What are the management and risks of a pregnancy with an intrauterine device (IUD) in place?

Management of Pregnancy with IUD In Situ

Remove the IUD immediately if the strings are visible or the device can be retrieved safely from the cervical canal. 1

Immediate Assessment and Counseling

When pregnancy is confirmed in a woman with an IUD:

• Advise the patient that the IUD should be removed as soon as possible to reduce risks of spontaneous abortion, septic abortion, preterm delivery, and chorioamnionitis. 1

• Perform ultrasound examination to:

  • Confirm intrauterine pregnancy location (rule out ectopic pregnancy, which has increased risk with IUD in place) 2
  • Determine IUD location within the uterus 1
  • Assess fetal viability 3

• Counsel the patient that pregnancies with retained IUDs carry substantial risks including spontaneous abortion, septic abortion, preterm delivery, and infectious complications. 1

Removal Strategy Based on String Visibility

If IUD Strings Are Visible or Device Is in Cervical Canal

• Remove the IUD by pulling gently on the strings. 1, 4
• This is the preferred approach as it improves pregnancy outcomes compared to leaving the device in place. 1
• No special instruments are typically required for removal when strings are visible. 4
• The procedure can be performed under real-time ultrasound guidance to minimize disruption to the pregnancy. 3

If IUD Strings Are Not Visible

• Perform or refer for ultrasound examination to determine IUD location. 1
• If the IUD cannot be located by ultrasound, it may have been expelled or perforated the uterine wall. 1
• If ultrasound confirms the IUD is inside the uterus but strings are not retrievable, specialized techniques (such as manual vacuum aspiration under ultrasound guidance) may be considered by experienced providers. 3
• If the IUD cannot be safely removed, counsel the patient about significantly increased risks and the need for close monitoring. 1

Post-Removal or Retained IUD Counseling

If IUD Is Successfully Removed:

• Advise the patient to return promptly for heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever. 1, 4
• Counsel that removal improves outcomes but does not eliminate all risks—outcomes remain worse than baseline pregnancies without an IUD. 1, 5

If Patient Chooses to Keep IUD or It Cannot Be Removed:

• Strongly counsel about substantially elevated risks:

  • Spontaneous abortion rate of 80% with levonorgestrel IUDs left in place 1, 5
  • High rates of late miscarriage, preterm delivery, and clinical chorioamnionitis 6
  • Microbial invasion of amniotic cavity occurs in 45.9% of cases (vs. 8.8% without IUD) 6
  • Candida intra-amniotic infection in 31.1% (vs. 6.3% without IUD) 6

• Instruct patient to seek care immediately for heavy bleeding, cramping, pain, abnormal discharge, or fever. 1

• Arrange close prenatal monitoring with heightened surveillance for infection and preterm labor. 6

Special Considerations

• Levonorgestrel IUD exposure: Theoretical concern exists for fetal hormonal exposure, though whether this increases risk for fetal abnormalities remains unknown. 1

• Ectopic pregnancy: Women conceiving with an IUD have increased ectopic pregnancy risk and require evaluation to confirm intrauterine location. 2

• Cervically located IUD: If the device has migrated to the cervix, removal is indicated regardless of pregnancy status due to reduced efficacy and increased complication risk. 4