Pregnancy outcomes with an IUD in situ: a systematic review

doi:10.1016/j.contraception.2011.06.010

Contraception

Volume 85, Issue 2, February 2012, Pages 131-139

https://doi.org/10.1016/j.contraception.2011.06.010 Get rights and content

Abstract

Background

While intrauterine devices (IUDs) provide highly effective contraception, pregnancies among IUD users do rarely occur. The objective of this systematic review is to assess the evidence about risks for adverse pregnancy outcomes among women who conceive with an IUD in situ.

Methods

We searched MEDLINE, POPLINE, EMBASE and LILACS databases from inception through April 2011 for peer-reviewed articles containing evidence related to pregnancy outcomes among women who conceived while using copper (Cu) and levonorgestrel-releasing (LNG) IUDs.

Results

Nine articles met our inclusion criteria. Women with retained IUDs were at the greatest risk of adverse pregnancy outcomes, including spontaneous abortion, preterm delivery, septic abortion and chorioamnionitis. Cu-IUD removal decreased risks but not to the baseline risk of pregnancies without an IUD. One case series examined the LNG-IUD; when left in situ, 8 in 10 ended in spontaneous abortions.

Conclusion

Pregnancies complicated by a remaining IUD in situ were at greater risk of adverse pregnancy outcomes. Early IUD removal appeared to improve outcomes but did not entirely eliminate risks.

Introduction

Pregnancy with an intrauterine device (IUD) in situ is a risk factor for adverse pregnancy outcomes including miscarriage and preterm labor. However, pregnancy among IUD users is a an uncommon event; the typical first-year failure rates for the copper IUD (Cu-IUD) and the levonorgestrel-releasing IUD (LNG-IUD) are 0.8% and 0.2%, respectively [1]. Among women who do become pregnant with an IUD in situ, there are risks associated with both removal of the IUD as well as with leaving the IUD in place during the pregnancy. This systematic review appraises the published evidence on the safety of extracting or leaving a Cu-IUD or LNG-IUD in place when a woman becomes pregnant and desires to continue her pregnancy.

Section snippets

Methods

We searched MEDLINE, POPLINE, EMBASE and LILACS databases from inception through April 2011 for peer-reviewed articles (in all languages) containing evidence related to pregnancy outcomes among women who conceived while using Cu-IUDs and LNG-IUDs. We used the following search strategies: MEDLINE (pregnancy outcome OR pregnancy complication) AND (IUD(s) OR IUCD(s) OR intrauterine devices OR intrauterine device); POPLINE Pregnancy outcomes[kw] & IUD[kw]; LILACS intrauterine devices or

Results

Our search identified 2209 studies, and 9 met all inclusion criteria [5], [6], [7], [8], [9], [10], [11], [12], [13]. Seven of the nine included studies were retrospective cohort studies of Cu-IUD users [6], [7], [8], [9], [10], [11], [12], one was a prospective cohort study of Cu-IUD users [13], and one was a case series describing pregnancy outcomes in LNG-IUD users [5].

Discussion

The evidence from the nine studies of overall fair quality included in this review consistently demonstrated that pregnancies conceived with an IUD in place are associated with adverse pregnancy outcomes, with the greatest risk among those pregnancies in which the IUD was not removed. Compared with women who conceived without an IUD, women with a retained IUD had a greater risk for spontaneous abortion, preterm delivery and chorioamnionitis [9]. Compared with women whose IUDs were removed in

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Cited by (79)

Case report of an unusual finding of intrauterine contraceptive device in the rectum
2024, International Journal of Surgery Case Reports
Intrauterine contraceptive device (IUCD) is a safe and effective method of contraception. It is however rarely associated with complications. Migration of this device to the rectum is very rare. We report a case of IUCD migrating to the rectum with the history of missing IUCD strings.
A 32-year-old multipara presented 8 weeks following IUCD insertion with missing thread, ultrasound scan done showed a viable pregnancy with IUCD in-situ. Following vaginal examination, IUCD could not be retrieved. Pregnancy was allowed to continue for IUCD to be retrieved at delivery. She presented again about 6 weeks later with IUCD strings protruding through the rectum and was subsequently removed.
Uterine perforation and migration of IUCD into the pelvic organs is an uncommon but major complication following insertion of the device. The risk of perforation appears to depend on type of device, skill of the operator and position of the uterus. Postpartum insertion, lactation and atrophic uterus also increase risk of perforation.
perforation and migration of IUCD to the rectum is a rare but possible complication of following insertion of the device. Family planning providers should continue to undergo training and retraining to minimize complications associated with the use of IUCD.
Pregnancy with retained intrauterine device: national-level assessment of characteristics and outcomes
2023, American Journal of Obstetrics and Gynecology MFM
Although intrauterine devices provide effective contraceptive protection, unintentional pregnancy can occur. Previous studies have shown that a retained intrauterine device during pregnancy is associated with adverse pregnancy outcomes but there is a paucity of nationwide data and analysis.
This study aimed to describe characteristics and outcomes of pregnancies with a retained intrauterine device.
This serial cross-sectional study used data from the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population comprised 18,067,310 hospital deliveries for national estimates from January 2016 to December 2020. The exposure was retained intrauterine device status, identified by the World Health Organization's International Classification of Diseases, Tenth Revision, code O26.3. The co-primary outcome measures were incidence rate, clinical and pregnancy characteristics, and delivery outcome of patients with a retained intrauterine device. To assess the pregnancy characteristics and delivery outcomes, an inverse probability of treatment weighting cohort was created to mitigate the prepregnant confounders for a retain intrauterine device.
A retained intrauterine device was reported in 1 in 8307 hospital deliveries (12.0 per 100,000). In a multivariable analysis, Hispanic individuals, grand multiparity, obesity, alcohol use, and a previous uterine scar were patient characteristics associated with a retained intrauterine device (all P<.05). Current pregnancy characteristics associated with a retained intrauterine device included preterm premature rupture of membrane (9.2% vs 2.7%; adjusted odds ratio, 3.15; 95% confidence interval, 2.41–4.12), fetal malpresentation (10.9% vs 7.2%; adjusted odds ratio, 1.47; 95% confidence interval, 1.15–1.88), fetal anomaly (2.2% vs 1.1%; adjusted odds ratio, 1.71; 95% confidence interval, 1.03–2.85), intrauterine fetal demise (2.6% vs 0.8%; adjusted odds ratio, 2.21; 95% confidence interval, 1.37–3.57), placenta malformation (1.8% vs 0.8%; adjusted odds ratio, 2.12; 95% confidence interval, 1.20–3.76), placenta abruption (4.7% vs 1.1%; adjusted odds ratio, 3.24; 95% confidence interval, 2.25–4.66), and placenta accreta spectrum (0.7% vs 0.1%; adjusted odds ratio, 4.82; 95% confidence interval, 1.99–11.65). Delivery characteristics associated with a retained intrauterine device included previable loss at <22 weeks’ gestation (3.4% vs 0.3%; adjusted odds ratio, 5.49; 95% confidence interval, 3.30–9.15) and periviable delivery at 22 to 25 weeks’ gestation (3.1% vs 0.5%; adjusted odds ratio, 2.81; 95% confidence interval, 1.63–4.86). Patients in the retained intrauterine device group were more likely to have a diagnosis of retained placenta at delivery (2.5% vs 0.4%; adjusted odds ratio, 4.45; 95% confidence interval, 2.70–7.36) and to undergo manual placental removal (3.2% vs 0.6%; adjusted odds ratio, 4.81; 95% confidence interval, 3.11–7.44).
This nationwide analysis confirmed that pregnancy with a retained intrauterine device is uncommon, but these pregnancies may be associated with high-risk pregnancy characteristics and outcomes.
Pregnancy outcomes with a copper 380 mm<sup>2</sup> intrauterine device in place: A retrospective cohort study in Turkey, 2011-2021
2023, Contraception
To investigate pregnancy outcomes in patients with pregnancies with a copper 380 mm² intrauterine device (IUD) in situ at conception.
In this retrospective study, we identified patients with pregnancies with a copper 380 mm² IUD between 2011 and 2021 from the electronic health record system. According to their initial diagnosis, we classified the patients as having nonviable intrauterine pregnancies (IUPs), viable IUPs, or ectopic pregnancies. Among the viable IUPs, we divided the ongoing pregnancies into two subgroups as IUD-removed and IUD-retained. We compared the pregnancy loss (miscarriage before 22 weeks) rates and adverse pregnancy outcomes (at least one of preterm birth, preterm premature rupture of membranes, chorioamnionitis, placental abruption, or postpartum hemorrhage) of IUD-removed and IUD-retained pregnancies.
We identified a total of 246 patients with pregnancies with an IUD. We excluded six (2.4%) patients without follow-up data and seven (2.8%) patients with levonorgestrel-IUD and included the remaining 233 (44 [18.9%] ectopic pregnancy, 31 [13.3%] nonviable IUP, and 158 [67.5%] viable IUP) patients. Among the 158 women with viable IUP, 21 (13.3%) underwent abortion, leaving 137 (86.7%) who elected to continue the pregnancy. A total of 54 (39.4%) patients with ongoing pregnancy had the IUD removed. We found a lower rate of pregnancy loss among those who underwent removal (18/54 [33.3%]) compared to those with a retained IUD (51/83 [61.4%], p < 0.001). After accounting for pregnancy loss, adverse pregnancy outcomes remained increased in the IUD-retained group (17/32 [53.1%]) compared to the IUD-removed group (10/36 [27.8%], p = 0.03).
Pregnancy in the setting of a copper 380 mm² IUD is high risk. Our results demonstrate that pregnancy outcomes improve by removal of the copper 380 mm² IUD.
Prior studies have suggested that the removal of the IUD improves outcomes, but all have limitations. Our results from a very large series with care in a single institution provide contemporary evidence to support copper 380 mm² IUD removal to reduce the risk of both early pregnancy loss and later adverse outcomes
Society of Family Planning Clinical Recommendation: Emergency contraception
2023, Contraception
Emergency contraception (EC) refers to several contraceptive options that can be used within a few days after unprotected or under protected intercourse or sexual assault to reduce the risk of pregnancy. Current EC options available in the United States include the copper intrauterine device (IUD), levonorgestrel (LNG) 52 mg IUD, oral LNG (such as Plan B One-Step, My Way, Take Action), and oral ulipristal acetate (UPA) (ella). These clinical recommendations review the indications, effectiveness, safety, and side effects of emergency contraceptive methods; considerations for the use of EC by specific patient populations and in specific clinical circumstances and current barriers to emergency contraceptive access. Further research is needed to evaluate the effectiveness of LNG IUDs for emergency contraceptive use; address the effects of repeated use of UPA at different times in the same menstrual cycle; assess the impact on ovulation of initiating or reinitiating different regimens of regular hormonal contraception following UPA use; and elucidate effective emergency contraceptive pill options by body mass indices or weight.
St. Elsewhere and hysteroscopy
2022, Fertility and Sterility
Outpatient hysteroscopic removal of intrauterine devices in early pregnancy: feasibility and outcomes
2022, Fertility and Sterility
To describe our experience with outpatient hysteroscopy for removal of intrauterine devices (IUDs) in pregnant patients, along with the pregnancy-related outcomes.
Retrospectively and prospectively collected data between January 2015 and April 2021.
Hysteroscopic outpatient clinic (See and Treat Clinic) at a university affiliated, tertiary medical center.
Forty-one patients with an inadvertent but desired pregnancy up to 12 weeks + 6 days gestational age with an IUD in situ, with documented failed attempts of IUD removal.
After ultrasonographic confirmation of IUD location, gestational age, and viability, a small-caliber hysteroscope was introduced via a vaginoscopic approach. The uterus was distended using 0.9% normal saline until a clear view was achieved. On visualization, the IUD was grasped by its strings, tail, or lateral arm using a semirigid hysteroscopic grasper. Oral antibiotic prophylaxis was prescribed in all cases.
The primary outcome of interest was term delivery, from 37 weeks of gestation. Secondary outcomes included patient-reported tolerability and satisfaction, and procedure-related and pregnancy related complications.
The procedure was completed successfully in all 41 patients. Thirty-three patients continued their pregnancies, resulting in 32 full-term singleton deliveries and 1 singleton preterm delivery at 33 + 4 weeks. Median gestational age at delivery was 39 weeks, with a median birthweight of 3,450 grams. Eight patients (19.5%) miscarried, 4 of these within a week of the procedure.
In cases of desired pregnancy with an IUD, outpatient hysteroscopic removal of the IUD is a safe and effective management option. Broader uptake of outpatient hysteroscopy and development of hysteroscopic skills will allow more clinicians to offer patients this effective solution.
Extracción histeroscópica ambulatoria de dispositivos intrauterinos en el embarazo temprano: viabilidad y resultados.
Describir nuestra experiencia con la histeroscopia ambulatoria para la extracción de dispositivos intrauterinos (DIU) en pacientes embarazadas, junto con los resultados relacionados con el embarazo.
datos recopilados de forma retrospectiva y prospectiva entre enero de 2015 y abril de 2021.
Clínica ambulatoria de histeroscopia (Clínica Ver y Tratar) en un centro médico terciario afiliado a una universidad.
Cuarenta y una pacientes con un embarazo involuntario pero deseado de hasta 12 semanas + 6 días de edad gestacional con un DIU in situ, con intentos fallidos documentados de extracción del DIU.
Después de la confirmación ecográfica de la ubicación del DIU, la edad gestacional y la viabilidad, se introdujo un histeroscopio de pequeño calibre a través de un abordaje vaginoscópico. El útero se distendió con solución salina normal al 0,9% hasta que se logró una visión clara. En la visualización, el DIU se sujetaba por los hilos, la cola o el brazo lateral utilizando una pinza histeroscópica semirrígida. En todos los casos se prescribió profilaxis antibiótica oral.
El resultado primario de interés fue el parto a término, a partir de las 37 semanas de gestación. Resultados secundarios incluyeron la tolerabilidad y la satisfacción informadas por las pacientes, y las complicaciones relacionadas con el procedimiento y el embarazo.
El procedimiento se completó con éxito en las 41 pacientes. Treinta y tres pacientes continuaron con sus embarazos, lo que resultó en 32 partos únicos a término y 1 parto único prematuro a las 33 + 4 semanas. La mediana de edad gestacional al momento del parto fue de 39 semanas, con una mediana de peso al nacer de 3450 g. Ocho pacientes (19,5%) abortaron, 4 de ellas dentro de la semana del procedimiento.
En los casos de embarazo deseado con DIU, la extracción histeroscópica ambulatoria del DIU es una opción de manejo segura y eficaz. Una aceptación más amplia de la histeroscopia ambulatoria y el desarrollo de habilidades histeroscópicas permitirán que más médicos ofrezcan a los pacientes esta solución eficaz.

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^☆: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the World Health Organization or the Centers for Disease Control and Prevention.

^☆☆: This review was supported by resources from the Department of Reproductive Health and Research at the World Health Organization, the Centers for Disease Control and Prevention, an Anonymous Foundation, and the National Institute of Child Health and Human Development, USA.

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Review articlePregnancy outcomes with an IUD in situ: a systematic review☆,☆☆

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Contraception

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Am J Prev Med

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

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Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group

JAMA

Pregnancy with an intrauterine device in situ and preterm delivery

Arch Gynecol Obstet

Review article
Pregnancy outcomes with an IUD in situ: a systematic review☆,☆☆