IUD Expulsion and Malposition

Expulsion is partial or complete loss of the device from the uterine cavity through the cervix. Malposition is a device that lies low in the uterus or lower segment, rotated, transverse, embedded in the myometrium or in the cervical canal. Expulsion is commonest in the first 3 months, in younger and nulliparous patients, with heavy or painful menses, uterine anomalies, fibroids, and when insertion is done soon after birth or abortion.

Presentation. Lengthened or shortened threads, visible device at the os, partner discomfort or pricking at intercourse, new pain, increased bleeding, discharge, missing threads, or pregnancy.

History. Time since insertion, type of device, parity, pain, bleeding, whether the patient saw the device, intercourse, symptoms of pregnancy.

Examination. Speculum examination for threads and device visible in the canal or at the os, and bimanual examination.

Differential diagnosis. Partial expulsion, complete expulsion, perforation, embedded device, pelvic infection, pregnancy and fibroid related symptoms.

Investigations. Pregnancy test. Ultrasound to assess the position and exclude infection. A plain film if the device is not found. Pelvic examination to assess for infection.

Ultrasound signs of malposition. Device in the lower segment or cervical canal, rotated or horizontal, one arm displaced, or the device with a body in the myometrium.

Confirmation of complete expulsion. The patient has seen the device, or ultrasound or a film shows no device in the pelvis.

Partial expulsion. Remove the device. Insert another if the patient wishes and pregnancy is excluded, and offer another method if she prefers.

Complete expulsion confirmed. Insert a new device if pregnancy is ruled out and no infection is present, or give any other method of her choice.

Embedded in the cervical canal. If it cannot be removed by the usual technique, refer.

Low-lying but asymptomatic. A device in the lower segment may offer reduced protection. Remove it and replace it when the patient wishes to continue the method.

Partner complaining of pricking. The threads may be too short or the device partly expelled. Examine, and replace the device if needed, with threads cut to 2 to 3 cm.

Pregnancy. Manage the pregnancy with the device in place: ultrasound to locate the device and the pregnancy, remove the device where threads are visible in the first 3 months, and exclude ectopic pregnancy.

Emergency contraception. If unprotected sex has occurred, give levonorgestrel 1.5 mg orally as a single dose, or ulipristal acetate 30 mg orally as a single dose, within 120 hours, or insert a copper device within 5 days.

Infection. Treat pelvic infection when present before replacing the device.

Prevention. After postpartum or postabortion insertion, place the device at the fundus and check the threads at follow up.

Follow up. Review 3 to 6 weeks after replacement or insertion, then annually. Teach the patient to check for threads and to return if she cannot feel them or if she feels the device.

Method decisions. After expulsion, offer replacement or another method. Repeated expulsion suggests uterine anomaly, fibroid or heavy menses, and a levonorgestrel intrauterine device or another method may be considered. Use condoms or another method until a new method is in place.

Referral and escalation. Refer embedded devices, suspected perforation, recurrent expulsion with suspected structural abnormality and any extrauterine device.