Malpositioned IUD after post-placental insertion

Question:

"D" had a Mirena IUD placed at the time of Cesarean section. At her 6-week visit, the strings could not be visualized; so, her provider ordered a pelvic US. The IUD is in utero at the level of the fundus but seems to be turned "sideways." Some of our team feel the IUD should be removed and replaced immediately. Others feel it should be providing effective contraception and need not be removed until we reach the 6 - 7 year mark or until "D" wishes to conceive. There is concern that it may perforate the uterus, but I do not see why it would cause perforation of its own volition. Any thoughts/recommendations appreciated."

Answer:

In my opinion each approach would be acceptable; here are relevant points to your management consideration:

• Almost all perforations occur at time of insertion -only rarely may they occur later due to uterine contractions forcing the IUD through the uterine wall (Rowlands S. et. al. 2016 – this review paper does not mention increased risk through a c-section scar). There’s no current evidence of perforation or even embedment in this patient, and I agree with you that it is unlikely, and not a reason to remove in this instance.

• IUD malposition, such as in your patient, occurs more frequently in post-placental insertions

• Expulsion rates for immediate postpartum IUD insertions are higher than for interval or postabortion insertions, vary by study, and may be as high as 10–35%

• If your patient had pain and / or bleeding that would be an indication to remove based on malposition.

• It is not uncommon for strings to remain in the uterus after post-placental insertion, occurring about 25% of the time. The strings may still find their way out, and the IUD may still shift in position. One study by Faundes and colleagues found that IUDs accommodate position in the uterus during the first three months after insertion. Because of this, you can argue to follow up with another ultrasound in three months. It would be interesting to see if there is a shift of position, and this is what I would do if cost is not an issue.

→ If doing an ultrasound, use of a 3-D ultrasound with coronal plane view, provides more information about position

• An IUD in the uterus is providing effective contraception. Even Mirenas found outside the uterus provide some contraception due to serum levels of levonorgestrel

• According to Speroff and Darney’s A Clinical Guide to Contraception, “We recommend removal of a device that appears more than 25% embedded (e.g., more than one arm and / or a portion of the stem) even in an asymptomatic woman, due to concerns regarding contraceptive effects.” But that is not the case here either.

• In this topic on UptoDate, the authors note that there is a paucity of data to guide the clinical scenario of malpositioned IUD after post-placental insertion.

→ In one related topic the authors recommend offering IUD replacement, but do not say it is required. In other words, offer the information so the patient can make the decision

→ In another related topic, the authors say that for asymptomatic women with an “incidentally found malpositioned IUD in the uterus that does not extend into the cervix (ie, those displaced in the lower uterine segment, rotated on their axis, or partially embedded in the myometrium), we do not routinely recommend IUD removal, as the IUD is likely still highly effective based on mechanism of action though further research is needed in this area.”

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