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4/1/2022

Intrauterine Device in Place During Pregnancy

The risk of becoming pregnant with an intrauterine device (IUD) in place is very low, similar to the risk of pregnancy occurring following tubal sterilization, about 2% over 10 years. If a pregnancy occurs in the setting of an IUD, the location of the pregnancy should first be identified, as ectopic pregnancy is more common among persons who become pregnant with an IUD in place.

Once verified to be intrauterine, a pregnancy with an IUD should be managed based on the patient’s preferences. If the patient is unsure or does not desire to continue the pregnancy, counseling about options should be offered. If pregnancy termination is chosen, the IUD should be removed at the time of procedural abortion. The IUD should be removed prior to initiating a medication abortion. A new device can be inserted once pregnancy termination is completed.

If the patient chooses to continue the pregnancy, the provider should counsel the patient regarding the increased risk for pregnancy complications, including spontaneous abortion, septic abortion, preterm delivery, and chorioamnionitis. The risk of preterm birth, late spontaneous abortion, and septic abortion are significantly reduced by removing the IUD if possible. Even after IUD removal, persons who conceive with an IUD in place remain at higher risk for preterm delivery compared with those whose pregnancies were conceived without an IUD. Risk of spontaneous abortion after IUD removal is about 20%. There are insufficient data to draw any conclusions or associations regarding fetal malformations in pregnancies conceived in the setting of an IUD.

Based on available data, and as recommended by the US Food and Drug Administration and the Centers for Disease Control, as soon as an intrauterine pregnancy is confirmed with an IUD in situ, a pelvic examination should be performed. IUDs should be removed if possible without an invasive procedure. If the strings are visible or if the IUD stem is in the endocervical canal, the IUD should be removed. If the IUD is identified within the endocervical canal, the IUD may be removed with alligator or Bozeman forceps. If strings are not visible and the IUD is noted to be above the level of the endocervix, attempted IUD removal is not advised. In this situation or if the IUD is not located on pelvic ultrasonography, the IUD may have been expelled, or it could be located intraabdominally following an unrecognized uterine perforation. In that case, at completion of the pregnancy, abdominal x-ray should be performed to identify the location of an extrauterine IUD.

 

Further Reading:

American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice; Long-Acting Reversible Contraceptive Expert Work Group. Committee Opinion No 672: Clinical Challenges of Long-Acting Reversible Contraceptive Methods. Obstet Gynecol. 2016 Sep;128(3):e69-77. doi: 10.1097/AOG.0000000000001644. PMID: 27548557. Reaffirmed 2020.

Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep. 2016 Jul 29;65(4):1-66. doi: 10.15585/mmwr.rr6504a1. PMID: 27467319.

Brahmi D, Steenland MW, Renner RM, et al. Pregnancy outcomes with an IUD in situ: a systematic review. Contraception. 2012 Feb;85(2):131-9. doi: 10.1016/j.contraception.2011.06.010. Epub 2011 Aug 16. PMID: 22067777.

Initial Publication April 2022. Revised November 2023

 

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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