GYN

CMECNE

IUDs and Implants: How to Manage Potential LARC Complications

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Determine the preferred management when complications arise using IUDs
2. Select the appropriate treatment for complications arising from contraceptive implants

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

Use of long-acting reversible contraceptive (LARC) methods, both intrauterine devices and subdermal contraceptive implants, has increased dramatically in the past ten years. Although the risk of complications is low, as use increases the absolute number of complications will increase.

CLINICAL ACTIONS:

Intrauterine device:

Pain
- Lidocaine paracervical block reduces pain scores on insertion
- Misoprostol does not improve pain scores and may be associated with nausea and vomiting
Strings not visualized
- Rule out pregnancy and expulsion
- Recommend backup contraception until IUD position can be verified
- Recommend emergency oral contraceptives (if appropriate)
- Ultrasound and X-ray of abdomen and pelvis can be used for localization
Possible expulsion
- IUDs seen in the cervix are partially expelled and should be removed
  - Replacement or use of another method are both acceptable options
- Low-lying IUDs (lower uterine segment) can be expectantly managed
Risk factors for expulsion include
- Young age
- Heavy menstrual bleeding and dysmenorrhea
- Placement postpartum or post second trimester abortion
- Presence of anatomic distortion of the uterine cavity
Uterine perforation
- Is rare and generally asymptomatic
- Usually occurs at the time of insertion
  - Do not use misoprostol routinely prior to insertion in nulliparous women but may be considered with difficult insertions
- Rule out pregnancy and remove surgically unless the surgical risks of removal outweigh the benefits
PID
- Can be treated with the IUD left in situ
- Consider removal if no clinical improvement after 48-72 hours of antibiotics
Pregnancy with an IUD in place
- Remove the IUD if the strings are visible or IUD within the cervix
- IUD can be removed at time of procedure if patient elects termination
- Evaluate for ectopic pregnancy

Implant:

Infection prevention
- Use antiseptic technique and cover the insertion/removal site
- Skin flora are the most common cause of infection
- Remove implant if infection does not resolve
Bruising
- Is common
- Ice and anti-inflammatory medication can help
Nonpalpable implant
- Locate with high frequency (>/= 10 MHz) ultrasound probe, two dimensional X-ray, or CT scan/fluoroscopy
- Obtain a serum etonogestrel level if all studies are negative/equivocal
- Refer to a surgeon with knowledge of the anatomy of the arm if implant is within muscle or neurovascular bundle
Pregnancy
- Is rare
- Remove the implant if the pregnancy is to be continued
- Rule out ectopic pregnancy

SYNOPSIS:

LARCs are highly effective contraceptives with a low risk of complications. Those mentioned above should be discussed with patients as part of informed consent.

KEY POINTS:

Recognition and prompt diagnosis/treatment of the untoward outcomes described above are important aspects of care
Overall, complication rates are low and LARCs remain a very effective mode of birth control

ICD-10 codes:

Z30.49 check/reinsertion/removal of implant
Z30.430 insertion of IUD
Z30.432 removal of IUD
Z30.433 removal and reinsertion of IUD

Learn More – Primary Sources:

ACOG Committee Opinion 672: Clinical challenges of long-acting reversible contraceptive methods

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