Gynecology
8 min read

Hysteroscopic Removal of Retained Intrauterine Devices in Pregnancy

Hysteroscopic Removal of Retained Intrauterine Devices in Pregnancy
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Video Description

This video outlines the surgical steps in performing hysteroscopic removal of retained intrauterine devices (IUDs) in early pregnancy.

Presented By

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Dr. Ari Sanders
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Dr. Barry Sanders
 

Affiliations

University of British Columbia, BC Women’s & Children’s Hospital

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What is Retained Intrauterine Devices in Pregnancy?

Retained intrauterine devices (IUDs) in pregnancy refer to situations where an IUD remains in the uterus during pregnancy. An IUD is a form of long-term, reversible contraception that is typically highly effective in preventing pregnancy. However, in rare cases, pregnancy can occur with an IUD in place.

  • The presence of an IUD during pregnancy can happen if the IUD fails to prevent conception, which is rare given the high efficacy of most IUDs. Another possibility is that the pregnancy was already underway when the IUD was inserted, due to an undetected early pregnancy.
  • A retained IUD during pregnancy poses several risks. These include an increased risk of miscarriage, preterm labor, and infection. There is also a heightened risk of complications such as ectopic pregnancy, where the embryo implants outside the uterine cavity, commonly in the fallopian tubes. The presence of an IUD can interfere with the normal development and implantation of the embryo, potentially leading to adverse outcomes.
  • The management of a retained IUD during pregnancy depends on various factors, including the location of the IUD, the gestational age at discovery, and the overall health and preferences of the patient. If the IUD strings are visible and easily accessible, removal of the device may be attempted to decrease the risk of complications. However, if the IUD is not easily accessible or if removal poses a risk to the ongoing pregnancy, it may be left in place with close monitoring throughout the pregnancy.
  • The decision on how to manage a retained IUD in pregnancy requires careful consideration of the risks and benefits, ideally involving a detailed discussion between the healthcare provider and the patient. This ensures that the chosen approach aligns with the best interests of both the mother and the developing fetus. Close monitoring throughout the pregnancy is crucial to manage and mitigate potential complications.

What are the Risks of Retained Intrauterine Devices in Pregnancy?

The presence of a retained intrauterine device (IUD) during pregnancy can pose several risks and complications, both to the mother and the developing fetus. Managing these risks involves careful consideration and often necessitates close medical supervision. Here are the key risks associated with retained IUDs in pregnancy:

  • Increased Risk of Miscarriage: The presence of an IUD in the uterus during pregnancy significantly raises the risk of miscarriage, especially in the first trimester. The foreign body can interfere with the implantation and development of the embryo.
  • Ectopic Pregnancy: IUDs are designed to prevent pregnancy, including reducing the risk of ectopic pregnancies when not pregnant. However, if a pregnancy occurs with an IUD in place, the risk of it being ectopic is higher than in pregnancies without an IUD. This is a potentially life-threatening condition where the embryo implants outside the uterine cavity, often in the fallopian tubes.
  • Infection: An IUD can act as a potential site for bacterial growth, which can lead to infections such as pelvic inflammatory disease (PID). During pregnancy, such infections are particularly concerning as they can affect the fetus and lead to complications like preterm labor.
  • Preterm Labor and Delivery: The irritation and inflammation caused by a retained IUD can lead to preterm labor. This is a significant risk as preterm birth is associated with numerous health issues for the newborn, ranging from respiratory distress syndrome to long-term neurological disabilities.
  • Placental Problems: The presence of an IUD during pregnancy can lead to complications involving the placenta, such as placental abruption (premature separation of the placenta from the uterus), which can be dangerous for both mother and fetus.
  • Management Challenges: The decision to remove or leave a retained IUD in situ during pregnancy can be complex. Removal of the IUD can itself trigger miscarriage or preterm labor, but leaving it in place may continue to pose risks as outlined. The process of removal, if the strings are visible and accessible, is usually straightforward; however, if the IUD has migrated or the strings are not visible, surgical intervention may be necessary, which carries additional risks.

Due to these complications, pregnancies with a retained IUD require enhanced prenatal care with regular monitoring to swiftly address any issues that arise. The management strategy should be individualized based on the IUD’s location, the stage of pregnancy, and the overall health of the patient.

Video Transcript: Hysteroscopic Removal of Retained Intrauterine Devices in Pregnancy

We present a video on the hysteroscopic removal of intrauterine devices in pregnancy. Intrauterine devices are a common form of contraception. While pregnancy is uncommon, first year failure rates are 0.8% for the copper IUD and 0.2% for the levonorgestrel-releasing intrauterine system.

Pregnancies complicated by a retained IUD are at increased risk of adverse outcomes, most commonly, spontaneous abortion and preterm labour. Removing a retained IUD in pregnancy can improve pregnancy outcomes. Studies show reductions in spontaneous abortion rates to around 20% and preterm labour rates to around 4% to 6%.

As a result, the World Health Organization recommends IUD removal at the earliest gestational age possible, when the strings are visible on exam. However, when the strings are not retrievable on exam, what are the options for management?

When pregnancy continuation is desired, three approaches to management include expectant management, IUD removal using a grasper under ultrasound guidance and hysteroscopic IUD removal with or without ultrasound guidance. This video will present four cases that highlight steps and technical tips in successfully performing this procedure.

Prior to the procedure, ensure pregnancy continuation is desired and obtain informed consent. Complications are uncommon, but risks of gestational sac rupture and miscarriage are discussed with all patients. Review preoperative imaging to plan your surgical approach, and before the procedure, we confirm viability and administer a single dose of cefazolin preoperatively.

Surgical steps include first performing hysteroscopy without cervical dilation, second, infusing minimal distension media at a very slow rate, third, identifying the IUD, and lastly, grasping and removing the IUD under direction visualisation.

This animation depicts the initial steps of the procedure. If the IUD is not easily visible or if it is known to be located near the uterine fundus, ultrasound guidance is recommended. Ultrasound guidance can help identify the IUD and facilitate its removal in an uncomplicated fashion.

Case one is a 35-year-old gravida two, para one who had a copper IUD removed at nine weeks and six days under ultrasound guidance. Hysteroscopy is performed without cervical dilation. Upon entering the endometrial cavity, the gestational sac becomes visible.

Visualisation is challenged by extensive mucus and debris that mixes with the limited infusion of saline distension media. A hysteroscopic grasper can be advanced through the operating channel of the hysteroscope and can be used as a probe to help identify the IUD.

Once located, the IUD is then grasped firmly to ensure that it can be successfully removed on the first attempt. The grasper and the IUD are kept in view until successful removal is obtained.

Case two is a 32-year-old gravida two, para one who had a copper IUD removed at 12 weeks and two days under ultrasound guidance. This case nicely depicts the challenges in visualisation posed by the extensive intrauterine mucus and debris in pregnancy. We attempt to minimise removal and reinsertion of the scope to clean the lens.

Here, you can see a track is created to pass the hysteroscope between the gestational sac and the lateral uterine wall. The hysteroscope is advanced slowly, with minimal infusion of distension media, to avoid disrupting the gestational sac. The IUD is located, and again, using the hysteroscopic grasper, the IUD is grasped firmly and slowly removed. It is kept in view as the hysteroscope is removed from the uterine cavity and endocervical canal.

Case three is a 33-year-old gravida two, para zero who had a copper IUD removed at nine weeks and one day under ultrasound guidance. In this case, you see that as we obtain entry to the uterine cavity, the hysteroscope is not advanced any further.

We then perform a gentle scan from one side of the uterine cavity to the other. This helps facilitate IUD identification without the need to advance the hysteroscope further into the uterine cavity, thus reducing the risk of disrupting the gestational sac. This technique is useful when the IUD is believed to be located within the lower uterine segment. It is then grasped and removed, again being kept in view at all times.

Case four is a 37-year-old gravida three, para two who had a copper IUD removed at 11 weeks and one day under ultrasound guidance. This case nicely depicts how the uterine cavity is entered slowly and carefully to avoid disrupting the gestational sac, which is now seen here.

Minimal distension media is again used to create a track between the sac and the lateral uterine wall. The hysteroscope is angled up and over the gestational sac before returning to the track against the lateral uterine wall when the IUD is not seen.

The hysteroscope is then advanced further along the uterine wall. The IUD eventually becomes visible at the uterine fundus, surrounded again by mucus and debris. It is then firmly grasped and slowly removed with the hysteroscopic grasper. Care is taken to retract the hysteroscope laterally, against the wall of the uterus, to avoid disrupting the gestational sac.

To review the steps of the procedure, step one is performing hysteroscopy without cervical dilation. Step two is the infusion of minimal distension media. Step three is identifying the IUD. And step four is grasping and removing the IUD under direct visualisation.

After the procedure, all patients have viability confirmed. They undergo same-day discharge, and a follow-up ultrasound and visit is arranged two weeks later. If all is well, patients and their obstetricians are advised that they can resume routine obstetrical care.

The four cases presented here all had successful outcomes. Case one, two and three all had uncomplicated pregnancies and vaginal deliveries at term. Case four had threatened preterm labour but eventually underwent caesarean section at 37 weeks and six days.