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[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
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[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

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

  1. Beatty MN, Blumenthal PD. The levonorgestrel-releasing intrauterine system: Safety, efficacy, and patient acceptability. Ther Clin Risk Manag. 2009;5(3):561-74.
  2. http://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/pdf/family-planning-methods-2014.pdf
  3. http://www.cdc.gov/reproductivehealth/contraception/pdf/management-during-contraception_508tagged.pdf

Authors:

Claire