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Case
19 yo female (G1P0) presents for hormonal IUD placement. Her past
medical history is not significant. An IUD is inserted without difficulty.
Routine STI screening test results come back 2 days after insertion
positive for Chlamydia.
What do you do?
Case: Post-Insertion Infection
Management:
Follow the CDC Guidelines for outpatient
management of cervicitis.
https://www.cdc.gov/std/treatment/2010/default.htm
The patient is treated with azithromycin 1
gm PO x 1.
Key points to know
Low rate of PID in women who have IUD
placed with unknown culture status
No benefit to presumptive treatment at time
of insertion (Grimes, et al. Cochrane Review, 2012)
Case: Post-Insertion Infection
She returns to clinic 4 days later with complaints of fever, nausea,
vomiting, and abdominal pain. On physical exam, her vital signs
show:
VS: T 102, HR 120
On bimanual exam, she has cervical motion tenderness and left
adnexal tenderness.
How do you manage her?
Case: Post-Insertion Infection
Management: insert screen shot of cdc guidelines for treatment options
Obtain blood cultures with sensitivities.
Follow the CDC Guidelines for inpatient management of cervicitis.
She is treated with IV doxycycline and cefotetan
She has clinical improvement in 24-48 hours, and is discharged home
What if she does not improve clinically after 24-48 hours?
Ultrasound to evaluate for a tubo-ovarian abscess.
If present, manage per OBGYN or general surgery guidelines
Consider removing the IUD and continue the antibiotics for an
additional 24-48 hours
PID Treatment
Outpatient PID Treatment
Inpatient PID Treatment
Slide courtesy of Bayer, Inc
Slide courtesy of Bayer, Inc
Ultrasound Imaging of Intrauterine
Devices
Basic Ultrasound (US) Evaluation
Transabdominal (TA) and transvaginal (TV) US
If obvious malpositioning on TA US (eg expulsion), may not need TV US
TA US inadequate for establishing appropriate positioning of IUD
3D US
Often critical for identifying the arms and their relationship to the uterine
cavity
Aids in detection of subtle problems in positioning (embedment)
IUD Image Acquisition
• 2D evaluation• Standard female pelvis protocol
• Sagittal (red) and coronal (blue) cine sweeps through uterus
IUD Positioning
• Optimal positioning• Stem entirely within endometrial cavity• Arms extending laterally within fundus (within 3 mm of top of fundal cavity)
• 3 common complications• Expulsion
• IUD within cervix/vagina• Frequently symptomatic with bleeding and pain
• Displacement• Low position• Often asymptomatic, but may cause bleeding and cramping
• Perforation• Embedment
• Endometrial/myometrial penetration
• Complete perforation• Penetration of all three uterine layers – may be partially or completely intraperitoneal
• Asymptomatic or symptomatic
Boortz HE et al. Migration of intrauterine devices – Radiologic findings and implications for patient care. Radiographics 2012; 32:335-352.
Mirena IUD –appropriately positioned
Mirena IUD – Malpositioned (expulsed)
[c
in
e]
Paraguard IUD – malpositioned & embedded
Mirena IUD – embedded
Mirena IUD – Malpositioned (inverted) and embedded
Mirena IUD –Malpositioned (inverted) with complete perforation
Mirena IUD – Perforation
Mirena IUD –Retained arm post removal
Value of Post-Partum LARC
More than half of unintended pregnancies occur within 2
years of delivery
35% of pregnancies occur within 18 months of a prior birth
– 75% are mistimed or unwanted
– 35% teen moms become pregnant within 2 years
Inter-pregnancy intervals < 6 months associated with
increased adverse perinatal outcomes
LARC users have 4x greater odds of
achieving optimal birth interval vs.
women using less effective methods
Zhu BP et al., N Engl J of Med, 1999; Thiel de Bocanegra et al.,
AJOG, 2011; Gemill et al., Obstet and Gynecol, 2013
What is the problem with waiting until 6 wks PP
>35% women do not attend 6 week PP visit
50% ovulate before 6 week PP visit
60% resume sex before 6 weeks PP visit
Timely access to PP contraception
Can prevent rapid repeat pregnancy
Improve next pregnancy outcomes
Prevent abortion
Interval Post-Partum Contraception
Potter et al., 2014; Tang et al., 2013
For an Implant
Before discharge from the hospital postpartum
Same process as outpatient device placement
No concerning effects on:
Maternal health
Breastfeeding outcomes
For an Intrauterine Device
Insertion technique and equipment differ from outpatient approach
Insert within 10 min of placental delivery
Delivery type: Vaginal or Cesarean section
Considerations
More data needed on risk of expulsion, but can be mitigated when recognized
PP LARC Insertion Basics
Brito MB et al., Contraception, 2009; Burtcheff SE, Obstet and Gyne, 2011
Equipment for PP IUD Placement
Post-placental:
Graves speculum
Betadine and cotton/sponges
Forceps (placement, +/- cervix)
Scissors
Postpartum:
Bed that breaks away
Light source
Immediate PP IUD Placement
Technique
I m p o r t a n c e o f f u n d a l p l a c e m e n t
“Hockey stick” shape to postpartum uterus
Cochrane review 2010, 2015
Safe and effective
No increase in bleeding, infection, or perforation risk
U/S may decrease perforation risk
Progestin methods safe with breastfeeding
Expulsions
Higher rate with PP versus interval IUD placement
Use of instruments, manual insertion, IUD modifications did not
change expulsion rates
Safety of Immediate PP LARC Use
Grimes D et al; Cochrane Syst Rev, 2010
Lopez LM et al.; Cochrane Syst Rev; 2015
ACOG Practice Bulletin #121, July 2011
Phillips et al Contraception 2015
Braga Contraception 2015
Gurtcheff SE et al, Obstet Gyncol 2011
Immediate PP Training Resources
SPIRES YouTube Tutorial
https://www.youtube.com/watch?v=uMcTs
uf8XxQ
Resources
ACOG Committee Opinion #672. Clinical Challenges of LARC
Methods. September 2016.
Brito MB et al., Contraception, 2009
Burtcheff SE, Obstet and Gyne, 2011
SPIRES YouTube Tutorial,
https://www.youtube.com/watch?v=uMcTsuf8XxQ
Boortz HE et al. Migration of intrauterine devices – Radiologic findings and implications for patient care. Radiographics 2012; 32:335-352.
