What is the management of a pregnancy with a copper Intrauterine Device (IUD) in place?

Management of Pregnancy with Copper IUD in Place

When a woman is found to be pregnant with a copper IUD in place, the IUD should be removed as soon as possible if the strings are visible or can be safely retrieved from the cervical canal to reduce risks of adverse pregnancy outcomes. 1

Initial Assessment

1. Evaluate for possible ectopic pregnancy

   • The risk of ectopic pregnancy is increased with IUD use
   • Perform ultrasound to confirm intrauterine pregnancy

2. Patient counseling regarding risks:

   • Inform the patient about increased risks if IUD remains in place:
     • Spontaneous abortion (including life-threatening septic abortion)
     • Preterm delivery
     • Infection
   • Explain that removing the IUD reduces these risks, but may not decrease risk to baseline level of pregnancy without an IUD 1

Management Algorithm

If IUD Strings Are Visible or Can Be Retrieved Safely:

1. Remove the IUD immediately by gently pulling on the strings 1

   • Early removal is associated with better pregnancy outcomes 2
   • Studies show that leaving the IUD in place more than doubles the risk of spontaneous abortion 2

2. Provide follow-up instructions:

   • Advise the patient to seek care promptly if she experiences:
     • Heavy bleeding
     • Cramping or pain
     • Abnormal vaginal discharge
     • Fever 1

If IUD Strings Are Not Visible and Cannot Be Retrieved Safely:

1. Perform or refer for ultrasound examination to:

   • Determine the location of the IUD
   • Rule out IUD expulsion or uterine wall perforation 1

2. If ultrasound confirms the IUD is inside the uterus but cannot be safely removed:

   • Provide close monitoring throughout pregnancy
   • Advise the patient to seek care promptly for any concerning symptoms (bleeding, pain, discharge, fever) 1
   • Be aware that the risk of premature birth is four times greater when the IUD remains in situ compared to when it is removed 2

Special Considerations

• Timing matters: The earlier in pregnancy the IUD is removed, the better the outcomes 3
• Retained fragments: In rare cases of IUD fragmentation, limited guidance exists for management, but close monitoring is essential 4
• Fetal anomalies: Data suggest that copper exposure from IUDs does not increase the risk of developmental defects 2

Common Pitfalls to Avoid

1. Delaying IUD removal: Prompt removal is crucial when safely possible, as delay increases risks of adverse outcomes
2. Aggressive removal attempts: If strings are not visible, avoid blind removal attempts which could disrupt the pregnancy
3. Inadequate follow-up: Ensure close monitoring, especially if the IUD cannot be removed
4. Overlooking infection risk: Be vigilant for signs of infection, particularly if the IUD remains in place

Patient Decision-Making

If the patient does not want to continue the pregnancy:

• Counsel her about pregnancy termination options
• The IUD should still be removed to reduce infection risk 1

If the patient wants to continue the pregnancy:

• Remove the IUD if possible
• Provide appropriate prenatal care with close monitoring
• Ensure patient understands warning signs requiring immediate medical attention 1