Should an intrauterine device (IUD) be removed in a pregnant patient?

From the Guidelines

If a patient is pregnant with an intrauterine device (IUD) in place, the IUD should be removed if the strings are visible and can be safely retrieved, ideally during the first trimester. This approach is based on the most recent and highest quality evidence available, which suggests that removing the IUD improves pregnancy outcomes by reducing the risks of spontaneous abortion, preterm delivery, and infection 1. The removal procedure is typically simple and can be done in an office setting by gently pulling on the visible strings.

Key Considerations

• If the strings are not visible or the IUD cannot be easily removed, attempts at removal should be abandoned as forced extraction could disrupt the pregnancy.
• In cases where the IUD cannot be removed, the patient should be monitored closely throughout pregnancy for complications such as preterm labor or chorioamnionitis.
• The patient should be informed that continuing a pregnancy with an IUD in place carries a slightly higher risk of adverse outcomes, though many pregnancies proceed normally.
• The IUD does not cause birth defects, but there is an increased risk of spontaneous abortion, preterm delivery, and infection, as noted in the guidelines 1.

Recommendations for Patient Care

• Patients should be counseled about the risks associated with an IUD in place during pregnancy and the importance of reporting any symptoms such as bleeding, cramping, or fever promptly.
• If the IUD is to be removed, it should be done as soon as possible, and the patient should be advised to return promptly if she experiences any adverse symptoms 1.
• Close monitoring and prompt medical attention for any complications are crucial for the best possible outcome in pregnancies with an IUD in place.

From the Research

Removal of IUD in Pregnant Patients

• The decision to remove an intrauterine device (IUD) in a pregnant patient depends on various factors, including the visibility of the IUD strings and the patient's desire to continue the pregnancy.
• Studies have shown that removing the IUD can reduce the risk of miscarriage, septic complications, and premature delivery 2, 3.
• If the IUD strings are visible, removal is generally recommended 3.
• However, if the strings are not visible, the management of the pregnancy is more controversial, and different techniques such as ultrasound-guided extraction or hysteroscopy may be used to remove the IUD 2, 4, 5.

Techniques for IUD Removal

• Ultrasound-guided extraction is a minimally invasive procedure that has been shown to be effective in removing lost IUDs with few postoperative complications 2.
• Hysteroscopy is another technique that can be used to remove IUDs with nonvisible filaments, and it has been shown to be a useful and effective method in early pregnancy 4.
• Manual vacuum aspiration is a simple office-based procedure that may be used to remove an IUD with missing strings, as reported in a case study 6.

Outcomes of IUD Removal

• The outcomes of pregnancies after IUD removal have been studied, and the results suggest that removal of the IUD can reduce the risk of adverse outcomes such as miscarriage and premature delivery 2, 3, 5.
• However, the risk of miscarriage is still higher than in normal pregnancies, especially in the first few weeks after the procedure 2.
• The rate of live births after IUD removal has been reported to be around 77% in one study, with a moderate miscarriage rate and no maternal complications 2.