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those with subtle problems of positioning, like embedment of the long arms of the
device within the myometrium.
Expulsion occurs in approximately 2% of IUD placements. The risk is highest
among nulliparous women. The symptoms of expulsion include persistent
abdominal discomfort following insertion that is not improving over time, or
worsening pain that suddenly resolved. Rarely, women may identify the device
following expulsion; more commonly, the device is only partially expulsed
resulting in ongoing pain.
Infection occurs following 1% of IUD placements and is most likely during 21
days following IUD placement. Patients with symptoms of vaginitis should be
evaluated for an STD, bacterial vaginosis, or a vulvovaginal yeast infection and
treated accordingly.

Management
Management of pregnancies with an in situ IUD depends on the woman’s desire
to continue or terminate the pregnancy, gestational age, IUD location, and
whether IUD strings are visible. The U.S. Food and Drug Administration, the
Centers for Disease Control, and the American College of Obstetricians and
Gynecologists (ACOG) recommend that the IUD be removed from a pregnant
woman as soon as possible, if the strings are visualized or if the IUD is in the
cervix.
If perforation is confirmed by ultrasound, and the patient recently had the
device placed (<24 hours) should be observed for hemodynamic compromise,
which would require surgical intervention. In the absence of vascular injury, the
patient can be referred to adolescent medicine or gynecology for device removal.
Rarely, an IUD is noted to be outside the uterus on imaging. If there are concerns
for visceral injury, the patient should be evaluated by gynecology or pediatric
surgery. If there are no concerns for visceral injury, the patient can be referred to
gynecology of general surgery for device removal, which can generally be
performed laparoscopically. If an ultrasound is performed and the device cannot
be located within the uterus, an x-ray or CT of the chest, abdomen, and pelvis can

be performed to locate the device, which is radiopaque. ACOG has an algorithm
for managing IUDs with lost strings and therefore an IUD of unknown location.
An x-ray is inexpensive and can be obtained fairly rapidly.
A partially expulsed IUD may be located within the vagina or the cervical os.
Removal is straightforward and can be performed by an ED provider using ring
forceps, a Kelly clamp, or another grasping device. After removal, the IUD
should be inspected to confirm that the entire device was removed.