Intrauterine device problems

Paragard, Mirena, and Skyla

Background

• Intrauterine devices (IUDs) are one of the most effective contraceptive methods
• T-shaped device inserted through cervix, can be used for up to 3-12 years
• Serious complications are rare, <1% of women with IUDs
• Copper IUD (Paraguard):
  • lasts up to 12 years, no hormones, usually cheaper
  • tend to cause more side effects (heavy/irregular menses, pelvic pain)
  • also extremely effective as emergency contraception if inserted within 120 hours of unprotected sex
• Hormonal IUDs (Mirena, Liletta, Mirena, Skyla, Kyleena): secrete small amount of progestin (levonorgestrel)
  • MIrena effective up to 6 years, the others for 3-5 years
  • Menses tend to get significantly lighter or disappear altogether after the first few months
  • Very little progestin absorbed systemically, so women tend NOT to have the hormonal side effects or increased DVT/PE risk associated with oral contraceptives

Complications and Management

"Lost" IUD

• Most common IUD-related reason for ED presentation
• Small removal strings are left protruding from cervix on insertion
• Women are instructed to feel for string with finger, if strings seem shorter or cannot be felt, may indicate malposition or complication
• Management:
  • Attempt to visualize strings
  • If cannot, IUD position can be confirmed on ultrasound or (for copper IUDs) abdominal x-ray
  • If extrauterine, needs surgical removal

IUD on ultrasound

Uterine perforation

• Extremely rare
• Suspect in patient with IUD and symptoms of endometritis, salpingitis, and/or peritonitis
• Diagnosed by imaging: IUD may be imbedded in uterine wall or free in peritoneum
• Requires emergent Ob/gyn consult for surgical removal/repair

Pregnancy with IUD in place

• Extremely rare, as IUDs are >99% effective in preventing pregnancy
• Increased risk of ectopic pregnancy if hCG positive and IUD still in place
• Consult OB/Gyn for urgent evaluation/management

PID

• IUD use associated with increased rate of PID, particularly in first 21 days after insertion
• Related to preexisting STDs rather than the IUD itself
  • Screening at time of insertion greatly reduces PID risk
• Management of PID with IUD in place
  • CDC does NOT recommend empirically removing IUD, as it is not the source of infection
  • No change in usual antibiotic treatment (ceftriaxone + azithromycin or doxycycline +/- metronidazole
  • If patient has had IUD for <3 weeks, consider referring to OB/Gyn for possible removal

Other Adverse Effects

• More common with copper IUD
• Irregular menses
• Heavy vaginal bleeding
• Pelvic pain

IUD Removal

• No real indication for removal in the emergency department
• However, if patient desires removal and outpatient referral is unfeasible, can be safely removed in the ED:
  • Visualize string(s) protruding from cervix
  • Grasp string with Kelly clamp or long forceps
  • Pull with steady, gentle force until device emerges
  • Do NOT jerk string, as this may detatch string from device, making removal much more difficult

See Also

• Pelvic pain, Vaginal bleeding
• Ectopic pregnancy
• PID

References

Authors

Claire