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Intrauterine Device (IUD) Malposition

Case Introduction

A 24 year old female, G3P103, presented to the Emergency Department (ED) with a chief complaint of 1 month of right lower quadrant (RLQ) abdominal pain, hematuria. She also reported associated nausea, headaches, and light-headedness
Vital signs in the ED were heart rate 78, blood pressure 108/74, respiratory rate 18, temperature 98.6°F, SpO2 100% and BMI 43.62. Upon physical exam, the patient was in noticeable pain and had mild abdominal tenderness to deep palpation in the right lower quadrant (RLQ) without rebound, guarding or CVA tenderness. Pelvic exam noted IUD string through cervix but no swelling, erythema, discharge, lesion or discharge.
A pelvic transabdominal and transvaginal ultrasound demonstrated a malpositioned IUD extending into the myometrial wall and a large left adnexal cystic structure. OBGYN was consulted and attempted to remove the IUD in ED but was unsuccessful. Strings were visualized, grasped with ring forceps and gentle traction was applied but could not be removed. She was consequently admitted to have her IUD removed in the operating room (OR).

Discussion of IUD Complications

IUDs are safe, effective and well tolerated and thus a very popular form of contraception. Complications are rare. Spontaneous expulsion occurs in about 3-6% of cases in the first year. The risk of pelvic inflammatory disease is 1% in the first month, and 0.5% in the first 6 months. Failure of contraception is between 0.1% and 0.6% with an increased risk of ectopic pregnancy. Perforation is even more rare at 0.01% of cases. Malposition, as in the case of our patient, is typically not life threatening and occurs in up to 10% of patients.1Braaten, Kari P., et al. “Malpositioned intrauterine contraceptive devices: risk factors, outcomes, and future pregnancies.” Obstetrics & Gynecology 118.5 (2011): 1014-1020.2Aoun, Joelle, et al. “Effects of age, parity, and device type on complications and discontinuation of intrauterine devices.” Obstetrics & Gynecology 123.3 (2014): 585-592.
Pelvic ultrasound of the malpositioned IUD (arrow)
Pelvic ultrasound of the malpositioned IUD (arrow)
Risk factors for complications include young age, postpartum or postabortion, actively lactating and “distortion” of the uterine cavity such as anatomic variants and leiomyomas. Uterine position does not appear to increase the risk of complications.3Chi, I-cheng, et al. “Do retroverted uteri adversely affect insertions and performance of IUDs?.” Contraception 41.5 (1990): 495-506.
Immediate post insertion complications are those characterized as occurring within the first 7 days. Post insertion bleeding, cramping and pain are very common. Historically, the presence of an IUD (i.e. a foreign body) was thought to increase the risk of pelvic inflammatory disease (PID). More recently, rates of PID have been found to be similar among asymptomatic infected patients whether they have an IUD or not. Infection directly attributed to insertion is rare.4Farley, Timothy MM, et al. “Intrauterine devices and pelvic inflammatory disease: an international perspective.” The Lancet 339.8796 (1992): 785-788. HIV does not appear to affect the risk of infection associated with IUD insertion. Patients diagnosed with PID should be treated appropriately, and IUD removal is not indicated unless actinomycosis infection is diagnosed or suspected.5Westhoff, Carolyn. “IUDs and colonization or infection with Actinomyces.” Contraception 75.6 (2007): S48-S50.
Illustration of types of IUD malposition
IUDs complications. (A): complete uterine perforation; (B): partial uterine perforation; (C): partial embedment into myometrium; (D): malposition; (E): expulsion after insertion1https://www.intechopen.com/chapters/58267
Early post insertion complications can be those characterized as having occurred in the first 3 months. Irregular bleeding and cramping are common, however it typically tapers off over time and depends on the type of IUD. It is uncommon for PID or endometriosis to develop after the time of insertion. Patients do not routinely need follow up visits after IUD insertions and studies have demonstrated no benefit. Other complications include nonpalpable strings, non visible strings and expulsion. While expulsion can occur at any time, it is more likely to occur in the first few months. Perforation is typically diagnosed when it occurs. Occasionally, the partner can feel the IUD strings.
The following represents a list of “anytime” post insertion complications. Most patients do experience bleeding and cramping, this typically tapers off over time. The pattern varies by IUD type. In patients with persistent bleeding and cramping, the first step is to confirm the IUD position and exclude other complications. Management of these symptoms depends on the IUD but includes NSAIDS, TXA, mifepristone and desmopressin.
Schematic showing multiple different IUD malpositions
Schematic showing multiple different types of malpositioned IUDs. A: low lying IUD. B: intracervical IUD. C: rotated IUD. D: inverted IUD. b Example of a low-lying IUD. Axial MPR noncontrast enhanced CT shows a malpositioned low-lying IUD with embedded arms into the lower uterine segment (green arrow). The uterine fundus is empty (red arrows). c Example of an intra-cervical IUD. Axial MPR noncontrast enhanced CT shows a completely empty uterine fundus (A, red arrows) and an intracervical IUD (B, green arrow). d Example of a rotated IUD. Axial MPR contrast enhanced CT shows a mildly rotated IUD, its right arm projecting posteriorly (green arrow) away from the cornu (red arrows). e Example of an inverted IUD. Axial MPR contrast enhanced CT shows an IUD (yellow arrow) with its stem pointing towards the fundus and arms located near the cervix (red arrow). The uterine fundus was empty (blue arrows)2Zhu, Grace G., et al. "CT imaging of intrauterine devices (IUD): expected findings, unexpected findings, and complications." Abdominal Radiology 49.1 (2024): 237-248.
Malposition refers to an IUD that is displaced into the lower uterine segment, partially expelled into the cervix, rotated, embedded into the myometrium or partially protruding through the uterine serosa. In the case of our patient, the IUD was embedded in the wall of the myometrium. The incidence of this is estimated to be around 10%. Symptoms typically include pain and bleeding. Diagnosis is made with ultrasound.6Benacerraf, B. R., T. D. Shipp, and B. Bromley. “Three‐dimensional ultrasound detection of abnormally located intrauterine contraceptive devices which are a source of pelvic pain and abnormal bleeding.” Ultrasound in Obstetrics and Gynecology 34.1 (2009): 110-115. Malpositioned IUDs are associated with an increased risk of contraceptive failure and should be removed depending on exactly where they are. Symptomatic patients should have their IUD removed and women’s health team can consider replacing it if wanted. If the patient is asymptomatic and the IUD is still located within the uterus, the IUD can be left alone.
Pregnancy with an IUD
Figure 2. Pelvic ultrasound of a 28-year-old female demonstrating an intrauterine pregnancy with an IUD. A. Sagittal view reveals rotated and inferiorly displaced IUD in the lower uterine segment and cervix (orange arrow) and an intact intrauterine gestational sac (yellow arrows). B. Sagittal image confirms an inferiorly displaced IUD (orange arrow) and an intrauterine pregnancy with gestational sac and embryonic pole (yellow arrows).3https://www.globalradiologycme.com/single-post/pregnancy-with-iud
Expulsion is defined by the IUD being expelled from the uterus. Patients typically endorse cramping, dyspareunia, vaginal discharge, bleeding or pregnancy. Diagnosis is made either by the patient identifying the device in their underwear or the toilet or with ultrasound. Patients who have experienced an expulsion can have a new IUD inserted however they are at increased risk of repeat expulsion.7Bahamondes, Luis, et al. “Performance of copper intrauterine devices when inserted after an expulsion.” Human Reproduction 10.11 (1995): 2917-2918.
Pregnancy is another complication of IUDs. They are highly effective and the failure rate is extraordinarily low. The risk of IUD failure resulting in pregnancy is greatest in the first year and is less than 1%.8Trussell, James. “Contraceptive failure in the United States.” Contraception 70.2 (2004): 89-96. Risk factors for failure include young age, IUD malposition, prior IUD expulsion, obesity and previous uterine scar. Patients are at higher risk for ectopic pregnancy when compared to the general population.9Sivin, I., and J. Stern. “Health during prolonged use of levonorgestrel 20 micrograms/d and the copper TCu 380Ag intrauterine contraceptive devices: a multicenter study. International Committee for Contraception Research (ICCR).” Fertility and sterility 61.1 (1994): 70-77. For patients who do not want to keep their pregnancy, the IUD should be removed prior to termination. For patients who want to continue the pregnancy, the IUD should be removed as soon as possible.
Issues at the time of IUD removal include nonvisualized strings, difficult removal, and broken IUD.

Case Conclusion

During admission, the patient underwent a successful hysteroscopy and removal of the IUD. The IUD had partially perforated her myometrium but remained in the uterus. There were no further complications postoperatively and the patient was subsequently lost to follow up.

3 Key Points

  1. IUDs are incredible safe and effective and complications are rare
  2. Mispositioning is seen in up to 10% of patients with an IUD and symptoms include abdominal pain and bleeding
  3. If symptomatic and depending on the location, the IUD should be removed by an OBGYN.

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