IUD Complications: Management Strategies

IUD Complications: Management Strategies Contraceptive Technology April 19, 2013 Mark Hathaway MD, MPH Dept of Ob/Gyn Washington Hospital Center Washington DC Learning Objectives Learn IUD placement techniques in women with severe obesity and stenotic os Understand options for pain control during placement Learn how to evaluate and manage missing strings, pregnancy, perforation and malpositioned device Conflict of Interest Disclosure MUSTs Prior to IUD Insertion Speaker/Trainer for Bayer and Merck 1. Bimanual exam to determine uterine position, flexure and to r/o CMT 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 Measure uterine length from external cervical os to fundus The 3 IUDs have different insertion techniques Copper IUD (Paragard) placed at fundus Levonorgestrel IUDs (Mirena and Skyla) placed approximately 2.5 cm below the fundus arms to extend normally Technique to Straighten a VERY POSTERIOR UTERUS Apply a tenaculum to ANTERIOR cervical lip; then lift up with tenaculum THEN apply a second tenaculum to the POSTERIOR cervical lip (pull forward to visualize the posterior cervical lip); then remove the ANTERIOR tenaculum 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: no decrease in pain with procedure 1,2 increase in pre-insertion pain 1, increase pre-insertion nausea and cramping 2 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 Doesn t Work Intracervical lidocaine gel: double blinded RCT with 200 participants, no decrease of insertion pain 1 Paracervical Block: RCT no statistical decrease of insertion pain 2 Length of procedure almost doubled Intrauterine Lidocaine: double blinded pilot RCT- 1.2 ml 2% lidocaine vs saline infused via endometrial sampler 3 min prior to insertion 3 What Does Work? Double Blind RCT with 103 women in Turkish University Hospital Both tramadol 50 mg & 550 mg naproxen, relieve pain during IUD insertion Tramadol capsules found to be more effective than naproxen 1. Contraception. 2012 Sep;86 Maguire K, et al 2. Contraception. 2012 Dec;86 Mody SK et al 3. Contraception 2013 Jan Nelson J Minim Invasive Gynecol. 2012 Sep-Oct;19(5):581-4. 2

Cervical Bleeding Bleeding from Tenaculum Punctures Apply pressure Monsel's solution or silver nitrate Tear from Tenaculum Rotate tenaculum 45 degrees Apply pressure Case Presentation: Cervical Stenosis Cathy, 32-year-old G1P1 Medical history: Cervical stenosis after LEEP Seeking long-term, forgettable contraceptive method Cervical Stenosis Case: Clinical Considerations Insertion difficulty Cervical Stenosis Case: Practice Tips Os finder as needed Insertion pain If due to hypoestrogenic condition, use estrogen vaginal cream 2 weeks When stenosis result of LEEP or other surgery, may need to dilate Cervical dilation: Start with lacrimal duct probe Increase size until regular dilators will pass Consider ultrasound guidance Needs experienced hands Consider misoprostol Güney M et al. Obstet Gynecol. 2006. more Cervical Stenosis Case: Practice Tips (continued) Management options: Paracervical block 1 Oral pain management with hydrocodone and lorazepam (etc) Consider parenteral analgesia (midazolam and fentanyl) Misoprostol priming 2 Cervical Stenosis Case: Counseling Points Ask patient to arrive a few hours before insertion to receive misoprostol Counsel patient about the chance of failure of insertion Potential for vasovagal reaction, even with paracervical block 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 Fibroids/Obesity Barbara, 42-year-old G3P3 Medical history: Uterine fibroids Obesity (BMI = 35) Heavy menstrual bleeding, dysmenorrhea Has completed childbearing, does not desire sterilization Seeks nonsurgical treatment for fibroids Consider: LNG IUD Kaunitz AM. Contraception. 2007; World Health Organization. Medical Eligibility Criteria for Contraceptive Use. 2004. IUD insertion in the Obese Woman CDC MEC Catagory 1 for obese women (>30 BMI) CDC MEC Catagory 1 after bariatric surgical procedures (restrictive or malabsorptive) IUD Placement in Obese Woman Is table wide and stable enough? Have hips just over edge exam table which drops the cervix posteriorly To perform bimanual exam place abdominal hand UNDER panniculus IUD Insertion in Obese Women Consider rectal palpation May use a flexible uterine sound to help ascertain uterine position Ring forceps (closed) to gently move walls 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 SM Schnare Kaunitz AM. Contraception. 2007; CDC US Medical Eligibility Criteria for Contraceptive Use. 2010; Grigorieva V, et al Fertil Steril. 2003 May;79(5):1194-8. Uterine Fibroids Case: Counseling Points Expulsion rates possibly higher for women with fibroids Counsel patient about possible signs of expulsion: Unusual vaginal discharge Severe cramping or heavy bleeding Longer-than-usual or absent strings protruding from cervix Tip of device protruding from cervix Signs of Possible Complications Symptom Possible Explanation Severe bleeding or abdominal cramping 3 5 Perforation, infection days after insertion Irregular bleeding and/or pain every cycle Fever, chills, unusual vaginal discharge Dislocation or perforation Infection 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 (Continued) General Management of Bleeding Issues for Progestin Methods Symptom Pain during intercourse Missed period, other signs of pregnancy, expulsion Shorter, longer, or missing threads Possible Explanation Infection, perforation, partial expulsion Pregnancy (uterine or ectopic) Partial or complete expulsion, perforation Counseling upfront and reassurance Ibuprofen 800mg po tid or Naproxen 500 mg BID for 5-7 days Estradiol 0.5-2mg po qd for 5-10 days OCPs for 2-3 cycles 5

Bleeding with the Copper T IUD Bleeding and/or pain rates are highest during 6 months of use Rates of expulsion and removal for bleeding and/or pain are higher in nulliparous than in parous women 1 Bleeding appears to decrease over time with most users 2 Managing Heavy Bleeding with the Copper T IUD NSAIDs can prevent increased bleeding, but does not impact discontinuation 1 NSAIDs and antifibrinolytic drugs may prevent and treat heavy blood loss 2,3 If heavy bleeding lasts >6 months: Get U/S to eval for malposition or fibroids 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 40 women with menorrhagia on anticoagulant medication after cardiac valve replacement LNG-IUDs inserted into 20 women PT, PTT, INR, HCT, Hg, ferritin and pictorial bleeding assessments recorded 3 months after insertion of LNG-IUDs, sig decrease in blood loss and higher Hg, HCT and ferritin. No difference in PT/INR Management of Cramping Mild: recommend NSAIDs Severe or prolonged: Examine for partial expulsion, perforation, or PID Remove IUC if severe cramping is unrelated to menses or unacceptable to patient Contraception. 2009 Aug;80(2):152-7 Kilic S CASE: M.L. is 17 y/o She has a LNG IUD placed 1 year ago. She cannot feel her IUD threads. Last time she checked her threads was 6 mos ago. What s your plan? When Threads Are Not Visible Is she pregnant? Is the IUD in place? Is there a perforation? 6

Management of Missing Threads Rule out pregnancy Probe for threads in cervical canal with cervical brush Prescribe back-up contraceptive method Obtain ultrasound or x-ray, as needed Remove IUD in abdomen promptly Offer EC when unprotected sex in past 5 days IUD Thread Retrievers There are several thread retrievers available Most clinician use alligator forceps Novak currette can also be helpful Embedded IUD Requires paracervical block for pain IUD may be located by palpation with sound Use alligator forcep and tap the IUD Pull forcep back ½ cm, open forcep jaws and move upward grasping any part of the IUD. Once IUD grasped, rotate to dislocate it from endometrium If IUD stem embedded, grasp any part of IUD and lift slightly upward and rotate to remove Expulsions Partial or unnoticed expulsion may present as irregular bleeding and/or pregnancy Risk of expulsion (2-5%) related to: Provider s skill at fundal placement Age and parity of woman Time since insertion Timing of insertion WHO. 2009.; CDC MMWR. 2010 Case Presentation: Heavy Menstrual Bleeding Diane, 24-year-old nulligravida Medical history: Heavy menstrual bleeding, dysmenorrhea Presents for relief of heavy bleeding and cramping Has tried OCs in the past, dislikes having to take a daily pill Heavy Menstrual Bleeding Case: Clinical Considerations Evaluate for underlying cause of heavy bleeding Differential diagnoses: Coagulopathy Endometrial lesion, fibroid, or polyp (consider emb, sonogram) 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) and the LnG IUD 163 women with HMB & w/o structural pathology received the LNG-IUS in pooled analysis of RCTs Relative to baseline, transient increase in bleeding days in first month of treatment Returned to baseline by the second month and declined thereafter Spotting days increased first month, then declined with continued use, remained elevated 1st yr of tx Jensen J et al Contraception Jan 2013 MANAGING INFECTIONS Counsel on STI prevention (bacteria cause infections not plastic) Consult & train emergency department colleagues to not remove IUDs Chlamydia/gonorrhea Treat without removal of IUD Bacterial vaginosis Treat without removal of IUD PID/Tubal infections Treat and monitor closely; remove IUD if no improvement recommendations to remove are not evidence based Grimes D. Lancet. 2000. ; CDC U.S. Medical Eligibility Criteria for Contraceptive Use Pregnancy with IUC In Situ Determine site of pregnancy Intrauterine or ectopic Remove IUD if threads available Removal decreases risk of: Spontaneous abortion Premature delivery UK Family Planning Research Network. Br J Fam Plann. 1989.; Foreman H, et al. Obstet Gynecol. 1981. Pregnancy Outcomes with IUD in situ Pregnancies with IUDs in situ were at greater risk of adverse pregnancy outcomes: spontaneous abortion preterm delivery septic abortion chorioamnionitis Early IUD removal may improve outcome, but did not entirely eliminate risks. (22) Brahmi 2012 CASE: EB is 27 y/o plans IUD placement today Her uterus is challenging to palpateretroflexed. During sounding of her uterus she expresses severe pain and you feel sudden decreased pressure with the sound. What do you do next? Risk of Uterine Perforation Rare:1 per 1,000 insertions Perforation linked to: Uterine position and consistency Skill and experience of provider with technique required Time of insertion after childbirth Risk doubled within first 12 weeks postpartum 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 Placement of an IUD deeper than sounded Sudden loss of resistance with insertion Pain/ cramping that persists > than 15 min Bleeding is unusual IUD Uterine Perforation Rarely an emergency Monitor pain, blood pressure and pulse Consider baseline Hct Refer if perforation of abdominal viscera suspected May be asymptomatic IUD Perforation Begins at Insertion During placement, if IUD partially perforates the endometrium, the device may eventually perforate through the uterine wall. In rare instances, an IUD may migrate beyond the uterine cavity; this is a result of partial or complete perforation of the IUD at the time of insertion. Management of Perforation at Insertion Remove device Provide alternative contraception Monitor for excessive bleeding Follow up as appropriate Can insert another device after next menses If IUD in abdomen refer for surgical removal case series 64% successful laproscopic removal 1 1. Contraception. 2012 Jan;85(1):15-8.Laparoscopic removal of an intraabdominal intrauterine device: case and systematic review. Gill RS et al Patient Follow-up Schedule a recheck visit (6-10wks) Ask follow-up questions: Are you satisfied with your contraceptive method? Consider speculum string check Is there anything you would change? Are you having bleeding problems or other side effects? Address primary care/annual appointments and STI counseling Plan Follow-Up for Side Effects Ensure client knows to call or return to see you for bothersome side effects Create a plan with client about preemptive treatment options in the event of bothersome spotting Reassure that there will be an adjustment period the first few months Discuss an OTC treatment plan in the event of cramping. ARHP. Clinical Proceeding. 2004. 9