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
• Pelvic inflammatory disease
  • 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 remain low and LARCs reamain 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

Related ObG Topics:

ACOG & SMFM Guidance on the Use of IUDs and Contraceptive Implants

CDC Guidance: Contraception in Women with Medical Conditions

Emergency Contraception: What, When and How?