Intrauterine device complications: Difference between revisions
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==Background== | |||
[[File:Blausen 0400 FemaleReproSystem 02b.png|thumb|Pelvic anatomy including organs of the female reproductive system.]] | |||
[[File:IUDs.png|thumb|Paragard, Mirena, and Skyla]] | [[File:IUDs.png|thumb|Paragard, Mirena, and Skyla]] | ||
*Intrauterine devices (IUDs) are one of the most effective contraceptive methods | *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 | *T-shaped device inserted through cervix, can be used for up to 3-12 years | ||
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**tend to cause more side effects (heavy/irregular menses, [[pelvic pain]]) | **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 | **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) | *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 | **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 | **Menses tend to get significantly lighter or disappear altogether after the first few months | ||
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==Complications and Management== | ==Complications and Management== | ||
[[File:IUDUS.png|thumb|IUD on ultrasound]] | |||
==="Lost" IUD=== | ==="Lost" IUD=== | ||
*Most common IUD-related reason for ED presentation | *Most common IUD-related reason for ED presentation | ||
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**If cannot, IUD position can be confirmed on [[ultrasound]] or (for copper IUDs) abdominal x-ray | **If cannot, IUD position can be confirmed on [[ultrasound]] or (for copper IUDs) abdominal x-ray | ||
**If extrauterine, needs surgical removal | **If extrauterine, needs surgical removal | ||
===Uterine perforation=== | ===Uterine perforation=== | ||
*Extremely rare | *Extremely rare | ||
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*Diagnosed by imaging: IUD may be imbedded in uterine wall or free in peritoneum | *Diagnosed by imaging: IUD may be imbedded in uterine wall or free in peritoneum | ||
*Requires emergent Ob/gyn consult for surgical removal/repair | *Requires emergent Ob/gyn consult for surgical removal/repair | ||
===Pregnancy with IUD in place=== | ===Pregnancy with IUD in place=== | ||
*Extremely rare, as IUDs are >99% effective in preventing pregnancy<ref>http://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/pdf/family-planning-methods-2014.pdf</ref> | *Extremely rare, as IUDs are >99% effective in preventing pregnancy<ref>http://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/pdf/family-planning-methods-2014.pdf</ref> | ||
*Increased risk of [[ectopic pregnancy]] if hCG positive and IUD still in place | *Increased risk of [[ectopic pregnancy]] if hCG positive and IUD still in place | ||
*Consult OB/Gyn for urgent evaluation/management | *Consult OB/Gyn for urgent evaluation/management | ||
===[[PID]]=== | ===[[PID]]=== | ||
*IUD use associated with increased rate of PID, particularly in first 21 days after insertion | *IUD use associated with increased rate of PID, particularly in first 21 days after insertion | ||
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**No change in usual antibiotic treatment ([[ceftriaxone]] + [[azithromycin]] or [[doxycycline]] +/- [[metronidazole]] | **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 | **If patient has had IUD for <3 weeks, consider referring to OB/Gyn for possible removal | ||
===Other Adverse Effects=== | ===Other Adverse Effects=== | ||
*More common with copper IUD | *More common with copper IUD | ||
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*Heavy [[Vaginal Bleeding (Non-Pregnant)|vaginal bleeding]] | *Heavy [[Vaginal Bleeding (Non-Pregnant)|vaginal bleeding]] | ||
*[[Pelvic pain]] | *[[Pelvic pain]] | ||
===IUD Removal=== | ===IUD Removal=== | ||
*No real indication for removal in the emergency department | *No real indication for removal in the emergency department | ||
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==See Also== | ==See Also== | ||
*[[Pelvic pain]] | *[[Pelvic pain]] | ||
*[[Vaginal bleeding]] | |||
*[[Ectopic pregnancy]] | *[[Ectopic pregnancy]] | ||
*[[PID]] | *[[PID]] | ||
*[[Medical device complications]] | |||
==External Links== | ==External Links== | ||
Latest revision as of 20:33, 3 August 2022
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[1]
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
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[2]
- 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[3]
- 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
External Links
References
- ↑ Beatty MN, Blumenthal PD. The levonorgestrel-releasing intrauterine system: Safety, efficacy, and patient acceptability. Ther Clin Risk Manag. 2009;5(3):561-74.
- ↑ http://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/pdf/family-planning-methods-2014.pdf
- ↑ http://www.cdc.gov/reproductivehealth/contraception/pdf/management-during-contraception_508tagged.pdf