EM@3AM: IUD Complications

Author: Rachel Bridwell, MD (@rebridwell, EM Resident Physician, San Antonio, TX) // Reviewed by: Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX); Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.


A 24-year-old female presents to the ED for pelvic pain that started 8 hours ago. The patient reports sudden onset pain this afternoon that is getting progressively worse, refractory to ibuprofen. She denies any fevers, rigors, or dysuria, but endorses constant pelvic pain, nausea, and vaginal bleeding. The patient has not had unprotected sex and no history of sexually transmitted infections.

Exam includes BP 115/68, HR 113, T 99.1 oral, RR 16, SpO2 98% on room air. She appears visibly uncomfortable, has dry mucous membranes, and is tender in the suprapubic area. Pelvic exam reveals scant blood per os, IUD strings seen, and she has pain with bimanual uterine palpation.

What’s the next step in your evaluation and treatment?


Answer: Intrauterine Device (IUD) Complications

IUD background and types

  • One of the most effective means of contraception
  • Device is T-shaped, inserted through cervix
  • Complications occur in < 1%
  •  Hormone
    • Levonorgestrel
      • Mirena, Kyleena, Skyla
      • Menses tend to lighten and may disappear after first months
      • Very little absorbed systemically; usually no hormonal side effects
    • Copper – lasts up to 12 years, no hormones but may cause more side effects such as bleeding and pain
      • May be used as emergency contraception if placed within 120 hours of unprotected intercourse

 

Epidemiology:

  • Migration
    • IUD moves from uterus to other periuterine areas1
      • Occurs in 1-3 in 1,000 IUD insertions2
      • Most common reason for patients to present to ED
  •  Perforation3
    • May occur secondary to uterine contracture, bowel peristalsis, bladder contraction, blunt trauma
    • More likely in retroverted uteri4
    • Postpartum risks: Hypoestrogenism and breastfeeding, thins uterine walls and increases risk of perforation5
    • Immediate—traumatic perforation of myometrium
      • Force required to insert IUD ranges from 1.5-6.5N, while perforation requires 50N6
    • Delayed—myometrial erosion
  • Failure
    • 1% failure rate, comparable to permanent sterilization techniques7
    • Failure in levonorgestrel is 0.2-0.02 per 100 woman years while copper is 0.1 to 0.8 100 woman years.8
    • If pregnancy occurs with IUD failure, more likely to be an ectopic pregnancy9
  • PID
    • Use of IUD associated with increased rate of PID, especially in first 21 days related to preexisting STDs
    • Screening for STI reduces risk of PID

 

Clinical Presentation:

  • Signs and symptoms
    • Pelvic pain
    • Vaginal bleeding
    • In migration, complication can cause peritoneal abdomen
    • May be asymptomatic
    • Patients are instructed to feel string with finger; if shorter or cannot feel string, this means the IUD may have migrated or be malpositioned.
    • Ddx: fibroids, appendicitis, ovarian torsion, PID, cervicitis, renal colic, hemorrhagic ovarian cyst, ectopic pregnancy, ovarian hyperstimulation syndrome

 

Evaluation:

  • Assess ABCs
    • Assess for hemodynamic instability in event of ectopic or peritoneal complication
  • Perform a complete physical examination.
    • Abdomen: Lower abdominal pain or uterine tenderness, abdomen may become peritoneal with complications
    • GU: speculum may show IUD strings, vaginal bleeding, bimanual tenderness
  • Laboratory evaluation:
    • Serum HCG, CBC, CMP, UA
      • Leukocytosis associated with prompt surgical intervention13
    • STI testing if concern for PID
    • Ensure not pregnant
    • Urinalysis may demonstrate concomitant urinary in vesicouterine fistula with IUD migration
  • Imaging:
    • Ultrasound (US)
      • Transvaginal ultrasound is optimal imaging modality for suspicion of malrotation or misplacement9,12
      • Rapid, cost effective, radiation sparing, good detail of uterine anatomy12
    • Computed Tomography (CT)
      • Ideal imaging modality for IUD migration1
        • If concerned for bladder migration, perform CT with full bladder1

Treatment:

  • If exam reveals peritonitis, resuscitation and antibiotics are recommended
  • Pain control
  • For PID, CDC does not recommend removing IUD; use normal antibiotic regimen
    • If IUD in place < 3 weeks, may be removed by OBGYN
  • Consult OBGYN for ectopic with IUD9
  • Consult gynecology versus surgery for laparoscopy in finding and removing migrated IUD14
    • Prompt removal reduces risk of adhesion, small bowel obstruction, and infertility4
  • Bladder is most common site of IUD migration15
    • May form vesicouterine fistula16

 

Pearls:

    • IUDs can migrate, perforate, or fail
    • Migration intraperitoneally most often occurs to bladder and requires surgical removal while vesicouterine fistula requires urologic consultation
    • Perforation occurs more often in retroverted uteri

Further Reading:

FOAM resources

  1. http://www.emdocs.net/em3am-uterine-perforation/
  2. https://epmonthly.com/article/iuds-in-the-ed/

References

  1. Rasyid N, Nainggolan HJ, Jonardi PA, et al. Early-onset complete spontaneous migration of contraceptive intrauterine device to the bladder in a post C-section patient: A case report. Int J Surg Case Rep. 2021;82. doi:10.1016/j.ijscr.2021.105850
  2. Nouioui MA, Taktak T, Mokadem S, Mediouni H, Khiari R, Ghozzi S. A Mislocated Intrauterine Device Migrating to the Urinary Bladder: An Uncommon Complication Leading to Stone Formation. Case Rep Urol. 2020;2020:1-4. doi:10.1155/2020/2091915
  3. Esposito JM, Zarou DM, Zarou GS. A Dalkon Shield imbedded in a myoma: Case report of an unusual displacement of an intrauterine contraceptive device. Am J Obstet Gynecol. 1973;117(4):578-581. doi:10.1016/0002-9378(73)90128-2
  4. Kho KA, Chamsy DJ. Perforated Intraperitoneal Intrauterine Contraceptive Devices: Diagnosis, Management, and Clinical Outcomes. J Minim Invasive Gynecol. 2014;21(4):596-601. doi:10.1016/j.jmig.2013.12.123
  5. Ber A, Seidman DS. Management of the malpositioned levonorgestrel-releasing intrauterine system. Contraception. 2012;85(4):369-373. doi:10.1016/j.contraception.2011.09.002
  6. Goldstuck ND, Wildemeersch D. Role of uterine forces in intrauterine device embedment, perforation, and expulsion. Int J Womens Health. 2014;6(1):735-744. doi:10.2147/IJWH.S63167
  7. Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397-404. doi:10.1016/j.contraception.2011.01.021
  8. Heinemann K, Reed S, Moehner S, Do Minh T. Comparative contraceptive effectiveness of levonorgestrel-releasing and copper intrauterine devices: The European Active Surveillance Study for Intrauterine Devices. Contraception. 2015;91(4):280-283. doi:10.1016/j.contraception.2015.01.011
  9. Makena D, Gichere I, Warfa K. Levonorgestrel intrauterine system embedded within tubal ectopic pregnancy: a case report. J Med Case Rep. 2021;15(1). doi:10.1186/s13256-021-02723-7
  10. Evans AT, Szlachetka K, Thornburg LL. Ultrasound Assessment of the Intrauterine Device. Obstet Gynecol Clin North Am. 2019;46(4):661-681. doi:10.1016/j.ogc.2019.07.005
  11. Aoun J, Dines VA, Stovall DW, Mete M, Nelson CB, Gomez-Lobo V. Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol. 2014;123(3):585-592. doi:10.1097/AOG.0000000000000144
  12. Nowitzki KM, Hoimes ML, Chen B, Zheng LZ, Kim YH. Ultrasonography of intrauterine devices. Ultrasonography. 2015;34(3):183-194. doi:10.14366/usg.15010
  13. Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Cannot exclude torsion—a 15-year review. J Pediatr Surg. 2009;44(6):1212-1217. doi:10.1016/j.jpedsurg.2009.02.028
  14. Zakin D, Stern WZ, Rosenblatt R. Complete and partial uterine perforation and embedding following insertion of intrauterine devices. II. Diagnostic methods, prevention, and management. Obstet Gynecol Surv. 1981;36(8):401-417. doi:10.1097/00006254-198108000-00001
  15. Kart M, Gülecen T, Üstüner M, Çiftçi S, Yavuz U, Özkürkçügil C. Intravesical Migration of Missed Intrauterine Device Associated with Stone Formation: A Case Report and Review of the Literature. Case Rep Urol. 2015;2015:1-4. doi:10.1155/2015/581697
  16. El-Hefnawy AS, El-Nahas AR, Osman Y, Bazeed MA. Urinary complications of migrated intrauterine contraceptive device. Int Urogynecol J. 2008;19(2):241-245. doi:10.1007/s00192-007-0413-x

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