CONGENITAL VIRILIZATION AFTER TWO PREGNANCIES WITH RETAINED INTRA-UTERINE MIRENA® DEVICE
Helen Hougen, MD, Casey Seideman, MD, Christopher Austin, MD.
Doernbecher Children's Hospital at Oregon Health and Science University, Portland, OR, USA.
Background: Pregnancy rate after hormonal intrauterine device (IUD) placement is low. The postnatal consequences of intra-uterine pregnancy with a retained IUD are not well-described. Mirena® is an IUD that secretes levonorgestrel, a progesterone analog. We aim to describe two patients with labial fusion and urogenital sinus after pregnancy complicated by retained Mirena® IUD.
Methods: Chart review was performed for two patients referred to urology clinic for ambiguous genitalia. Both were term 46 XX females whose pregnancies were complicated by a retained Mirena IUD. Both patients were taken to the operating room for initially exam under anesthesia (EUA), cystoscopy, vaginoscopy, then later vaginoplasty. We describe the operative outcome of these two cases.
Results: Both patients were found to have normal length clitoris, small but present labia minora, fusion of the labia majora with short urogenital sinus with normal single patent vagina and cervix, and a long perineal body with normal anal location. Workup for congenital adrenal hyperplasia, and other disorders of sexual differentiation was negative. Subsequently, vaginoplasty was performed for both patients. A posterior flap vaginoplasty was performed in both patients without need for significant urogenital sinus mobilization (Figure). No operative complications occurred. Both patients recovered appropriately, voided spontaneously and were discharged on post-operative day 1.
Conclusions: We present the first report of congenital virilization associated with persistent hormone IUD during pregnancy. While the presence of retained IUDs has been associated with increased maternal complications, and high doses of progestins during pregnancy have been associated with fetal virilization, no reports have associated the presence of a hormone IUD with increased fetal malformations thus far.
Figure. Pre- and post-op appearance of the genitalia of one patient.
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