Michelle Meglin
History of present illness
A 35-year-old gravida 2, para 2 woman presents for an urgent visit 4 weeks after a levonorgestrel intrauterine device (IUD) insertion. She reports intermittent left lower quadrant pain and inability to palpate the IUD strings. She is concerned that she may no longer be protected from unplanned pregnancy.
Her IUD insertion was performed six weeks after an uncom- plicated elective repeat Cesarean delivery. Her uterus was noted to be retroverted at the time of insertion. The insertion was performed without difficulty. She had mild cramping and bleeding that resolvedfive days following insertion.
Her obstetric history is significant for two Cesarean deliv- eries at term. Her gynecologic history is unremarkable. She has no chronic medical problems and takes no medications. She has had no other surgeries.
Physical exam
General appearance:Woman in no apparent distress Vital signs:
Temperature: 37.3°C Pulse: 75 beats/min
Blood pressure: 125/85 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 100% on room air Abdomen:Soft, nontender, nondistended External genitalia:Normal
Vagina:Normal
Cervix:Normal appearing cervix, no IUD strings visualized, unable to tease string from endocervix with cytobrush Uterus:Small, retroverted uterus, mobile, no tenderness Adnexa:No masses or tenderness
Laboratory studies:Urine pregnancy test: Negative Imaging:Transvaginal ultrasound revealed a normal appearing uterus and thin endometrial stripe without evidence of an IUD. A following pelvic x-ray noted an IUD in the left pelvis overlying the left inferior iliac bone (Fig. 11.1)
How would you manage this patient?
This patient has an extrauterine intrauterine device (IUD) that should be removed by laparoscopy or laparotomy [1,2,3]. She underwent laparoscopy and the IUD was noted to be enveloped in omentum in the left paracolic gutter (Fig. 11.2).
There was no evidence of uterine defect or stigmata from uterine perforation. The IUD was teased from the omentum and removed via a 5 mm port.
IUD string not visible
The use of IUDs for contraceptive and noncontraceptive indications is increasing in the United States. The copper IUD (ParaGard® T380A, Teva Women’s Health, Inc.) is approved for 10 years of contraceptive use in the United States and has contraceptive failure rates similar to tubal ligation.
The levonorgestrel IUD is a highly effective contraceptive method that is approved for five years of use in the United States and also has several noncontraceptive benefits [1]. The levonorgestrel IUD effectively reduces blood loss in patients with heavy menstrual bleeding, adenomyosis, and uterine fibroids, and improves pain in patients with endometriosis and dysmenorrhea [4]. The levonorgestrel IUD may be used
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Fig. 11.1 Pelvic x-ray showing an extrauterine IUD in the left pelvis overlying the left inferior iliac bone. (Image provided by Steven Cohen, MD.)
to provide endometrial protection in patients on hormone therapy and tamoxifen and provide therapeutic progestin in women with endometrial hyperplasia [4].
Following IUD insertion many providers instruct patients to return for follow-up 4–12 weeks following insertion and instruct patients to periodically perform string checks [2,3]. However, according to the US Selected Practice Recommendations for Contraceptive Use, 2013 [5], there is insufficient evidence to recommend a routine follow-up visit after IUD insertion and it should not be required. Patients with IUD should be evaluated if they have problems or would like to change contraceptive method. Additionally, when a patient with an IUD returns for routine gynecologic care, providers should consider performing a pelvic examination to confirm the presence of IUD strings [5]. Possible explanations of nonvi- sible IUD strings include retraction of strings into the cervical canal, unrecognized expulsion of the IUD, pregnancy causing an enlarging uterus that draws the device upward, and partial or complete uterine perforation [6].
The incidence of inability to see IUD strings has been reported as 4.5–18.0% [6]. One study reviewed over 14 000 women who underwent IUD insertion (copper and levonor- gestrel) and found that IUD strings were missing at 5% of routine follow-up visits [6]. In this study, 98.2% of the time the IUD strings had retracted into the cervical canal and the IUD was appropriately located in the uterus. Inadvertent expulsion occurred in 1.2% of cases and uterine perforation in 0.7% of cases [6]. In other studies, rates of expulsion range from 2 to 10% in thefirst year of use [1]. The perforation rate has been reported as 1 per 1000 insertions [1].
There are risk factors at time of IUD insertion that increase the risk of expulsion. IUD expulsion is more likely to occur if the insertion was difficult or performed by an inexperienced provider [6]. Expulsion rates are higher in adolescents and nulliparous women, but IUD use in these groups is US Medical
Eligibility Criteria for Contraceptive Use category 2 (advan- tages outweigh risks) [7]. Immediate postpartum insertion is associated with an expulsion rate up to 24%, but use in the immediate postpartum periods is still category 1 (no restric- tions for use) for the copper IUD and category 2 for the levonorgestrel IUD [1]. Similarly, insertion of an IUD following a second-trimester abortion is category 2 due to a higher risk of expulsion [7]. The presence of risk factors for expulsion should not preclude recommending IUDs to these women.
Both uterine perforation and expulsion should be con- sidered if the patient is pregnant. Uterine perforation should be considered when patients present with pain. Perforation may also be more likely when insertion is difficult, required cervical dilation, was performed by an inexperienced provider, in nulliparous women, and in women with prior Cesarean or retroverted or retroflexed uterus [6].
Several recent papers have proposed similar algorithms for management of missing IUD strings [6,8,9]. Initial evaluation of nonvisible strings typically involves attempts to visualize strings in the office. Strings can be retracted into the endocer- vical canal, and, in these instances, they can be visualized with an endocervical speculum or brought into view by probing the endocervical canal with a cytobrush or q-tip.
A pregnancy test should be performed if the strings cannot be found in the canal. If a pregnancy test is positive, an ultrasound should be performed to confirm an intrauterine pregnancy and to determine if the IUD has been retained in the uterus. Continuing a pregnancy with an IUD in utero increases the risk for miscarriage, septic abortion, preterm delivery, and chorioamnionitis; therefore, IUD removal is rec- ommended if the IUD strings are visible or in the cervical canal. If the IUD strings are not visible or in the cervical canal then the IUD cannot be removed noninvasively and should remain in place [1].
If a pregnancy test is negative and the patient desires continuation of IUD use, then a transvaginal ultrasound should be performed. If transvaginal ultrasound confirms the IUD in the uterus (Fig. 11.3) and the patient desires continu- ation, then no further intervention is required. The IUD remains effective and, if the patient is otherwise happy with the IUD, then continuation should be encouraged [2,3,8].
Serial ultrasounds are not necessary and the IUD may be removed with an IUD hook at the usual time, or when con- ception is desired.
If a patient desires IUD removal and no strings are visible, the uterine cavity can be probed in the office with an IUD hook or forceps prior to ultrasound in the setting of negative preg- nancy test [9]. If initial efforts to remove the IUD in the office are unsuccessful a transvaginal ultrasound is recommended to determine location of the IUD. If ultrasound is readily access- ible, ultrasound can also be performed prior to attempts to instrument the uterus. If transvaginal ultrasound confirms the IUD in the uterus and the patient desires removal, further attempts at removal may be undertaken in the office. IUD
Fig. 11.2 IUD enveloped in omentum in the left paracolic gutter on laparoscopy. (Image provided by Steven Cohen, MD.)
removal is often limited by poor pain control leading some to advocate for preparing the cervix with misoprostol or use of a paracervical block to facilitate removal in the office [8]. If this remains unsuccessful, the patient may be taken to the operating room for removal under anesthesia using an IUD hook or forceps. In rare cases, use of the hysteroscopy may be necessary.
If transvaginal ultrasound does not show the IUD in the uterus, as with our patient, one cannot assume the IUD has been expelled. An abdominal/pelvic x-ray is required to evalu- ate for extrauterine location of the IUD. Intraperitoneal adhesions, intestinal perforation, intestinal obstruction, and
erosion into adjacent viscera have been reported when the IUD is left in the peritoneal cavity [2,3]. The American College of Obstetricans and Gynecologists (ACOG) and device manu- facturers recommend removal of intraperitoneal IUDs via laparoscopy or laparotomy [1,2,3]. Removal of an intraperito- neal IUD is typically accomplished via laparoscopy. Laparo- scopic forceps are used to grasp the IUD, scissors are used to lyse any adhesions and the IUD is removed via an accessory port. Occasionally, the location of the IUD is not apparent upon laparoscopic intra-abominal survey and the use of intraoperative x-rays may be helpful.
While patients are undergoing evaluation for missing IUD strings, they should be counseled to use back-up contraception since they are no longer receiving contraceptive benefit from their IUD.
Key teaching points
Possible explanations for not being able to see intrauterine device (IUD) strings include retraction of strings into the cervical canal, IUD expulsion, pregnancy, and partial or complete uterine perforation.
Many IUD strings may be retrieved from the cervical canal in the office by probing the endocervical canal with a q-tip or a cytobrush.
Evaluation should include a transvaginal ultrasound followed by an x-ray if the IUD is not seen on ultrasound.
If ultrasound confirms an intrauterine location, the IUD is effective and does not need to be removed.
If ultrasound confirms that the IUD is not in the uterus, a pregnancy test should be performed and the patient should initiate another form of contraception immediately.
Intraperitoneal IUDs can generally be removed by laparoscopy.
References
1. American College of Obstetricians and Gynecologists. Long-acting reversible contraception: implants and intrauterine devices. Practice Bulletin No. 121.Obstet Gynecol2011;118(1):184–96.
2. Mirena levonorgestrel-releasing intrauterine system: full prescribing information [package insert]. Bayer HealthCare Pharmaceuticals Inc.; 2013.
3. ParaGard T380A intrauterine copper contraceptive: prescribing information and instructions for use [package insert]. FEI Products LLC; 2003.
4. American College of Obstetricians and Gynecologists. Noncontraceptive uses of hormonal contraceptives. Practice Bulletin No. 110.Obstet Gynecol 2010;115:206–18.
5. Centers for Disease Control and Prevention. US Selected practice recommendations for contraceptive use, 2013.MMWR2013;62(RR-5):
1–46.
6. Marchi N, Castro S, Hidalgo MM, et al.
Management of missing strings in users of intrauterine contraceptives.
Contraception2012;86:354–8.
7. Centers for Disease Control and Prevention. US medical eligibility criteria for contraceptive use, 2010.MMWR2010;59(RR-4):
1–86.
8. Prabhakaran S, Chuang A. In-office retrieval on intrauterine contraceptive devices with missing strings.
Contraception2011;82:102–6.
9. Vilos GA, Di Cecco R, Marks J.
Algorithm for nonvisible strings of levonorgestrel intrauterine system.
J Minim Invasive Gynecol2010;17(6):
805–6.
Fig. 11.3 IUD in situ at the uterine fundus on 3-D transvaginal ultrasound.
Case 11: A 35-year-old woman with IUD string not visible