How to manage a patient with an Intrauterine Device (IUD) and Retained Products of Conception (RPOC)?

Management of IUD with Retained Products of Conception (RPOC)

Remove the IUD and manage the RPOC separately, prioritizing hysteroscopic removal over blind curettage to minimize endometrial trauma and reduce the risk of intrauterine adhesions, particularly in patients desiring future fertility.

Initial Assessment and Diagnosis

When a patient presents with an IUD and suspected RPOC, confirm the diagnosis through:

• Pelvic ultrasound with color Doppler to identify intrauterine hyperechogenic vascularized tissue and assess uterine vasculature for arteriovenous malformations (AVM) 1
• Clinical evaluation for symptoms including irregular or continuous vaginal bleeding, lower abdominal/pelvic pain, and signs of infection 1
• Rule out ectopic pregnancy as this is a critical differential diagnosis when an IUD is present with pregnancy-related tissue 2

IUD Removal Strategy

The IUD should be removed as part of the management plan, though the timing depends on the clinical scenario:

• If the IUD strings are visible or can be safely retrieved, remove the IUD after initiating appropriate treatment for RPOC 2
• Consider emergency contraceptive pills at the time of IUD removal if residual sperm may be present and the patient has had recent intercourse 2
• If infection is present, removal should occur after antibiotics are started to avoid bacterial spread from the removal procedure 2

RPOC Management Options

First-Line: Hysteroscopic Removal (Preferred)

Hysteroscopic resection under direct visualization is the preferred surgical approach for RPOC management, especially in patients with reproductive desires:

• Minimizes endometrial trauma compared to blind dilation and curettage, reducing risk of intrauterine adhesions and Asherman syndrome 3, 4, 5
• Allows complete evacuation under direct visualization while preserving endometrial integrity 4, 5
• Particularly important for patients with subfertility history or failed blind curettage 3
• Limit electrosurgery use during hysteroscopy to minimize thermal damage to the endometrium 4

Alternative: Medical Management with Misoprostol

If the patient is hemodynamically stable without active infection, medical management may be considered:

• Vaginal misoprostol can avoid surgical intervention in approximately 65% of cases 6
• Most effective (76% success) when the primary miscarriage treatment was expectant management 6
• Less successful after primary medical management (44%) or surgical management (40%) 6
• This approach is extrapolated from miscarriage literature but has demonstrated efficacy specifically for RPOC 6

When to Proceed Directly to Surgical Management

Immediate surgical intervention is indicated in the following scenarios:

• Severe or persistent vaginal bleeding 1
• Hemodynamic instability 3
• Signs of infection (fever, purulent discharge, pelvic tenderness) 1
• Patient preference for definitive management 3

Infection Management

If infection is present:

• Initiate broad-spectrum antibiotics immediately, following standard treatment guidelines for pelvic inflammatory disease 2, 1
• The IUD does not need immediate removal; reassess in 24-48 hours 2
• If no clinical improvement occurs after 24-48 hours, continue antibiotics and proceed with IUD removal 2

Post-Procedure Care

After RPOC removal and IUD extraction:

• Offer alternative contraception if the patient desires ongoing contraception 2
• Consider emergency contraceptive pills if appropriate based on timing of recent intercourse 2
• NSAIDs (ibuprofen 600-800 mg every 6-8 hours or naproxen 440-550 mg every 12 hours) with food for post-procedure pain management 7
• Monitor for resolution of bleeding and symptoms 1

Critical Pitfalls to Avoid

• Do not perform blind dilation and curettage as the first-line surgical approach, as this significantly increases the risk of intrauterine adhesions and Asherman syndrome, particularly problematic for patients desiring future fertility 3, 4, 5
• Do not remove the IUD before starting antibiotics if infection is present, as this may cause bacterial spread 2
• Do not assume the IUD caused the RPOC; these are separate clinical entities requiring distinct management approaches 1
• Do not delay evaluation for AVM using color Doppler ultrasound, as this can complicate management and increase bleeding risk 1