What are the management options for an intrauterine device (IUD) found in place during pregnancy?

Management of an IUD Found in Place During Pregnancy

When an intrauterine device (IUD) is found in place during pregnancy, it 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 ectopic pregnancy - This is critical as the first step
2. Determine IUD location and string visibility - This guides management options
3. Assess patient's desire to continue pregnancy
4. Counsel on risks of retained IUD:
   • Increased risk of spontaneous abortion (including life-threatening septic abortion)
   • Increased risk of preterm delivery
   • Potential for infection (chorioamnionitis)

Management Algorithm Based on IUD String Visibility

If IUD Strings Are Visible or Can Be Retrieved Safely:

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

   • Removal significantly improves pregnancy outcomes
   • Note: Even with removal, risks remain higher than in pregnancies without prior IUD

2. Provide anticipatory guidance:

   • Instruct patient to seek care promptly for heavy bleeding, cramping, pain, abnormal discharge, or fever
   • Schedule appropriate follow-up for pregnancy care

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

1. Perform ultrasound examination to determine IUD location 1

   • Assess whether the IUD is inside the uterus
   • Rule out IUD expulsion or uterine perforation

2. If IUD is confirmed to be intrauterine but inaccessible:

   • Counsel patient on substantially increased risks with retained IUD
   • Evidence shows doubled risk of spontaneous abortion and quadrupled risk of preterm delivery with retained IUD 2
   • Monitor closely throughout pregnancy
   • Instruct patient to seek care promptly for concerning symptoms

Evidence on Pregnancy Outcomes with IUD in situ

• Spontaneous abortion risk: Significantly higher when IUD remains in place

  • One case series of LNG-IUDs showed 8 in 10 pregnancies ended in spontaneous abortion when not removed 1, 3
  • Studies show spontaneous abortion rates more than double with retained IUDs 2, 4

• Preterm delivery risk: Four times greater when IUD remains in situ compared to when removed 2

• Infection risk: Increased risk of septic abortion and chorioamnionitis 3

Important Considerations and Caveats

• Timing matters: Early removal provides better outcomes than later removal 4

• Hormonal exposure: With LNG-IUDs, theoretical concern exists about fetal exposure to levonorgestrel, though specific risks of fetal abnormalities are unknown 1

• Removal limitations: Even when IUD is removed, pregnancy risks don't return completely to baseline levels of pregnancies without an IUD 1, 3

• Contraindications to removal: If attempting removal might disrupt an ongoing pregnancy, risks and benefits must be carefully weighed

• Patient autonomy: While removal is strongly recommended when possible, some patients may choose to keep the IUD despite counseling about risks

Follow-up Care

• Schedule close monitoring throughout pregnancy
• Maintain high vigilance for signs of infection, bleeding, or preterm labor
• Consider more frequent ultrasound assessments to monitor fetal growth and development

The evidence clearly demonstrates that IUD removal, when possible, significantly improves pregnancy outcomes, though risks remain elevated compared to pregnancies without an IUD.