What is the management plan for a 16-year-old female (YOF) with heavy vaginal bleeding, soaking a pad approximately every hour, nausea, and abdominal pain (7/10) for 3 days following an intrauterine device (IUD) insertion?

Emergency Management of Post-IUD Insertion Heavy Bleeding

This patient requires immediate evaluation for pregnancy (including ectopic), IUD displacement/experforation, and infection, followed by hemodynamic stabilization and likely IUD removal if strings are visible.

Immediate Assessment Priorities

Rule Out Life-Threatening Conditions

• Obtain quantitative β-hCG immediately to exclude pregnancy, as IUD failure with pregnancy carries risk of septic abortion and ectopic pregnancy 1
• Assess hemodynamic stability given the severity of bleeding (soaking pad hourly for 3 days) which suggests significant blood loss 2
• Perform pelvic ultrasound to evaluate IUD position, rule out perforation, assess for free fluid, and exclude ectopic pregnancy 1
• Check complete blood count to quantify anemia and guide transfusion needs 2

Critical Diagnostic Considerations

• IUD displacement or expulsion is a common cause of abnormal bleeding and pain in recent insertions 1, 3
• Uterine perforation must be excluded given the severity of pain (7/10) and bleeding 1
• Pelvic inflammatory disease should be considered with the combination of pain, bleeding, and recent instrumentation 1, 3
• Pregnancy with IUD in situ carries substantial risk of septic abortion which can be life-threatening 1

Management Algorithm Based on Findings

If Pregnancy Test is Positive

• Remove the IUD immediately if strings are visible by pulling gently on the strings, as this reduces risk of spontaneous abortion, septic abortion, and preterm delivery 1
• Evaluate for ectopic pregnancy with ultrasound and serial β-hCG if indicated 1
• If strings are not visible and ultrasound shows IUD in uterus, counsel about substantially increased risks (spontaneous abortion including life-threatening septic abortion) and arrange urgent gynecology consultation 1

If Pregnancy Test is Negative

Check IUD String Visibility and Position

• If strings are visible and IUD is displaced: Remove the IUD, as malposition causes bleeding and pain 1, 3
• If strings not visible: Ultrasound to locate IUD - may be expelled, perforated through uterus, or strings retracted 1
• If perforation suspected: Immediate gynecology consultation for possible laparoscopic retrieval 1

Evaluate for Infection

• Obtain cervical cultures for gonorrhea and chlamydia given recent instrumentation, pain, and bleeding 1, 3
• Consider empiric antibiotic treatment if clinical suspicion for PID (fever, cervical motion tenderness, purulent discharge) 1
• Note that PID risk is highest in first 20 days after IUD insertion 1

Acute Bleeding Management

Pharmacologic Treatment

• Initiate NSAIDs immediately - ibuprofen 600-800mg every 6-8 hours or naproxen 500-550mg twice daily for 5-7 days, which reduces menstrual blood loss by 20-60% 1, 3, 4
• Avoid aspirin as it may paradoxically increase bleeding 5, 4
• Consider tranexamic acid 1300mg three times daily if NSAIDs insufficient, though use cautiously due to thrombosis risk 3, 4

Hormonal Stabilization

• Combined oral contraceptives for 10-20 days can stabilize the endometrium if bleeding persists despite NSAIDs 5, 4
• This approach is particularly useful if the patient wishes to retain a properly positioned IUD 4

Critical Decision Point: IUD Removal vs. Retention

Remove IUD If:

• Pregnancy is confirmed (reduces catastrophic risks) 1
• IUD is malpositioned or partially expelled 1, 3
• Perforation is suspected 1
• Bleeding remains unacceptable despite medical management and patient desires removal 1, 3
• Signs of infection are present (though evidence shows removal may not improve PID outcomes, it facilitates treatment) 1

May Retain IUD If:

• Properly positioned on ultrasound 1, 3
• No infection present 1
• Patient desires to continue after counseling 1, 3
• Bleeding improves with medical management 1, 3

Important Clinical Pitfalls

• Do not assume bleeding is "normal post-insertion bleeding" when this severe - soaking a pad hourly for 3 days with 7/10 pain warrants full evaluation 1, 3
• Never miss pregnancy testing - IUD failure occurs and consequences of retained IUD in pregnancy are severe 1
• Bleeding in first 3-6 months is common but should be light spotting, not heavy flow requiring hourly pad changes 1, 3
• This presentation (heavy bleeding + significant pain + nausea) suggests a complication, not typical post-insertion adjustment 1, 3

Disposition and Follow-Up

• Admit if hemodynamically unstable, severe anemia (Hgb <7), or suspected perforation 2
• Urgent gynecology consultation if IUD cannot be located, perforation suspected, or pregnancy with non-visible strings 1
• Discharge with close follow-up (24-48 hours) only if stable, IUD removed or confirmed well-positioned, infection treated, and bleeding controlled 1, 3
• Provide explicit return precautions: fever, worsening pain, increased bleeding, syncope, or signs of shock 1