Immediate Complications of the IUD Insertion Procedure

Some patients may develop pain with IUD insertion. Nulliparity and history of severe dysmenorrhea are associated with greater insertion-related pain.⁴ Some pain, such as cramping and changes in bleeding pattern, may be normal in the initial weeks after IUD placement. Some patients may develop vasovagal reactions with syncope, nausea, and/or vomiting. Because primary uterine perforation can occur during insertion and cause severe pain, these patients may need to be evaluated with pelvic examination and further imaging to assess IUD location and determine if primary perforation has occurred. IUDs can lead to irregular menstrual bleeding, which typically improves with time.⁵ For these patients, nonsteroidal anti-inflammatory medications are first-line therapies for treating dysmenorrhea and abnormal bleeding.⁴ Naproxen in particular has been shown to decrease pain and bleeding.¹

IUD Removal in the ED

IUDs rarely require removal in the emergency department. Some circumstances do require this, including a partially expelled IUD causing pain and bleeding. The procedure for IUD removal is simple: Grasp the strings securely using ring forceps and apply gentle traction outward. If IUD removal with gentle traction and without resistance is unsuccessful, the procedure should be discontinued as the IUD may be embedded, perforated, or translocated. Such instances likely require hysteroscopy or laparoscopy for further evaluation.

Case Resolution

A point-of-care urine pregnancy test is positive. Pelvic examination shows a closed cervical os with IUD strings visible, no vaginal bleeding, and left adnexal tenderness. Point-of-care ultrasound shows an empty uterus, no free fluid, and possible left adnexal mass. The patient is taken to the operating room by ob-gyn for diagnostic laparoscopy, leading to the diagnosis of a left adnexal unruptured ectopic pregnancy. Salpingectomy is performed. The patient is discharged from the hospital and later decides to have her IUD removed as an outpatient because of anxiety related to possibility of developing a future ectopic pregnancy.

Dr. Goett is an assistant professor and assistant director for advanced chronic illness and bioethics in the departments of senior residents emergency medicine and palliative care at New Jersey Medical School and Rutgers University in Newark.
Dr. Shaker is a senior resident in emergency medicine at New Jersey Medical School and Rutgers University.

References

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