If infection does develop, it may take several forms and typically requires broad-spectrum antimicrobials. Pelvic inlammatoy disease (PID) without abscess is treated with antibiotics on an outpatient or inpatient basis, depending on infection severity. here are theoretical concerns that a coexistent IUD may worsen the infection or delay resolution. A provider may choose to remove an IUD in this setting, although some evidence supports allowing a device to remain during treatment in those hospitalized with mild or moderate PID (Centers for Disease Control and Prevention, 2015; Tepper, 2013). Ifinfection fails to improve during 48 to 72 hours of treatment, the device is removed. Tuboovarian abscess can complicate PID and is treated aggressively with intravenous broad-spectrum antibiotics and IUD removal. Last, septic abortion mandates immediate uterine evacuation and antibiotics.
Actinomyces israelii is a gram-positive, slow-growing, anaerobic indigenous vaginal bacterium that rarely causes suppurative infection. Some have found it more frequently in the vaginal lora or on the Pap smears of IUD users (Curtis, 1981; Kim, 2014). Current recommendations advise that an asymptomatic woman may retain her IUD and does not require antibiotic treatment (American College of Obstetricians and Gynecologists, 2017c; Lippes, 1999; Westhof, 2007a). However, if signs or symptoms of infection develop in a woman who harbors Actinomyces species, then the device is removed and antibiotics are given. Early indings with infection include fever, weight loss, abdominal pain, and abnormal uterine bleeding or discharge. Actinomyces species are sensitive to antibiotics with gram-positive coverage, notably the penicillins.
Pregnancy with an IUD
For women who conceive while using an IUD, ectopic pregnancy should be excluded. With intrauterine pregnancy, if the tail is seen, it should be grasped and the IUD removed by gentle outward traction. his action reduces complications such as abortion, chorioamnionitis, and preterm birth (Fulkerson Schaefer, 2017; Kim, 2010). Speciically, in one cohort, a 54-percent abortion rate and 17 -percent preterm delivery rate was noted if the device remained in situ. More favorably, rates of 25 percent and 4 percent, respectively, resulted from prompt Cu-IUD removal (Tatum, 1976). Few data guide management with the LNG-IUS, and most practice extrapolates from copper devices.
If the tail is not visible, attempts to locate and remove the device may result in abortion. Although not our practice, some case reports and small series describe sonography or hysteroscopy to assist in diicult device removals (Perez-Medina, 2014; Schiesser, 2004). Ater fetal viability is reached, it is unclear whether it is better to remove an IUD whose strings are visible and accessible or to leave it in place. Fetal malformation rates are not greater with a device let in situ (Tatum, 1976; Vessey, 1979).
Second-trimester miscarriage with an IUD in place is more likely to be infected (Vessey, 1974). Sepsis may be fulminant and fatal. Pregnant women with a device in utero who demonstrate any evidence of pelvic infection are treated with broadspectrum antibiotics and prompt uterine evacuation. Because of these risks, a woman should be given the option of early pregnancy termination if the device cannot be removed early in pregnancy. Last, in women who give birth with a device in place, appropriate steps should be taken at delivery to identiy and remove the IUD.
To reduce expulsion rates and perforation risks, IUD insertion 6 weeks after delivery. Women delivered at Parkland Hospital are seen 3 weeks postpartum, and IUDs are inserted 6 weeks postpartum or sooner if involution is complete.