How to manage a patient with a potential retained IUD after 30 years?

Management of Potential Retained IUD After 30 Years

A patient with linear echogenicity in the endometrial cavity and lower uterine segment on ultrasound with history of IUD placement 30 years ago should undergo hysteroscopy for direct visualization and removal of the retained IUD to prevent potential complications. 1

Assessment of the Current Situation

Based on the ultrasound findings:

• Linear echogenicity in the endometrial cavity and lower uterine segment
• History of IUD placement 30 years ago
• No visible strings on clinical examination (implied by the need for further evaluation)

This presentation strongly suggests a retained IUD that requires management to prevent potential complications.

Management Algorithm

Step 1: Confirm IUD Presence and Location

• The ultrasound already performed shows linear echogenicity consistent with a retained IUD
• The IUD appears to be within the uterine cavity rather than perforated through the wall

Step 2: Attempt Removal Based on IUD Location

Since the ultrasound shows the IUD is likely within the uterine cavity but strings are not visible:

• Hysteroscopy is indicated for direct visualization and removal 1, 2
• This approach allows for:
  • Direct visualization of the IUD
  • Safe removal under direct visualization
  • Assessment of any endometrial abnormalities

Step 3: If Hysteroscopy Unsuccessful or Perforation Suspected

• Consider additional imaging if hysteroscopy cannot locate the IUD:
  • CT scan to identify potential migration to adjacent organs 3
  • MRI if further tissue characterization is needed

Rationale for Removal

1. Prevention of complications: Even long-retained IUDs can cause:

   • Infection risk
   • Embedment in uterine wall
   • Perforation into adjacent organs (bladder, bowel) 4, 5

2. Potential for migration: IUDs can migrate over time, especially with a scarred uterus 5

   • The risk increases with duration of retention
   • Migration can occur even decades after insertion

3. Guidelines recommendation: The CDC Selected Practice Recommendations for Contraceptive Use clearly states that when an IUD is identified but strings are not visible, ultrasound should be used to locate the IUD, and if found within the uterus, it should be removed 1

Common Pitfalls and Caveats

• Do not assume expulsion: Although the IUD might have been expelled spontaneously over the years, the linear echogenicity on ultrasound suggests it is still present 6

• Do not attempt blind removal: Without visible strings, blind removal attempts could cause uterine perforation or fragmentation of an aged IUD 5, 6

• Do not ignore even if asymptomatic: Retained IUDs can remain asymptomatic for years before causing serious complications 3

• Consider anatomical changes: After 30 years, the patient likely has postmenopausal changes to the uterus which may affect the removal approach

• Fragmentation risk: Older IUDs may have deteriorated and could fragment during removal attempts, requiring careful extraction of all pieces 6

By following this approach, you can safely manage this patient with a potential 30-year retained IUD, minimizing risks of complications while ensuring complete removal of the device.