LARC Complications & Difficult Placement and Removals

Patty Cason MS, FNP-BC UCLA School of Nursing Envisionsrh.com [email protected] Disclosures

• Advisory Board/Consultant – Teva, Cooper Surgical, Merck, ContraMed, Evofem • Trainer/speaker – Merck, ContraMed, Medicines 360 Objectives • Identify tenaculum and sound techniques for optimizing success with placement of an IUD • Display familiarity with use of os finders for challenging IUD placement • Discuss strategies for dealing with IUD removals with missing strings • Describe counseling strategies for responding to bleeding complaints with LARC US Medical Eligibility Criteria: Categories

1 No restriction for the use of the contraceptive method for a woman with that condition Advantages of using the method generally 2 outweigh the theoretical or proven risks Theoretical or proven risks of the method usually outweigh the advantages – not usually 3 recommended unless more appropriate methods are not available or acceptable Unacceptable health risk if the contraceptive 4 method is used by a woman with that condition

http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf Free and User-Friendly Download the 2016 US MEC & US SPR app • An easy to use reference that combines information from both the CDC family planning guidance. It features a streamlined interface so providers can access the guidance quickly and easily. • Available for iOS and Android operating systems Formal (Merck) training for insertion/removal required Migration of Implant

N=38 cases of migration: • lung/pulmonary artery (n=9) • chest wall (n=1), • vasculature at locations other than the lung/pulmonary artery (n=14) • extravascular migrations (n=14) to other body sites (e.g., the axilla and clavicle/neck line/shoulder) (Kang, Niak et al. 2017) 1.3 Migrations per Million Placements

• 7 cases reported pain, discomfort, dyspnea • 3 cases describe pulmonary fibrosis and skin reactions from migration to the vasculature, chest wall and other distant body sites • 16 cases reported surgical removal in an operating room setting

(Kang, Niak et al. 2017) Clinicians are now advised to avoid placement in the biceps groove, no matter how superficial that placement might be.

Place over the triceps

(Rowland, Mansour et al. 2017) "pop-out" or "fingers-only" Implant Removal Technique

https://www.screenr.com/MS7N Interim Results From The Nexplanon Observational Risk Assessment Study (NORA) • 7369 placements • Providers reported 208 events involving 189 patients (2.6% of the study population) • Difficulty removing the protection cap was the most common event (93 insertions) NORA 0.7% of patients reported an event at insertion

• Pins/needles/numbness in the arm/hand/fingers –repeat or consecutive implant users: 10.1 per 1000 –first-time implant users: 1.2 per 1000 NORA 0.7% of patients reported an event at insertion

• 271 patients reported 394 events • pins/needles/numbness (145) • severe pain (120) • altered strength (47) • other events (82) NORA- Removal

• 1413 removal procedures, 16 (1.1%) involved one or more challenges: –encasement in fibrotic tissue (7) –multiple removal attempts needed (5) –Local migration (1) –deep implant (1) –other challenges (3) Simone 21 year old G0 • Using contraceptive implant for 3 years • Her regular provider attempted to remove it 2 weeks ago and was unsuccessful • On palpation, you feel the body of the implant, but the distal tip is hard to discern and the implant is somewhat fixed to the underlying tissue and is not very mobile Difficult Implant Removal: The “U” Technique Extra instrument: Modified vasectomy clamp Make incision next to implant Insert modified vasectomy clamp Gently pull implant up out of incision Use second forceps to grasp implant Tips

• Can use curved and straight mosquitos if needed

• Use 4x4 gauze and scalpel to cut and loosen fibrous sheath

• Never make an incision if you’re not positive you can feel the implant Tips • It’s OK to do the removal from the proximal end if that’s the end that pops up to the surface

• Don’t spend more than 15 minutes

• Wait at least 2 weeks between removal attempts to allow swelling to completely resolve Counseling Tips Language for LARC

• Rather than using the words “long acting,” use: –The most effective methods –Highly effective methods IUD or Implant

“This method is good for up to 10, 5, 3 years and if you want to get pregnant before then or you would like it removed for any reason, come in, we will take it out for you and your ability to get pregnant will go back to whatever is normal for you, immediately.” Choosing Which IUD

Brand Name Skyla® Kyleena® Mirena® Liletta® CuT

LNG content (mg in 13.5 19.5 52 52 0 reservoir) Release rate (mcg/24 14 17.5 20 19.5 0 hrs) 5 7.4 +/-10 17, 14.8, 12.9, At end 11.3, 9.8 0

Max duration, years 3 5 5 (7) 4 (7) 10 (12+)

T-frame, mm 28x30 28x30 32x32 32x32 32x36

Insertion tube 3.80 3.80 4.40 4.80 4.75 diameter

String color Brown Blue Brown Blue White

Silver ring Yes Yes No No No Single-rod Etonogestrel (ENG) Contraceptive Implant Nexplanon® • Most effective method • Suppression of ovulation • Thickens cervical mucous

Moderate progestin dose not associated with a hypo-estrogenic state

(Darney, Patel et al. 2009) LNG IUDs

• Highly effective • Cervical mucus thickened • Sperm motility and function inhibited • Alterations in ovulation

(Jonsson, Landgren et al. 1991; Lewis, Taylor et al. 2010; Natavio, Taylor et al. 2013; Ortiz, Croxatto 2007; Rivera, Yacobson et al. 1999; Stanford, Mikolajczyk 2002; Videla-Rivero et al. 1987) Best Question

“Do you have a sense of what is important to you in your birth control method?”

(Dehlendorf, Henderson et al. 2016) Questions to Ask after Giving Information

• How would that be for you? • Knowing that how would it be for you…? • Has it ever happened before? • How did you manage it? • Do you have a sense of how you would manage it? Progestin Side Effects

• 1-3% of women discontinue use due to complaints of: –weight gain, acne, hair loss, headache, moodiness, depression, emotional lability • Even less likely: vaginal dryness, breast pain, abdominal pain, nausea, decreased sex drive LNG 52 IUD Side Effects

• Weight gain comparable to users of CU T

• Acne rarely reported

• Uncommon: headaches, nausea, breast tenderness, mood changes, and ovarian cyst formation (Ilse, Greenberg et al. 2008; Modesto, de Nazare Silva dos Santos et al. 2015; Vickery, Madden et al. 2013) BLEEDING COMPLAINTS Cases

• Wanda is a 36 y.o. G3P3 who had a LNG IUD placed 2 months ago. She complains of irregular bleeding and is wondering when it will stop.

• Skye is 21 y.o. G0 who has had an etonogestrel implant for 8 months. She has had spotting every day for a month and is tired of it. She wants her implant removed. Unscheduled Bleeding with Progestin-Only Contraceptives

• Etiology poorly understood • Depends on dose/route of progestin • Initially due to rapid endometrial thinning caused by progestin • Sustained exposure may lead to endometrial instability and atrophy leading to fragile endometrium that bleeds easily (Zigler, McNicholas 2017) Implant Menstrual Effects • Most women have minimal, scant bleeding or no bleeding • Bleeding pattern is unpredictable • 1 in 4-5 women have frequent or prolonged bleeding • Pattern tends to get better with time • 20% discontinuation rate – half of discontinuation is for bleeding

(Alie, Akin et al. 2016; McNicholas, Maddipati et al. 2015; McNicholas, Swor et al. 2017) LNG 52 IUDs: Menstrual Effects • Initially some women have frequent spotting and irregular bleeding

• Usually resolves after 3-6 months

• Menses become increasingly light

• Amenorrhea 20-80%

(Bachmann, Korner 2009; Backman, Huhtala et al. 2002; Gemzell-Danielsson, Schellschmidt et al. 2012; Hidalgo, bahamondes et al. 2002; Mansour, 2012) Levonorgestrel 52 IUDs: Ovulatory Effects • 93% of the cycles were ovulatory but just 58% of these 'ovulatory' cycles showed normal follicular growth and rupture.

• Ovulation 63% of amenorrheic group; 58% in regularly menstruating group

(Barbosa, Olsson et al. 1995; Nilsson, Lahteenmaki et al. 1984) It Just Gets Better and Better…

Decreased bleeding with placement of subsequent LNG IUD

(Heikinheimo, Inki et al. 2014) Levonorgestrel 19.5 and 13.5 IUDs: Menstrual Effects • Less data about bleeding profile

• Initially some women have frequent spotting and irregular bleeding

• Usually have light, regular menses--become increasingly light

• Less amenorrhea than LNG 52

(Gemzell-Danielsson, Schellschmidt et al. 2012; Nelson, Apter et al. 2013) Copper IUC Menstrual Effects • Longer/heavier menses/dysmenorrhea o Gets better with time o NSAIDs prophylactically WITH FOOD . Pre-emptive use for 1st 3 cycles . Start before onset of menses for anti-prostaglandin effect  Naproxen sodium 220mg x2 BID (max 1100mg/day)  Ibuprofen 600-800mg TID (max 2400mg/day)

(Godfrey, Folger et al. 2013; Grimes, Hubacher et al. 2006; Hubacher, Chen et al. 2009) Addressing Unscheduled Bleeding

• Anticipatory guidance • Ask what concerns her • Normal side effect, not dangerous, doesn’t indicate reduced effectiveness • Any concomitant medications that may reduce effectiveness of progestin Work up of unscheduled bleeding Work up in context of other symptoms (pain, vaginal discharge, postcoital bleeding) Consider: • Pregnancy test • Speculum and bimanual exam • Cervical cancer screening • GC/CT • Pelvic ultrasound • EMB

Estrogen for Unscheduled Bleeding with Implant • Estrogen to build/support/ repair endometrium • Options –Monophasic combined OCP –Vaginal Ring –Estradiol 2 mg PO –Conjugated Equine Estrogen 1.25 mg PO

(Zigler, McNicholas 2017) NSAIDs for Unscheduled Bleeding • Inhibit prostaglandin synthesis which is increased in the endometrium of women with abnormal bleeding –Most effective when bleeding is “heavier” • Options –Naproxen sodium 220 mg PO BID –Ibuprofen 800mg PO TID –Mefanamic acid 500 mg PO TID

(Zigler, McNicholas 2017) Treatment for Bleeding with LNG IUD in the First 90 days • Naproxen sodium may work-- particularly if bleeding is heavy

• Progesterone Only Pill

• Transdermal E2 and tranexamic acid likely not to work

(Madden, Proehl et al. 2012; Sordal, Inki et al. 2013; Varma, Sinha et al. 2016) Tranexamic Acid For Unscheduled or Heavy Bleeding • Tranexamic acid –Anti-fibrinolytic to treat heavy menstrual bleeding, decreases clot breakdown –650 or 1300 mg PO TID • Contraindicated in women with ↑risk of VTE

(Zigler, McNicholas 2017) Not Useful, Not Practical or Still Experimental:

• Doxycycline • Mifepristone • Tamoxifen

(Zigler, McNicholas 2017) Meena 29 y.o. G1P1 “What is it about not getting your period that is concerning to you?”

“I would always worry that I might be pregnant.”

“I can see that it’s very important to you not to get pregnant until you are ready.”

“Many of my patients like to get their period every month because they feel like it lets them know they aren’t pregnant.” Amenorrhea • Don’t… –Assume you know why she objects to amenorrhea –Ask her “why” • Do… –Ask what about not getting her period is concerning to her –Let her know many women feel that way Meena 29 y.o. G1P1

• “Interestingly many women still bleed in the beginning of a pregnancy...”

• “Pregnancy tests at the 99 cent store are plentiful and can be very reassuring!” Kristal 22 y.o. G2P1 “My mom said it’s not healthy not to get my period.” • “Your mother is completely right!.... when you are not on hormonal contraceptives, it is important to get a monthly period. It’s great that you know that.”

•“I’m so glad you know that when you are not on contraceptive hormones and you miss your period you need to come in so we can see what’s up!” Kristal 22 y.o. G2P1 “My mom said it’s not healthy not to get my period”

• “I wish all of my patients knew that if they miss their period and they aren’t on contraceptive hormones it could mean something is wrong!”

• ... “Interestingly, if a woman is using contraceptive hormones it keeps her uterus very healthy and thin. It actually prevents cancer of the uterus.” Dalkon Shield Dalkon Shield: Multi-filament String How Long to Wait to Place an IUD After Treatment for Cervical Infection?

• The optimal time for IUD placement after treatment is unclear

• Delay IUD placement until: – treatment is complete – symptoms have resolved – the cervical examination appears normal – no masses or tenderness on bimanual exam (ACOG Practice Bulletin 2017) Genital Tract Infections • If cervical or vaginal infection diagnosed • Treat infection IUC removal not necessary • If PID diagnosed • IUC removal usually not necessary • Treat infection • Recommendations to remove IUC are not evidence-based • Consider removal if no improvement 48- 72 hours after starting treatment

(Penney, Brechin et al. 2004; WHO Selected Practice Recommendations for Contraceptive Use 2002)

Jennifer 39 year old G2 P2 “What Was That Pain?” • In for a 6 week post-partum visit after a NSVD…requests LNG 52 IUD. • She is lactating, no longer bleeding, and doing well. • Exam shows a 8-9 week size uterus that is firm and non-tender; adnexal exam negative. Jennifer 39 year old G2 P2 “What Was That Pain?”

• During sounding, moderate resistance is encountered at the internal os…then sounded to 14 cm. • She complained of pain only during the initial part of the sounding procedure • What’s going on here?? Uterine Perforation

• More likely to occur in relation to: –Posterior uterine position –Post-partum placement, especially in lactating women –Skill/experience of provider Uterine Perforation

• Typical location is midline at uterine fundus • Perforation often asymptomatic • Suspect if sounding is much deeper than expected or if ↑ resistance followed by none at fundus • Can be confirmed by real-time office ultrasound, if available Uterine Perforation Rates European Active IUD Surveillance Study

• Multinational, prospective, non- interventional cohort study • New IUD users –Baseline information –Follow-up at 12 months • 61,448 women in 6 countries –70.1% LNG; 29.9% copper (30 types)

(Heinemann, Reed et al. 2015) Uterine Perforation Rates European Active IUD Surveillance Study

• Perforation: partial (20%); complete (80%) • 50% diagnosed first 2 months

• Perforation rates by 12 months –LNG: 1.4/1,000 –Copper: 1.1/1,000

(Heinemann, Reed et al. 2015) Uterine Perforation Rates European Active IUD Surveillance Study • Breastfeeding significantly increased risk –6/1000 –No difference between IUD types • 63/81 perforations had risk factors – Breastfeeding – Time since delivery < 36 weeks • No serious injury to intraperitoneal or pelvic structures

(Heinemann, Reed et al. 2015) Factors That Did Not Affect Perforation Risk European Active IUD Surveillance Study

• Cervical dilation at time of placement • Use of anesthesia • History of cesarean section • Last delivery by cesarean section

(Heinemann, Reed et al. 2015) Prevention of Perforation • Careful assessment of uterine position • Bend the sound to mimic uterine flexion • Exert adequate traction with the tenaculum to straighten the axis of the uterus • Brace fingertips on speculum to achieve control of force while advancing the sound Prevention of Perforation

• Once you have passed through the internal os—STOP and pause for a second • Then intentionally proceed to the fundus in a controlled fashion Prevention of Perforation

• You will feel resistance when the uterine sound touches the fundus • This "fundal feel," or resistance should be a signal to STOP advancing the sound –Do not push beyond fundal resistance even if the flange is not yet at the external os. –Flange or fundal feel- STOP whichever comes first Prevention of Perforation • Plastic sound may have less risk of perforation than metal

• EMB device can be used instead of metal sound

• Place cervical block and dilate cervix if resistance is encountered in order to avoid excessive force during sounding and placement Prevention of Perforation

• Do not use the white stabilizing rod as a plunger during placement of a copper IUC Management of Perforation

• If before placement of IUC, stop procedure • If during placement of IUC, remove IUC • Monitor BP and pulse, bleeding, pain for 30-60 minutes • Provide alternative method of contraception • Can place another device in 1 month Expulsion • Occurs in 2-10% IUD insertions within first year • Risk of expulsion related to: –Provider’s skill at fundal placement –Age, parity, uterine configuration –Time since insertion (↑ within 6 mos) –Timing of insertion (menses, postpartum, post-abortion) Expulsion • Unnoticed expulsion may present with pregnancy • Partial expulsion may present with –Pelvic pain, cramps, intermenstrual bleeding –IUD string longer than previously

(WHO Medical Eligibility Criteria For Contraceptive Use 2000) Pregnancy With IUD

Determine site of pregnancy (IUP or ectopic) • If IUP, and planning to continue pregnancy –Discuss informed consent –Removal is recommended when strings are visible/can be removed safely from the cervical canal

(ACOG 2016; Brahmi, Steenland et al. 2012) Pregnancy With IUC In Situ

If termination planned • The IUC can be removed or wait until procedure to avoid triggering spontaneous abortion (SAB) • The IUD should be removed before medication abortion

(Atrash et al. 1994; Foreman, Stadel et al. 1981; UK Family Planning Research Network 1989) Pregnancy Outcomes

• Large hospital in Israel • Retrospective review of all pregnancies beyond 22 weeks 1998 -2007 • If retained IUC, increased rates of abruption, previa, cesarean delivery, preterm delivery, LBW infants, and chorioamnionitis vs. without an IUD

(Ganer, Levy et al. 2009) Pregnancy Outcomes

Women who became pregnant with an IUD in place, but whose IUD was removed had outcomes that were intermediate between the group that retained the IUD and the group who became pregnant without an IUD in place

(Ganer, Levy et al. 2009) Pregnancy With IUC in Situ • Missing String: –If continuing IUP and strings are not visible, do not attempt removal –Counsel regarding the increased risks of SAB, septic abortion, chorioamnionitis, and preterm delivery –Increase surveillance during antenatal care

(Brahmi, Steenland et al. 2012; Foreman, Stadel et al. 1981) Pregnancy With IUC in Situ

• Continued pregnancy with IUC: –No greater risk of birth defects, since IUC is outside of the amniotic sac –Insufficient evidence re: negative fetal effects with small exposure to LNG during gestation

(Brahmi, Steenland et al. 2012; Foreman, Stadel et al. 1981) Actinomyces-Like Organisms • Actinomyces israelii has characteristics of both bacteria and fungus; part of GI flora • May asymptomatically colonize the frame of the IUC, which in itself is not dangerous • Very small percentage of women with IUC + actinomyces will develop pelvic actinomycosis which presents as severe PID Actinomyces-Like Organisms (ALO)

Patients with ALO on Pap test • Should be examined to exclude PID however it is likely that the patient was already examined at time of cytology testing • If no PID, don’t treat actinomyces or remove IUC Difficult IUC Placement More Difficult in Nullips or Teens??

• N= 1,177 aged 13–24 years old • 59% nulliparous • First-attempt success rate of 95.5% • 86% of placements done by advanced practice clinicians • Complications were rare • No perforations were reported

(Teal, Romer et al. 2015) Kristin 29 y.o. G0

• Seen in the clinic for placement of a LNG 52 IUD • Just graduated from BSN program • No menses on DMPA for 2 years • History of LEEP 3 years ago for CIN 3 • Cervical cytology negative 2 months ago Kristin 29 y.o. G0

Physical examination • Normal sized retroverted uterus • Very low pain tolerance with speculum placement • Unsuccessful attempt to sound • Kristin becomes increasingly uncomfortable Tenaculum

1. Change the amount of traction

2. Apply traction in different direction

• At what point would you recommend or offer a block? Uterine Sound 3. Gently hold the sound at the internal os and then wait --to allow the os to yield 4. Change the curvature of the sound (if metal) 5. Apply light pressure at various angles 360o and positions with the sound looking for an opening 6. Approach more anteriorly or posteriorly

Have you used ultrasound guidance? Still Unable To Pass Through the Internal Os

7. Use os finder device 8. Use a thinner sound (endometrial sampler) 9. Dilate internal os with small dilator 10. Try a shorter wider speculum 11. Reposition the tenaculum onto a different place or add a second tenaculum Os Finder Device

Cervical Os Finders (Disposable Box/25) Cervical Os Finder Set (Reusable Set of 3) “Failed First Attempt”

12. If unsuccessful, return after misoprostol 200 mg per vagina 10 hours and 4 hours prior to placement

13.Place paracervical or intracervical block at any point

(Bahamondes, Espejo-Arce et al. 2015) Passed Through with Sound …But not the Device!

1. Choke up on the handle 2. Sterile lubricant on tip 3. Leave the (small) sound in the canal and come alongside the sound with the inserter Mary 18 y.o. G0 P0 “I Am So Afraid to Have This Done!”

• Will this hurt? Pain Relief Principles And Application • Verbicaine • Slow technique • Tenaculum site local anesthetic • Pre-placement NSAIDs • Paracervical and intracervical block • Oral sedation • Nitrous Verbicaine

• Keep her talking! • Calm, soothing vocal tone • Slow, easy pace • Utilize whatever works for the patient (ASK) • Breathing techniques • Mindful mediation • Guided imagery Wonderful Distraction NSAIDs • Cochrane review, 2015 • Tramadol and naproxen had some effect on reducing IUD placement pain in speciﬁc groups • Lidocaine 2% gel, misoprostol, and most NSAIDs did not help reduce pain • Helps with post-placement cramping

(Lopez, Bernholc et al. 2015) Oral Sedation • Reserve for special cases • Obtain informed consent before meds given • Options - Benzodiazepine eg. alprazolam, diazepam - PLUS - Acetominophen 300 mg + codeine or hydrocodone • Take 30 minutes before • Develop a protocol for your office or clinic

• Needs to have a driver or escort

(Carrie Cwiak, MD, MPH) Cervical Anesthesia

20 ml of 1% lidocaine (NO epinephrine) Paracervical Block

• Target is uterosacral ligaments, which contain the cervical and uterine nerves • Use spinal needle • OR 25g, 1 ½” needle + extender • Inject at reflection of cervico-vaginal epithelium Paracervical Block

• 5-10 cc 1% lidocaine (no epinephrine) each side • Submucosal injection 5mm-1cm deep

• Short speculum allows more movement • WAIT 1-2 minutes after placing block

Paracervical Block

. Paracervical Block

X X 8 o’clock 4 o’clock Paracervical Block

X X X X 8 o’clock 4 o’clock 6 o’clock Intracervical Block

• Targets the paracervical nerve plexus • 1 ½ inch 25g needle with 12 cc “finger lock” syringe • Inject ½- 1 cc. at 12 o’clock, then apply tenaculum Intracervical Block • Angulate needle at the hub to 45o lateral direction • At 3 o’clock, insert needle into cervix to the hub 1 cm lateral to external os, then aspirate –Inject 4 cc of local, then last 1 cc while withdrawing • Rotate barrel 180o, then inject at 9 o’clock

Intracervical Block

9 o’clock X X 3 o’clock

8 o’clock 4 o’clock 6 o’clock Lidocaine Safety

• Inject in correct spot • Aspirate to avoid intravascular injection • Metallic taste is a common side effect Betsy 17 y.o. G0

• While having her copper IUC placed, Betsy says, “Is this going to take much longer? I really need to go to the bathroom” • What’s going on here?? Betsy 17 y.o. G0

• She recalls after the fact that she had a fainting spell after her HPV immunization • She had told her PCP about this problem…heart auscultation and an ECG were normal Vasovagal Response Episode, or Attack AKA: Non-cardiogenic Syncope

• Mechanism –Starts with peripheral vasodilation –Bradycardia + drop in B/P • More likely with dehydration or NPO –Pain with cervical manipulation –Previous episodes of vaso-vagal fainting

(Grubb 2005) Symptoms - Presyncopal

• Weakness • Light-headedness • Diaphoresis • Visual blurring • Headache • Nausea • Feeling warm or cold • Sudden need to go to the bathroom Presyncopal Signs • Facial pallor (distinct green hue) • Yawning • Pupillary dilatation • Nervousness How to Avert Vasovagal Syncope • Isometric contractions of the extremities • Intense gripping of the arm, hand, leg and foot muscles • No need to bring the legs together or change position– just tense the muscles • This stops the reaction Vasovagal Prevention

• Anticipatory guidance! • Good hydration • Eat before placement • Prophylactically contract muscles if known history

(Grubb 2005) Missing String Ultrasound Guidance

Carrie Cwiak, MD, MPH Missing String…Possibilities

1. IUD in-situ ─ String coiled in canal or endometrial cavity – String short, broken, or severed 2. Unnoticed expulsion 3. Intrauterine pregnancy

ACOG 2016 Missing String…Possibilities

4. Malpositioning of the IUD, following perforation –Embedment into the myometrium –Translocation into the abdomen or pelvis • The perforation is not the problem; the abnormal position of the IUD is!

ACOG 2016 On X-ray On X-ray Embedment –Diagnosed at failed attempt at extraction or imaging –Remove when diagnosed, as embedment may progress to translocation –Advanced imaging (3-D ultrasound or pelvic CT) is critical, as it is used to direct treatment to hysteroscopy, laparoscopy, or laparotomy Translocation

–Since copper IUD may cause more adhesions, must extract promptly via laparoscopy –LNG-IUS is less reactive, but experts recommend laparoscopic removal Other Possibilities

• In situ placement: desires retention –Leave in place for remainder of IUD lifespan –Option: annual pelvic ultrasound in lieu of string check CT or 3-D Ultrasound? Why?

A: Hysteroscopy B: Laparotomy C: Laparoscopy

D1: Laparoscopy D2: Hysteroscopy Missing String: Office Ultrasound • No IUD string in canal • Pregnancy test negative • Office ultrasound (UTZ)

Present Absent

Desires Desires KUB removal retention

Present Absent Extract Leave + guidance In Situ “Formal” UTZ Expelled

Absent Present

Extracted Not found Translocated Embedded? Embedded Hysteroscopy Laparoscopy 3D-UTZ or or 3D-UTZ or CT CT with contrast with contrast No Office Ultrasound •No IUD string in canal •Pregnancy test negative

Desires Desires removal retention

OR Attempt Ultrasound KUB extraction

Extracted In Situ Absent Absent Present

KUB Embedded Not felt Ultrasound

Op hysteroscopy Present Absent In Situ Absent

Extracted Translocated Expelled Translocated Thread Retriever Thread Retriever Fulcrum 1 cm from the tip of the device

Opened and closed completely within the uterine cavity

No cervical dilation necessary

(ACOG 2016; Prabhakaran, Chuang 2011) Extraction of IUD in-situ • Intrauterine exploration for a T-shaped IUD –Gently open/ close ¼ turn forceps at progressive depths until “purchase” of stem or arm –Real-time ultrasound guidance may help • Maneuver hook along anterior, then posterior, uterine wall from fundus to canal • If embedment suspected, consider evaluate 3-D ultrasound or pelvic CT with contrast Desires Removal

• Additional measures, as indicated • Pain management –Cervical block + oral NSAIDs for pain –Conscious sedation • Cervical dilation –Osmotic dilator –Rigid dilators –Misoprostol may facilitate IUD extraction Removal Post Menopause • Strings seen: remove • No strings visible…weigh risks –Hazards of continuation (post-menopausal bleeding, ? pelvic actinomycosis) –Hazards of removal (pain, perforation) • Tail-less IUD (e.g., Chinese stainless steel coil ring) should not be removed unless she requests it Sarah 30 y.o. G3P3 BMI 41 • Sarah is in the office for a Cu IUD placement • Unable to feel uterus on bimanual exam • Attempts to place the tenaculum are unsuccessful as the cervix keeps slipping out of view Obesity: Bimanual Exam

• It may be difficult or impossible to palpate the uterus or ovaries • Place the abdominal hand UNDER the panniculus to decrease amount of adipose tissue between the hand and the uterus • Pelvic sonogram if sounding difficult The Elusive Cervix • Ensure adequate lighting • Significant uterine flexion causes cervix to be anterior or posterior • Extreme retroversion of uterus can cause cervix to be lodged behind symphysis pubis • Exert more pressure on posterior fornix to manipulate it into view

(Bates et al. 2011) Obesity: Have Appropriate Instruments in the Room

• Specula of varying sizes • Tongue blades or retractors or ring forceps –Use closed ring forceps or tongue blade to gently push vaginal walls to the side to improve visibility Obesity: The Right Speculum • Too narrow--will not allow for good visualization • Increase width rather than length • Avoid a long speculum • It can firmly splint the cervix in place • Does not allow you adequate cervical mobility to straighten the uterine flexion when using a tenaculum Open the speculum blades at the base as well as the tip

Upper blade

Thumb screw Lower blade Thumb hinge Handle screw

Handle

Optimize Position

• Position Sarah as far down on the exam table as possible to allow maneuvering of the speculum once in place

• Hips over the edge of the exam table drops her pelvis and cervix forward and makes visualization easier Optimize Position

• Raise her buttocks… • Have her place her hands in a fist under her own buttocks • Lower the head of the table • Place a lift under her buttocks Knees To Chest Or “Cannon Ball"

She pulls her knees up and back Rachel 35 y.o. G0 P0

• Over the past 2 years, her periods have been heavier and longer than previously • LNG IUC chosen for contraception and bleeding control • Bimanual exam: Irregular 12 week uterus • Clinical dilemmas… LNG-IUS and Fibroids

–Off-label use; may violate precaution regarding cavity depth and distortion of uterine cavity –Reasonable to attempt treatment of bleeding with LNG 52; effective 50% of the time –Document informed consent IUC Placement with Fibroids

• Ultrasound guidance may facilitate safe placement • No data on efficacy, but probably not compromised with LNG IUC or with copper IUD if fundal placement Tips for IUC Placement

• Determine fibroid location by ultrasound –Fundal fibroids (intramural, sub-serous) that do not distort uterine cavity do not preclude IUC use –Large sub-mucous fibroids, especially in lower uterine segment, contraindicate IUC use –Evaluate for other pathology, e.g., polyp INTRAUTERINE CONTRACEPTIVES ON ULTRASOUND Images courtesy of Matt Reeves MD Principles of Ultrasound: How sound travels: Reflections

• A structure at a right angle to the sounds waves will reflect more sound that the same structure at any other angle PARAGARD

End of IUD

End of Copper PARAGARD

• Very echogenic PARAGARD in retroverted uterus PARAGARD Mirena on Ultrasound

Pronounced shadowing Pronounced Shadowing With Mirena

• On some machines, the Mirena shadows more than others Mirena

• Not very echogenic except where perpendicular to the probe • Strings may be as echogenic as the IUD Mirena on an Older Machine

Echogenic tip of Mirena

• This is a scanned image from an old GE machine Mirena in the Cervix

Tip of Mirena extends to external os Anterior vaginal wall Mirena in Cervix What Is Too Low?

Tip of Mirena extends below internal os What Is Not Too Low?

Tip of Mirena well above internal os Skyla LNG IUC 13.5

The silver ring

(Edelman 1979) Lippes Loop Lippes Loop Saf-T-Coil Steel Ring (China) Steel Ring (China) Steel Ring (China) Summary • Copper devices are usually easy to see • Mirena can be hard to see –Getting the angle right is key –You can use the TVUS probe to move the uterus to improve visualization Helpful Resources

• National Clinical Training Center for Family Planning: www.ctcfp.org • U.S. MEC Guidelines: www.cdc.gov/mmwr • LARC Practice Resources: www.acog.org/goto/larc References

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