Where’s my IUD? A pictorial review of malpositioned intrauterine devices and clinical implications

Sana Hava DO, Alyssa Goldbach DO, Harshad Patel MDDepartment of Diagnostic Radiology, Temple University Hospital, Philadelphia, PA USA

DISCUSSIONAn IUD is considered malpositioned when described as:

• Located in the lower uterine segment or cervix

• Embedded in the myometrium (Figure 2)

• Protruding partially through the uterus or completely outside of the uterus and within the abdominopelvic cavity (perforated) (Figure 3)

• Rotated (Figure 4)

• Partially expelled

Radiologists play a critical role in assisting clinicians with the location of IUDs and providing clinically impactful information on potential associated complications of a malpositioned IUD, which include:

Radiologists should be familiar with the normal appearance and location of IUDs, along with the treatment algorithm for locating IUDs that are not identified within the uterus, as these patients may require further medical or surgical management, and also because of the decreased contraceptive efficacy.

OBJECTIVE

This pictorial review is directed towards in-training radiology residents and fellows, general and body radiologists, and non-radiology audiences to recognize the normal and abnormal imaging findings associated with intrauterine devices (IUD), the clinical implications of a malpositioned IUD, and the appropriate imaging follow-up that will provide guidance for physicians and clinical management.

INTRODUCTION

IUDs are a commonly used form of contraception worldwide, with a 98-99% effectiveness in preventing pregnancy. The mechanism of contraception is due to the chronic inflammatory changes induced by the IUD in the endometrium and fallopian tubes, which in turn has spermicidal effects, inhibits fertilization, and creates an inhospitable environment for implantation. However, a frequent complication of IUDs is migration from its normal position, leading to secondary complications of malpositioning such as ectopic location, embedment, perforation, or expulsion. Malpositioned IUDs may also result in unplanned pregnancies or surgical intervention for device retrieval.

This exhibit displays a few cases of malpositioned IUDs from patients in North Philadelphia who presented at our institution for care, the radiological follow-up they underwent, and their clinical outcome.

CASE REVIEW

(A) Transabominal longitudinal US image of the uterus demonstrates an IUD with its stem entirely within the endometrial cavity.

(B) On a Coronal 3D US image, the arms of the IUD extend laterally within the uterus.

FIGURE 1: IUD in a normal expected position

A B

26 year old female presented for incomplete removal of IUD. Ultrasound showed a detached arm of the IUD penetrating into the myometrium near the lower uterine segment.

FIGURE 2: Embedded IUD

28 year old female presented for abnormal vaginal bleeding and pelvic pain. An inverted IUD was noted during ultrasound, illustrated in the Coronal 3D image. The patient eventually underwent hysteroscopy for IUD removal.

FIGURE 3: Malpositioned IUD

42-year-old female for IUD evaluation. IUD was not identified on ultrasound, at which time abdominal radiograph was recommend. Abdominal radiograph demonstrated the IUD projecting in the pelvic region. Further evaluation with CT showed the IUD posterior to the bladder. She underwent laparoscopic removal of the IUD, which was identified partially embedded in the left fallopian tube.

FIGURE 4: Malpositioned IUD

TREATMENT ALGORITHM

Adapted from Boortz HE, Margolis DJA, Ragavendra N, Patel MK, KadellBM. Migration of intrauterine devices: radiologic findings and implications for patient care. RadioGraphics 2012;32:335– 352.