Should an Intrauterine Device (IUD) be removed during pregnancy?

Management of IUD During Pregnancy

An IUD should be removed as soon as possible when a pregnancy is diagnosed if the strings are visible or can be safely retrieved from the cervical canal, as this significantly reduces risks of adverse pregnancy outcomes including spontaneous abortion, preterm delivery, and infection. 1

Assessment of Pregnancy with IUD in situ

When a woman with an IUD is found to be pregnant:

1. First step: Evaluate for possible ectopic pregnancy
2. Counsel the patient about increased risks if the IUD remains in place:
   • Spontaneous abortion (including life-threatening septic abortion)
   • Preterm delivery
   • Intrauterine infection/chorioamnionitis

Management Algorithm Based on IUD String Visibility

If IUD Strings Are Visible or Can Be Retrieved from Cervical Canal:

• Remove the IUD immediately by gently pulling on the strings
• Removal improves pregnancy outcomes compared to leaving the IUD in place
• Advise the woman to seek care promptly if she experiences:
  • Heavy bleeding
  • Cramping or pain
  • Abnormal vaginal discharge
  • Fever

If IUD Strings Are Not Visible:

1. Perform or refer for ultrasound to determine IUD location
2. If the IUD is confirmed to be inside the uterus but cannot be safely retrieved:
   • Counsel about increased risks of adverse outcomes
   • Advise to seek care promptly for warning signs (bleeding, pain, discharge, fever)
3. If ultrasound shows the IUD has been expelled or has perforated the uterine wall:
   • Document findings and continue pregnancy care

Evidence Supporting IUD Removal

The 2013 U.S. Selected Practice Recommendations for Contraceptive Use clearly states that removing the IUD improves pregnancy outcomes when strings are visible or the device can be safely retrieved 1. A systematic review found that women who did not have their IUDs removed during pregnancy faced greater risks for:

• Spontaneous abortion
• Septic abortion
• Preterm delivery
• Chorioamnionitis

For copper IUDs, removal decreased these risks, though not to baseline levels of pregnancies without an IUD. For LNG-IUDs, when not removed, 80% of pregnancies ended in spontaneous abortion 1, 2.

Advanced Retrieval Techniques

When strings are not visible but ultrasound confirms an intrauterine IUD, ultrasound-guided retrieval may be considered. Studies have demonstrated successful retrieval of occult IUDs in early pregnancy using ultrasound guidance, which allowed pregnancies to progress to term 3, 4.

Special Considerations

• LNG-IUD: Theoretical concern exists about fetal exposure to hormones, though whether this increases risk for fetal abnormalities is unknown 1
• Timing: The earlier the IUD is removed in pregnancy, the better the outcomes 2

Common Pitfalls to Avoid

1. Delaying removal decision: Evidence clearly supports prompt removal when safely possible
2. Attempting blind retrieval when strings aren't visible: This can damage the pregnancy; always use ultrasound guidance
3. Failure to counsel about warning signs: Patients must know when to seek immediate care
4. Missing ectopic pregnancy: Always evaluate for this possibility before proceeding with IUD management

Remember that while IUD removal improves outcomes, it does not completely eliminate the increased risks associated with conception with an IUD in place 1, 2.