Contraindications to IUD use are few and shown in Table 38-2. In the past, IUDs were perceived to increase the risk of ectopic pregnancy, but this has since been clariied. Speciically, IUDs provide efective contraception and lower the absolute number of ectopic pregnancies by half compared with the rate in noncontracepting women (World Health Organization, 1985, 1987). But, the IUD mechanisms of action are more efective in preventing intrauterine implantation. hus, if an IUD fails, a higher proportion of pregnancies are likely to be ectopic (Backman, 2004; Furlong, 2002).
Expulsion of an IUD from the uterus is most common during the first month. hus, women are examined approximately 1 month following IUD insertion, usually after menses, to identiy the tails trailing from the cervix. Following this, a woman is instructed to palpate the strings each month after menses. Regardless of IUD type, the cumulative 3-year expulsion rate approximates 10 percent (Madden, 2014; Simonatto, 2016). This rate is higher in those :;25 years Qatlaoui, 2017).
If the tail of an IUD cannot be visualized, the device may have been expelled, may have perforated the uterus, or may be malpositioned. Alternatively, the device may be normally positioned with its tails folded within the endocervical canal or uterine cavi ty. To investigate, after excluding pregnancy, a cytological brush can be twirled within the endocervical canal to entangle the strings and bring them gently into the vagina. If unsuccessful, the uterine cavity is probed gently with a Randall stone clamp or with a specialized rod with a terminal hook to snare the strings or device.
One should not assume that a device has been expelled unless it was seen. Thus, if tails are not visible and the device is not felt by gentle probing of the uterine cavity, transvaginal sonography can be used to ascertain if the device lies within the uterus. lthough traditional sonography will document IUD position adequately in most cases, three-dimensional sonography ofers improved visualization, especially with the LNG-IUS (Moschos, 201l). If sonography is inconclusive or if no device is seen, then a plain radiograph of the abdominopelvis is taken. Computed tomography (CT) scanning or, less commonly, magnetic resonance (MR) imaging is an alternative (Boortz, 2012). It is safe to perform MR imaging at 1.5 and 3 Tesla (T) with an IUD in place (Ciet, 2015).
During uterine sounding or IUD insertion, the uterus may be perforated, which is identiied by the tool traveling farther than the expected uterine length based on initial bimanual examination. Rates approximate 1 per 1000 insertions, and risks include puerperal insertion, lactation, provider inexperience, and extremes of uterine lexion (Harrison-Woolrych, 2003; Heinemann, 2015). Although devices may migrate spontaneously into and through the uterine wall, most perforations occur, or at least begin, at the time of insertion (Ferguson, 2016).
With acute perforation, the fundus is the more common site, and bleeding is typically minimal due to myometrial contraction around the puncture hole. If no brisk or persistent bleeding is noted from the os following instrument or device removal, then patient observation alone is reasonable. Rarely, acute lateral perforations may lacerate the uterine artery, and subsequent brisk bleeding may prompt laparoscopy or laparotomy for control. Following any perforation, although this is not irmly evidence-based, a single dose of broad-spectrum antibiotic may mitigate infection.