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 POSTERIOR UTERUS Measure uterine length from external cervical os to fundus Apply a tenaculum to ANTERIOR cervical lip; then lift up with tenaculum…THEN The 3 IUDs have different insertion apply a second tenaculum to the techniques POSTERIOR cervical lip (pull forward to Copper IUD (Paragard) placed at fundus visualize the posterior cervical lip); then Levonorgestrel IUDs (Mirena and Skyla) remove the ANTERIOR tenaculum placed approximately 2.5 cm below the fundus arms to extend normally
1 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: 1,2 no decrease in pain with procedure 1, increase in pre-insertion pain 2 increase pre-insertion nausea and cramping
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 1 no decrease of insertion pain Turkish University Hospital Paracervical Block: 2 Both tramadol 50 mg & 550 mg naproxen, RCT no statistical decrease of insertion pain
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
2 Case Presentation: Cervical Cervical Bleeding Stenosis Bleeding from Tenaculum “Cathy,” 32-year-old Punctures G1P1 Apply pressure Medical history: Monsel's solution or silver nitrate • Cervical stenosis after LEEP 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
3 Case Presentation: Uterine IUD insertion in the Obese Woman Fibroids/Obesity “Barbara,” 42-year-old G3P3 CDC MEC 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 May use 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
4 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 Fever, chills, unusual • Tip of device protruding from cervix 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, Pain during intercourse Counseling upfront and reassurance partial expulsion Ibuprofen 800mg po tid or Naproxen 500 Missed period, other Pregnancy signs of pregnancy, mg BID for 5-7 days (uterine or ectopic) expulsion 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
5 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: 2 • Get U/S to eval for malposition or fibroids with most users • 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?
6 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 Partial or unnoticed expulsion may present IUD may be located by palpation with sound as irregular bleeding and/or pregnancy Use alligator forcep and tap the IUD Risk of expulsion (2-5%) related to: Pull forcep back ½ cm, open forcep jaws and • Provider’s skill at fundal placement move upward grasping any part of the IUD. • Age and parity of woman • Time since insertion Once IUD grasped, rotate to dislocate it from • Timing of insertion endometrium If IUD stem embedded, grasp any part of IUD and lift slightly upward and rotate to remove 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.
7 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: retroflexed. During sounding of her • Uterine position and consistency • 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.
8 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- Ensure client knows to call or return to 10wks) see you for bothersome side effects Ask follow-up questions: Create a plan with client about • Are you satisfied with your contraceptive method? “preemptive” treatment options in the • Consider speculum string check event of bothersome spotting • Is there anything you would change? Reassure that there will be an adjustment • Are you having bleeding problems period the first few months or other side effects? Address primary care/annual Discuss an OTC treatment plan in the appointments and STI event of cramping. counseling
ARHP. Clinical Proceeding. 2004.
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