Learning Objectives

IUD Complications:
Management Strategies  Learn IUD placement techniques in women
with severe obesity and stenotic os

Contraceptive Technology  Understand options for pain control during

April 19, 2013 placement
Mark Hathaway MD, MPH
Dept of Ob/Gyn
Washington Hospital Center
 Learn how to evaluate and manage missing
Washington DC
strings, pregnancy, perforation and
malpositioned device

Conflict of Interest Disclosure MUSTs Prior to IUD Insertion

1. Bimanual exam to determine uterine position,

flexure and to r/o CMT
Speaker/Trainer for Bayer and Merck

2. “The tenaculum is your friend, not a torture

device” 1

3. Determine intrauterine length with sound

 avoids improperly placed IUDs and perforation

1. Kirtly Parker Jones MD

Perforation Prevention Technique to Straighten a VERY

Measure uterine length from external cervical
os to fundus
The 3 IUDs have different insertion
techniques
 Copper IUD (Paragard) placed at fundus
 Levonorgestrel IUDs (Mirena and Skyla)
placed approximately 2.5 cm below the
fundus arms to extend normally
POSTERIOR UTERUS
Apply a tenaculum to ANTERIOR cervical
lip; then lift up with tenaculum…THEN
apply a second tenaculum to the
POSTERIOR cervical lip (pull forward to
visualize the posterior cervical lip); then
remove the ANTERIOR tenaculum

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 Sounds
SM Schnare

Marking sounded depth with a ring forceps IUD insertion pain management:
What Doesn’t Work!

 Misoprostol prior to IUD placement in

nullips- results of 2 RCTs:
 no decrease in pain with procedure 1,2
 increase in pre-insertion pain1,
 increase pre-insertion nausea and cramping 2
 no difference in provider reported ease of
insertion 1,2

1. Obstet Gynecol. 2012 Aug Swenson C, et al

2. 2. Contraception. 2011 Sep Edelman AB et al

IUD insertion pain management:

What Does Work?
What Doesn’t Work
 Intracervical lidocaine gel:
 double blinded RCT with 200 participants,
 Double Blind RCT with 103 women in
 no decrease of insertion pain1
Turkish University Hospital
 Paracervical Block:
 RCT no statistical decrease of insertion pain2  Both tramadol 50 mg & 550 mg naproxen,
 Length of procedure almost doubled relieve pain during IUD insertion
 Intrauterine Lidocaine:  Tramadol capsules found to be more
 double blinded pilot RCT- 1.2 ml 2% lidocaine vs saline effective than naproxen
infused via endometrial sampler 3 min prior to insertion3

1. Contraception. 2012 Sep;86 Maguire K, et al 2. Contraception. 2012 Dec;86 J Minim Invasive Gynecol. 2012 Sep-Oct;19(5):581-4.
Mody SK et al 3. Contraception 2013 Jan Nelson

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 Case Presentation: Cervical
Cervical Bleeding Stenosis
Bleeding from Tenaculum “Cathy,” 32-year-old
Punctures G1P1
 Applypressure Medical history:
• Cervical stenosis after LEEP
 Monsel's solution or silver nitrate
Seeking long-term,
“forgettable”
Tear from Tenaculum contraceptive method
 Rotate tenaculum 45 degrees
 Apply pressure

Cervical Stenosis Case: Cervical Stenosis Case:

Clinical Considerations Practice Tips
Insertion difficulty
Os finder as needed

Insertion pain Cervical dilation:

• Start with lacrimal duct probe
• Increase size until regular dilators will pass
If due to hypoestrogenic condition, use • Consider ultrasound guidance
estrogen vaginal cream 2 weeks • Needs experienced hands
• Consider misoprostol

When stenosis result of LEEP or more…

other surgery, may need to dilate Güney M et al. Obstet Gynecol. 2006.

Cervical Stenosis Case: Cervical Stenosis Case:

Practice Tips (continued) Counseling Points
Management options:
Ask patient to arrive a few hours before
• Paracervical block1 insertion to receive misoprostol
• Oral pain management with Counsel patient about the chance of failure
hydrocodone and lorazepam (etc)
of insertion
• Consider parenteral analgesia Potential for vasovagal reaction, even with
(midazolam and fentanyl)
paracervical block
• Misoprostol priming2
more…
1. Güney M et al. Obstet Gynecol. 2006 2. Gynecol Obstet Invest 2006;62:115–120. Role of
Misoprostol in Overcoming an Unsatisfactory Colposcopy: A Double-Blind RCT

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 Case Presentation: Uterine
IUD insertion in the Obese Woman
Fibroids/Obesity
“Barbara,” 42-year-old
G3P3  CDCMEC Catagory 1 for obese
Medical history:
• Uterine fibroids women (>30 BMI)
• Obesity (BMI = 35)
• Heavy menstrual bleeding,
dysmenorrhea
Has completed  CDC MEC Catagory 1 after bariatric
childbearing, does not surgical procedures (restrictive or
desire sterilization
Seeks nonsurgical
malabsorptive)
treatment for fibroids Consider: LNG IUD
Kaunitz AM. Contraception. 2007; World Health Organization. Medical Eligibility Criteria
for Contraceptive Use. 2004.

IUD Placement in Obese Woman IUD Insertion in Obese Women

 Is table wide and stable enough?  Consider rectal palpation

 Have hips just over edge exam table  Mayuse a flexible uterine sound to help
which drops the cervix posteriorly ascertain uterine position

 To perform bimanual exam place  Ring forceps (closed) to gently move walls
abdominal hand UNDER panniculus
 Have patient pull up and abduct her knees

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 Uterine Fibroids Case:
Clinical Considerations
Both IUDs CDC MEC 2011 Cat 2
Fibroids must not obstruct cervical os
Fibroids distal to uterine cavity do not
preclude IUC
Levonorgestrel IUS associated with a
profound reduction in menstrual blood loss

Kaunitz AM. Contraception. 2007; CDC US Medical Eligibility Criteria for

SM Schnare Contraceptive Use. 2010; Grigorieva V, et al Fertil Steril. 2003 May;79(5):1194-8.

Uterine Fibroids Case:

Counseling Points Signs of Possible Complications
Expulsion rates possibly higher for women Symptom Possible Explanation
with fibroids Severe bleeding or
Counsel patient about possible signs of abdominal cramping 3–5 Perforation, infection
expulsion: days after insertion
• Unusual vaginal discharge
• Severe cramping or heavy bleeding Irregular bleeding and/or Dislocation or
• Longer-than-usual or absent strings protruding from pain every cycle perforation
cervix
• Tip of device protruding from cervix Fever, chills, unusual
Infection
vaginal discharge
more…
Kaunitz AM. Contraception. 2007. Zapata LB Intrauterine device use among women with
uterine fibroids: a systematic review. Contraception. 2010 Jul; 82(1): 41-55.

Signs of Possible Complications General Management of Bleeding Issues for

(Continued) Progestin Methods
Symptom Possible Explanation
Infection, perforation,  Counseling upfront and reassurance
Pain during intercourse
partial expulsion
 Ibuprofen 800mg po tid or Naproxen 500
Missed period, other Pregnancy
signs of pregnancy, mg BID for 5-7 days
expulsion (uterine or ectopic)  Estradiol 0.5-2mg po qd for 5-10 days
Shorter, longer, or Partial or complete  OCPs for 2-3 cycles
missing threads expulsion, perforation

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 Managing Heavy Bleeding with the
Bleeding with the Copper T IUD Copper T IUD
 NSAIDs can prevent increased bleeding,
 Bleeding and/or pain rates are highest
but does not impact discontinuation1
during 6 months of use
 Rates of expulsion and removal for
 NSAIDs and antifibrinolytic drugs may
bleeding and/or pain are higher in prevent and treat heavy blood loss 2,3
nulliparous than in parous women1
 Bleeding appears to decrease over time  If heavy bleeding lasts >6 months:
• Get U/S to eval for malposition or fibroids
with most users2 • Treat anemia, if indicated

1. Hubacher D, Contraception 2007; 2. Hubacher D et al., Contraception 2009.; 1. Hubacher D et al, Hum. Reprod. (June 2006) 21 (6): 1467-1472. 2. D.A. Grimes et
al .Cochrane Rev (2006), 3. Godfrey EM et al Contraception 2012

LNG-IUDs for menorrhagia from

anticoagulant therapy Management of Cramping
 40 women with menorrhagia on anticoagulant Mild:
recommend
medication after cardiac valve replacement NSAIDs
 LNG-IUDs inserted into 20 women
Severe or prolonged:
 PT, PTT, INR, HCT, Hg, ferritin and pictorial • Examine for partial expulsion,
bleeding assessments recorded perforation, or PID
 3 months after insertion of LNG-IUDs, sig • Remove IUC if severe cramping
decrease in blood loss and higher Hg, HCT and is unrelated to menses or
ferritin. No difference in PT/INR unacceptable
to patient

Contraception. 2009 Aug;80(2):152-7 Kilic S

CASE: M.L. is 17 y/o When Threads Are Not Visible

Is she pregnant?
She has a LNG IUD placed 1 year
ago. She cannot feel her IUD Is the IUD in place?
threads. Last time she checked her Is there a perforation?
threads was 6 mos ago.
What’s your plan?

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 Management of Missing IUD Thread Retrievers
Threads
Rule out pregnancy  There are several “thread retrievers” available
Probe for threads in cervical canal with
cervical brush
 Most clinician use alligator forceps
Prescribe back-up contraceptive method
Obtain ultrasound or x-ray, as needed
 Novak currette can also be helpful
Remove IUD in abdomen promptly
 Offer EC when unprotected sex in past 5
days

Embedded IUD Expulsions

 Requires paracervical block for pain
 IUD may be located by palpation with sound
 Use alligator forcep and tap the IUD
 Pull forcep back ½ cm, open forcep jaws and
move upward grasping any part of the IUD.
 Once IUD grasped, rotate to dislocate it from
endometrium
 If IUD stem embedded, grasp any part of IUD
and lift slightly upward and rotate to remove
Partial or unnoticed expulsion may present
as irregular bleeding and/or pregnancy
Risk of expulsion (2-5%) related to:
• Provider’s skill at fundal placement
• Age and parity of woman
• Time since insertion
• Timing of insertion
WHO. 2009.; CDC MMWR. 2010

Case Presentation: Heavy Heavy Menstrual Bleeding

Menstrual Bleeding Case: Clinical Considerations
“Diane,” 24-year-old
nulligravida Evaluate for underlying cause of heavy
Medical history: bleeding
• Heavy menstrual bleeding,
dysmenorrhea Differential diagnoses:
Presents for relief of heavy • Coagulopathy
bleeding and cramping
• Endometrial lesion, fibroid, or polyp (consider emb,
Has tried OCs in the past,
dislikes having to take a sonogram)
daily pill • Anovulation

Consider: LNG IUS

James AH et al. Am J Obstet Gynecol. 2009; Kingman CEC et al. Br J Obstet Gynaecol. 2004;
Mansour D. Best Pract Res Clin Obstet Gynecol. 2007.

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 Heavy Menstrual Bleeding (HMB)
MANAGING INFECTIONS
and the LnG IUD
 163 women with HMB & w/o structural pathology  Counsel on STI prevention (bacteria cause
received the LNG-IUS in pooled analysis of RCTs infections not plastic)
 Consult & train emergency department colleagues
to not remove IUDs
 Relative to baseline, transient increase in  Chlamydia/gonorrhea
bleeding days in first month of treatment  Treat without removal of IUD
 Bacterial vaginosis
 Returned to baseline by the second month and  Treat without removal of IUD
declined thereafter  PID/Tubal infections
 Treat and monitor closely; remove IUD if no
improvement
 Spotting days increased first month, then declined  recommendations to remove are not evidence based
with continued use, remained elevated 1st yr of tx
Grimes D. Lancet. 2000. ; CDC U.S. Medical Eligibility Criteria for Contraceptive Use
Jensen J et al Contraception Jan 2013

Pregnancy Outcomes with IUD in situ

Pregnancy with IUC In Situ
Determine site of pregnancy Pregnancies with IUDs in situ were at greater
• Intrauterine or ectopic risk of adverse pregnancy outcomes:
Remove IUD if threads available spontaneous abortion
Removal decreases risk of: preterm delivery
• Spontaneous abortion septic abortion
• Premature delivery chorioamnionitis
Early IUD removal may improve outcome, but
did not entirely eliminate risks.
(22) Brahmi 2012
UK Family Planning Research Network. Br J Fam Plann. 1989.; Foreman H, et al. Obstet
Gynecol. 1981.

CASE: EB is 27 y/o plans IUD

placement today Risk of Uterine Perforation
Rare:1 per 1,000 insertions
Her uterus is challenging to palpate- Perforation linked to:
• Uterine position and consistency
retroflexed. During sounding of her • Skill and experience of provider with technique required
uterus she expresses severe pain and • Time of insertion after childbirth
you feel sudden decreased pressure  Risk doubled within first 12 weeks postpartum

with the sound.

What do you do next? Perforations reduced through directed
training and observation
Caliskan E, et al. Eur J Contracept Reprod Health Care. 2003.; Van Houdenhoven K, et al.
Contraception. 2006.; Prema K, et al. Contracept Deliv Syst.1981.; Markovitch O, et al.
Contraception. 2002.; Harrison-Woolrych M, et al. Contraception. 2003.

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 Signs of Uterine Perforation IUD Uterine Perforation
 Placement of an IUD deeper than sounded
 Rarely an emergency
 Sudden loss of resistance with insertion  Monitor pain, blood pressure and
pulse
 Pain/ cramping that persists > than 15 min  Consider baseline Hct
 Refer if perforation of abdominal
 Bleeding is unusual viscera suspected
 May be asymptomatic

IUD Perforation Begins at Insertion Management of Perforation at

Insertion
 During placement, if IUD partially perforates Remove device
the endometrium, the device may eventually Provide alternative contraception
perforate through the uterine wall. Monitor for excessive bleeding
Follow up as appropriate
 In rare instances, an IUD may “migrate” Can insert another device after next menses
beyond the uterine cavity; this is a result of If IUD in abdomen refer for surgical removal
partial or complete perforation of the IUD at  case series 64% successful laproscopic removal1

the time of insertion.

1. Contraception. 2012 Jan;85(1):15-8.Laparoscopic removal of an intra-
abdominal intrauterine device: case and systematic review. Gill RS et al

Patient Follow-up Plan Follow-Up for Side Effects

 Schedule a recheck visit (6-
10wks)
 Ask follow-up questions:
• Are you satisfied with your
contraceptive method?
• Consider speculum string check
• Is there anything you would
change?
• Are you having bleeding problems
or other side effects?
 Address primary care/annual
appointments and STI
counseling
ARHP. Clinical Proceeding. 2004.
 Ensure client knows to call or return to
see you for bothersome side effects
 Create a plan with client about
“preemptive” treatment options in the
event of bothersome spotting
 Reassure that there will be an adjustment
period the first few months
 Discuss an OTC treatment plan in the
event of cramping.