Solanki D, McCurdy PR. Delayed hemolytic transfusion reactions. JAMA 1978;239:729.

2. Wintrobe MM, ed. Clinical hematology 8th ed. Philadel­phia: Lea & Febiger, 1981:504.

3. Pineda AA, Taswell HF, Brzica SM. Delayed hemolytic transfusion reaction. Transfusion 1978;18:107.

Management of the missing intrauterine contraceptive device: Report of a case

John C. Gorsline, M.D., and Newton G. Osborne, M.D., Ph.D.

Syracuse, New York

A case of postpartum intrauterine contraceptive device insertion that resulted in a remote complication is described. At the postinsertion follow-up visit the intrauterine contraceptive device was missing and presumed expelled. Four years later it was recovered from a complex mass involving the bladder and the appendix. Management for the missing intrauterine contraceptive device is recommended. (AM J OBSTET

GYNECOL 1985;153:228-9.)

Key words: Management, intrauterine contraceptive device

Problems unique to intrauterine contraceptive de­vices such as uterine perforation and silent expulsion have been described. 1.

2 The incidence of these com­plications appears to be related to the experience of the clinician and, to some degree, to the timing of in­sertion. Most perforations occur at the time of inser­tion. The rate of expulsion varies between 2% and 20% in the first year of use. Devices inserted in the post­partum and postabortion periods are reportedly more prone to expulsion. Half of the expulsions occur within the first 3 months following insertion. The device may be missing as a result of tail retraction into the uterus,

From the Department of Obstetrics arul Gynecology, Upstate Medical Center, State University of New York.

Received for publication January 14, 1985; revised February 14, 1985; accepted February 25, 1985.

Reprint requests: Newton G. Osborne, M.D., Ph.D., Department of Obstetrics arul Gynecology, State University of New York, Upstate Medical Center, 750 E. Adams St., Syracuse, NY 13210.

expulsion, or perforation. The overall rate has been reported as 0.9/1000 insertions.

We report a case of unrecognized uterine perforation that was associated 4 years later with a complication that required surgical intervention.

Case report L. L., a 27-year-old woman, gravida 9, para 5-0-4-5,

had a normal spontaneous vaginal delivery 8 months before her hospital visit, followed by a postpartum tubal ligation. The patient was well up to 4 weeks before admission when she had intermittent right lower-quad­rant abdominal pain and severe dyspareunia. She also noticed, 2 weeks before admission, difficulty in initia­tion of micturition associated with occasional chills but no fever. Two days before admission the pain inten­sified in severity and compelled her to seek medical attention.

The patient reported that a Cu-7 intrauterine con­traceptive device was inserted in 1980 during her 6-

Volume 153 Number 2

week postpartum visit. She was unable to feel the strings of the intrauterine contraceptive device 1 week later, but at the follow-up examination, she was told that the device had been expelled. The patient opted to use a

. barrier method of contraception, and no further stud­ies were performed to document expulsion. Subse­quently, the patient had two uneventful pregnancies and vaginal deliveries.

On physical examination she was found to have a right-sided pelvic mass estimated to be 7 cm in diam­eter. The mass was firm and fixed. The uterus was normal in size and configuration, but on uterine and cervical motion, there was referred pain to the area of the right adnexa.

A sonogram revealed a 5 cm right pelvic mass inter­preted as a right ovarian tumor. On admission, the patient had a normal complete blood cell count, uri­nalysis, and kidney function tests. Results of a quali­tative serum test for the f3-subunit of human chorionic gonadotropin were negative.

The patient underwent an exploratory laparotomy. The uterus was found to be normal. Both fallopian tubes were interrupted at the isthmic portion. The ova­ries were normal with a small follicular cyst on the right ovary. A mass was noted on the posterior right bladder wall partially dissecting the leaves of the broad ligament on the right side. The cecum was fixed in the same area, forming a complex mass that involved the ap­pendix. The mass was firm, having the consistency of hard rubber. It extended anteriorly and obliquely out of the lesser pelvis along the right lateral pelvic wall behind the peritoneum and involved the right round ligament. It was intimately associated with the bladder muscularis. The adhesions between the cecum and lat­eral peritoneum were lysed, and an inflamed appendix perforated by a Cu-7 was noted. The device was re­moved and an appendectomy was performed. No sup­puration or abscess cavity was found. A needle biopsy of the mass revealed acute and chronic inflammatory

Missing intrauterine contraceptive device 229

granulation tissue with fibrosis. Cultures yielded no growth.

After operation the patient had a fever of 39° C that responded to parenteral penicillin, clindamycin, and gentamicin. She was discharged on the fifth postop­erative day on a regimen of ampicillin by mouth for 5 additional days. On her outpatient visit I month after operation she was completely asymptomatic, and no unusual pelvic masses or tenderness could be detected.

Comment

It is impossible to determine when the intrauterine contraceptive device became involved with the appen­dix or how they in turn became involved with the blad­der wall, but early recognition of perforation might have prevented this complication. Failure to locate the strings of the device at any time in a patient who has not noticed expulsion should be considered a perfo­ration until proved otherwise. Any other assumption may be dangerous.

When the strings are not visible, a thorough search for the device is mandatory before a diagnosis of ex­pulsion is made. This search should include a sonogram and, if inconclusive, abdominal x-ray examination may be required. In this case, the sonogram failed to reveal the Cu-7 in the phlegmonous mass. It is advisable to obtain anteroposterior and lateral x-ray views with a contrast medium in the uterine cavity if other studies fail to provide a definite answer about the location of the intrauterine contraceptive device.

REFERENCES

I. Burkman RT, The Women's Health Study. Association be­tween intrauterine device and pelvic inflammatory disease. Obstet Gynecol 1981;57:269.

2. Mishell DR. Intrauterine devices. In: Newton JR, ed. Clin­ics in obstetrics and gynecology, vol two. Contraception update. Philadelphia: WB Saunders, 1984:689.