IUDs in the ED

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To better understand what emergency physicians need to know about Intrauterine Devices (IUDs), EPM reached out to Jaiva Larsen, MD, and Patty Cason, FNP, who conducts trainings across the United States on placement, complications and management of intrauterine contraception.

Q. How prevalent are IUDs?
Over the last ten years, use of Intrauterine Devices (IUDs) has increased dramatically. Emergency departments can expect to see more and more women who are using an IUD as their contraceptive method. The term LARC (Long Acting Reversible Contraception) refers to IUDs and contraceptive implants. LARC methods are more effective and convenient than other forms of birth control. ACOG, CDC, and AAP all endorse the use of IUDs and contraceptive implants as first line in patients needing contraception.  In the past, IUDs were offered predominantly to women who already had children. The package insert language was changed in 2005 to remove language suggesting nulliparous women should avoid IUDs. IUDs are also sometimes used for their non-contraceptive indications, such as heavy menstrual bleeding or dysmenorrhea. Post-menopausal women may have IUDs containing levonorgestrel as the progestin portion of their hormone therapy for menopausal symptoms.

Q. How many types of IUDs are there?
There are five types of IUDs. The non-hormonal (copper) IUD is PARAGARD. There are four IUDs containing levonorgestrel (LNG): Mirena, Liletta, Kyleena, and Skyla. However, like most things in medicine there are a few different names for the same device. The copper IUD is also called CUT380A or the copper “T”. A LNG IUD may be referred to as an intrauterine system (IUS) and can be referred to by the mg of levonorgestrel in its reservoir. For example, Mirena and Liletta would be called LNG IUS 52. Kyleena and Skyla contain less LNG and may be called LNG 19.5 and LNG 13.5 respectively. To add to the confusion LNG IUDs may instead be referred to by its average daily release rate of progestin (in mcg) such as LNG 20 for Mirena and Liletta.

Q. What types of IUD complications might I encounter in the ED?
The mnemonic “3Ps” is useful for considering IUD complications in the ED.

  • PID. During the first three weeks after IUD placement, rates of infection/PID are slightly increased. For women using an IUD beyond that time period, rates of PID are equivalent to the background population. This means that a woman using an IUD is at no greater risk of developing PID than she would if she were not using an IUD.
  • Pregnancy. The risk of pregnancy with an IUD in place runs from 0.2% to 0.8%, depending on the IUD. For a woman with a hormonal IUD in place who has a positive pregnancy test, there is a 50% chance that the pregnancy is ectopic. For those with a copper IUD the chance that the pregnancy is ectopic is 6-12%.
  • Positioning. The IUD can be out of ideal location in several ways. It can be expelled or partially expelled, or if there has been a perforation, the IUD may be embedded in the myometrium, or translocated through the uterus into the abdominal cavity.

Q. What do I do if the patient has PID and an IUD in place?
In general, patients with IUDs can be treated the same as patients without IUDs in place and it is not advised to remove the IUD for PID. All women diagnosed with PID should have follow-up to assess for clinical improvement in 48-72 hours. In patients who have not had clinical improvement after antibiotic treatment for 48-72 hours, IUD removal should be considered.

Q. What should I do if the IUD is not in the correct position?
The correct position of the IUD is in the upper uterine segment with the entire device within the endometrial cavity. The patient may specifically voice a concern that the IUD is out of place, either because of symptoms such as pain or bleeding or because she can no longer feel the IUD strings. Other times, improperly positioned IUDs are an incidental finding on imaging. There are several ways for the IUD to be out of position.

  • Expulsion. Expulsion is when the IUD is expelled completely from the body and occurs in 2-10% of placements within the first year. If the strings are not visible on pelvic exam, a plain film (KUB) can show if the IUD is still in the patient.  An ultrasound can show if the IUD is present in the uterus, but by itself cannot fully exclude location outside the uterus. If the KUB shows no IUD present, the device has been fully expelled (usually in the toilet).
  • Partially expelled. If any part of the IUD other than the strings is in the endocervix or protruding out of the external cervical os, the IUD is partially expelled. It should removed as it is likely ineffective contraception and may cause discomfort. After an expulsion, a woman may safely have another IUD placed immediately or at any time thereafter. Her risk for another expulsion is increased by 30%.
  • IUD in the lower uterine segment. This is basically a variation on normal. There is no evidence of increased risk of pregnancy. Your radiologist may, however, may make note of it. IUDs are often seen on imaging to be in the lower uterine segment at one time and will subsequently be seen to have regained fundal positioning.
  • Embedded. Part or all of the IUD is embedded in the myometrium. Generally, embedded IUDs require removal, although not emergently. If the IUD is minimally embedded, it may be able to be removed with the standard procedure. However, we should never apply more then gentle traction and efforts to remove the IUD should be abandoned if any resistance is met.
  • Translocated. The IUD has perforated partially or completely through the uterine serosa into the abdominal cavity. Perforation occurs in approximately 1/1,000 IUD placements. In almost all cases, the perforation occurs during placement of the IUD, rather than migrating through uterine wall spontaneously. Diagnosis, however, is usually delayed. Translocation, particularly of a copper IUD can lead to adhesions, but damage to other organs is rare. The EURAS study followed over 68,000 women with IUD placement for 5 years and there were no serious sequella secondary to uterine perforations, IUD embedments, or translocations.

Perforation, as well as an embedded or translocated IUD that results from perforation can be entirely asymptomatic and scheduled for prompt outpatient follow-up if no other surgical emergencies are present. An IUD that is deeply embedded will have to be removed by ob/gyn using hysteroscopy or laparoscopy depending on the positioning. A translocated IUD will have to be removed by ob/gyn using laporoscopy.

Q. What should I do if the patient is pregnant with an IUD? 
The first step, as with all pregnancies, is to determine if the patient has an IUP or ectopic pregnancy. An ectopic pregnancy is managed the same as in patients without an IUD.  In intrauterine pregnancy, if the IUD strings are visible, IUD removal is recommended. Removal will entail a slight risk of spontaneous abortion, but early IUD removal significantly decreases risks of first-trimester spontaneous abortion, second-trimester spontaneous abortion, and premature delivery. If the patient consents and the strings are visible, the IUD should be removed as described below.

Q. What should I do for women who have pelvic pain, cramping, or other discomfort that may be associated with IUD use?
As with all ED evaluations we first consider a broad differential, since pelvic and abdominal symptoms are most often unrelated to IUD use. Pelvic infection or an IUD that is translocated, embedded or expelled can cause pain. In the first few weeks after placement, pain and cramping can be normal. Discomfort can be managed with NSAIDS and/or referral.

Q. What should I do for women with bleeding complaints associated with IUD use?
Abnormal bleeding is the primary side effect for which women elect to discontinue IUD use. For the copper IUD the most frequent complaint is heavier menses. Hormonal IUDs are more likely to cause frequent irregular, sometimes prolonged, spotting and light bleeding. The heavier menstrual bleeding that many women get with the copper IUD and the frequent light bleeding associated with hormonal IUDs is very likely to improve or go away altogether 3-4 months after placement. NSAIDS in high dose such as Naproxen 220 BID have been showed to reduce heavy bleeding as well as cramping or discomfort in IUD users due to prostaglandin inhibition.

Q. When and how should I remove an IUD?
If the patient desires to continue using an IUD and it is removed, it may it be logistically cumbersome, expensive and uncomfortable for her to have it replaced. There are four main reasons to consider removal of an IUD in the ED.

  1. If the device is in the endocervical canal. Do not push the IUD back into the uterus
  2. When PID is worsening or not improving 48-72 hours after starting antibiotics
  3. When there is an IUP and the IUD strings are visible
  4. In response to patient request -once her concerns and questions have been addressed

To remove a properly positioned IUD, simply grasp the IUD strings securely with a long ring (or straight) forceps and apply gentle traction toward the operator. If you encounter significant resistance do not continue to pull strings because a pre-existing embedment can be worsened or the strings may break off.

Q. What about emergency contraception?
For victims of sexual assault, EPs frequently offer hormonal methods of decreasing the risk of pregnancy (i.e emergency contraceptive pills (ECPs) containing 1.5mg levonorgestrel; Plan B One-Step, Next Choice or Take Action or ECPs containing an anti-progestin ulipristal acetate; ella). All EPs should be aware that emergent copper IUD placement is highly effective, approaching a zero failure rate, when used for emergency contraception up to 5 days after intercourse. The copper IUD is the most effective form of emergency contraception, and may be used in patients with contraindication to hormonal treatment. In circumstances when a woman needs emergency contraception consider ob/gyn consult for emergent placement.


REFERENCES

  1. Cheng L, Che Y, Gülmezoglu AM. Interventions for emergency contraception. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD001324. DOI: 10.1002/14651858.CD001324.pub4.
  2. Curtis, K. M. (2016). US selected practice recommendations for contraceptive use, 2016. MMWR. Recommendations and Reports, 65.
  3. Heinemann, K., Reed, S., Moehner, S., & Do Minh, T. (2015). Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European Active Surveillance Study on Intrauterine Devices. Contraception, 91(4), 274-279.
  4. Heinemann, K., Reed, S., Moehner, S., & Minh, T. D. (2015). Comparative contraceptive effectiveness of levonorgestrel-releasing and copper intrauterine devices: the European Active Surveillance Study for Intrauterine Devices. Contraception, 91(4), 280-283. doi:10.1016/j.contraception.2015.01.011
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