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INTRAUTERINE DEVICE DEFINITIONThere are five FDA approved intrauterine contraceptive devices (IUD) available in the U.S. The Copper T380A IUD (ParaGard) is approved for up to 10 years; evidence-based use supports 12-20 years. It has a first-year failure rate of 0. 5% to 0.8%; 1.4 to 2.2 failure rate at 7 years and its 12-year cumulative failure rate is 2.2%. The 52 mg levonorgestrel-releasing IUDs-Mirena is approved for up to 6 years: evidence-based use supports 7 years. It has a first-year failure rate of 0.1-0.2%, a 5-year failure rate of 0.5-1.1% and a 7-year failure rate of 0.5%. Liletta is approved for up to 6 years; evidence-based use supports 7 years. It has a first-year failure rate of 0.1-0.2%, a 5-year typical use failure rate of less than 1%.0.5-1.1% and a 7-year failure rate of 0.5%.The 19.5 mg levonorgestrel-releasing IUD- (Kyleena) is approved for up to 5 years. It has a 5-year failure rate of 1.1+/- 0.5%.The 13.5 mg levonorgestrel-releasing IUD- (Skyla) is approved for up to 3 years of use. It has a first-year failure rate of 0.48% and 0.9% over 3 years. SUBJECTIVEAssessment must include:LNMP and menstrual history. Document any unprotected intercourse in last 5 days.Medical and sexual history Do not insert an IUD until a minimum of 4 weeks after full term/or second trimester delivery or until uterus fully involuted. An IUD may be inserted immediately after first trimester abortion or pregnancy loss.Review of contraindications and risks:Note: All CDC category 4 conditions– (Unacceptable risk for method use). Use caution with CDC category 3 conditions- (Risks outweigh advantages for method use) individualized management must be based on protocols approved by the Medical Director or clinic physician. Pregnancy (CDC 4)Postpartum puerperal sepsis (CDC 4) (in the past 3 months)Post-septic abortion (immediate) (CDC 4) (in the past 3 months)Ischemic heart disease (current and history of) (LNG continuation is CDC 3)Systemic Lupus Erythematous- Positive (or unknown) antiphospholipid antibodies (LNG CDC 3)Systemic Lupus Erythematous with severe thrombocytopenia (CU-IUD initiation CDC 3)Gestational trophoblastic disease -persistently elevated -hCG levels or malignant disease, with evidence or suspicion of intrauterine disease (CDC 4)Unexplained vaginal bleeding (initiation CDC 4)Breast cancer (current, LNG CDC 4) (past and no evidence of current disease for 5 years, LNG CDC 3)Distorted uterine cavity or other anatomical abnormalities (CDC 4)Cervical cancer (initiation CDC 4)Endometrial cancer (initiation CDC 4)Pelvic Inflammatory disease – current (CDC 4)Current untreated purulent cervicitis, chlamydial infection or gonorrhea (initiation CDC 4; continuation is CDC 2)Cirrhosis (severe-decompensated) (LNG CDC 3)Liver tumors (benign hepatocellular adenoma or malignant hepatoma) (LNG CDC 3)Solid organ transplantation- complicated (initiation CDC 3)Pelvic tuberculosis (initiation CDC 4) (continuation CDC 3)The following are contraindications found in the manufacturers Package Insert:Known or suspected allergy to copper (Copper IUD only) (PI)History of Wilson’s Disease (Copper IUD only) (PI)Small uterine cavity with sounding less than manufacturer’s recommendation Suspected or known uterine perforation occurring with the placement of a uterine sound during the current insertion procedureOBJECTIVEAssessment must include:Pelvic Exam (bimanual and speculum exams)Complete uterine involution is needed following pregnancy, unless placing immediately following pregnancy loss or placing immediately post-partum.If placing IUD immediately following pregnancy loss, must have uterus evacuated of all products of conception, no signs of infection and no excessive, ongoing bleeding.If placing, must have uterine depth consistent with sounding of:Kyleena large enough to accommodate deviceLiletta: 5.5 cmMirena: 6.0-10 cmParaGard: 6.0-9.0 cm Skyla: large enough to accommodate deviceLABORATORYNo routine laboratory tests needed for IUD placementMay include based on indication:Hgb/Hct if recent history of excessive menstrual blood loss or anemia. Pregnancy test if client at risk. If indicated by age, screening guidelines, sexual history or symptoms, perform needed tests to rule out GC or chlamydial cervicitis or trichomonas vaginitis.ASSESSMENTCandidate for IUDPLANIf possible, place the IUD at this visit. If IUD not placed during this visit, insure client has an interim birth control method and instruct when to return for placement according to the type of IUD desired. Select IUD-Refer to CDC Medical Eligibility Criteria to determine if any category 3 or 4 contraindications exist. If no contraindications to one type exists, consider the following to help select between copper and LNG IUD: Considerations for Copper IUD:Avoidance of exogenous hormonesContinuation of normal bleeding patternDesire for longer-term contraceptionNeed for emergency contraceptionConsider if history of progestin-related side effects with prior birth controlDysmenorrhea or menorrhagia are relative contraindication as these may worsen with the copper IUDConsiderations for LNG IUD:Reduction of menstrual bleeding and anemiaPossible amenorrheaReduction in dysmenorrheaTreatment of endometriosis-related pelvic painReview product information brochure with client, answer all questions, obtain informed consent and signatures on all appropriate forms. Place forms into client’s record.Premedication has not been found to decrease discomfort of IUD placement, but may be indicated in the following situations:NSAIDs (Ibuprofen 400-600mg orally every 6 hours) to reduce cramping after placement.Paracervical block if client has history of vasovagal reaction or cervical stenosis.If client found to have BV, treat with systemic not topical antibiotics (See Bacterial Vaginosis protocol). No need to delay IUD placement, but reinforce the importance of completing antibiotics.If no recent pregnancy, place IUD according to manufacturer’s instructions with close attention to aseptic technique. Important elements include:Gently place tenaculum on cervical lip to straighten axis of uterus and to stabilize uterus. Apply traction on tenaculum to reduce risk of perforation.Careful uterine sounding to confirm that client is a candidate for desired IUD:Kyleena - large enough to accommodate deviceLiletta - minimum of 5.5 cm Mirena - 6.0-10.0 cm.ParaGard - 6.0-9.0 cm.Skyla - large enough to accommodate deviceOpen IUD package, load IUD and place IUD following manufacturer’s instructions.Trim strings to 3-4 cm from cervical os. Write procedure note which records uterine position and size, depth of uterine sounding, depth to which IUD placed, and length to which the strings trimmed, how well the client tolerated the procedure, as well as any complications that may have been encountered during the procedure. Document IUD type, lot number and expiration date.Instruct client to return to clinic for routine preventive health care and earlier PRN problems with the IUD. No routine post-placement visit needed.Unless client has contraindications to use of NSAIDs, advise use as needed for problem with cramping or bleeding. Typical recommendation: Ibuprofen 400-600 mg orally every 6 hours when needed for cramping or heavy bleeding. Other NSAIDs at equivalent doses may be used.PLACEMENTSchedule Copper IUD (ParaGard) placement any time in the cycle provided a negative urine pregnancy test.Placement after completion of menses may reduce early expulsion risk. If possible, avoid placing IUD during heavy menstrual flow days.Copper IUD is effective as post-coital emergency contraceptive for up to 5 days after exposure. May place a new IUD (copper or hormonal one) immediately after removing an existing IUD, if client is a candidate for desired new IUD.Labeling supports placement immediately after an abortion or delivery. If not inserted at time of delivery it is best to wait until after 4 weeks to lessen expulsion rate.Schedule a levonorgestrel IUD placement any time during the menstrual cycle provided reasonable assurance exists the patient is not pregnant: Within first 7 days of the start of last normal menses. To reduce early expulsion rates, try to avoid placement on heavy flow days.Has not had intercourse since last normal menses.Is using a reliable method of contraception correctly and consistently.Is ≤7 days from induced or spontaneous abortionIs ≤4 weeks post-partumIs ≤6 months post-partum, amenorrheic, and exclusively breast feeding If placement is desired at any other time in cycle or under different conditions, perform a urine pregnancy test and instruct abstinence or a back-up method for 7 days following IUD placement. If unprotected intercourse occurred within the last 120 hours and choosing LNG-IUD, offer ECPClient switching from OCs, advise completion of pill pack, especially if IUD placed during the last week of active pills.May place new IUD immediately after removal of existing IUD if client is still a candidate. Advise 7 days of abstinence or use of a backup method following removal of a copper IUD with replacement by a LNG IUD.Consider EC if client has had recent intercourse and the IUD has been in place longer than the manufacturer’s recommendation or client is having a copper IUD replaced with an LNG IUD. None of the LNG-IUD products are a post coital contraceptive.Labeling supports placement immediately after an abortion or delivery. If not inserted at time of delivery it is best to wait until after 4 weeks to lessen expulsion rate.REMOVAL If IUD strings visible:If there are any signs or symptoms of severe cervical infection, PID, or systemic infection provide appropriate systemic antibiotics and administer first dose prior to removal.Remove IUD following manufacturer’s instructions.If IUD string(s) are missing or break during removal attempt, refer to Management of IUD Complications.If client seeking pregnancy, provide preconception counseling.If client desires contraception:If client is qualified for an IUD, you may place another IUD this same visit. If client desires another method, provide it.If client has had intercourse in the last five days and is at risk for pregnancy if IUD removed, offer emergency contraception or delay removal of IUD.Documentation of reason for IUD removal request.If client wants to continue IUD use, but is requesting removal because IUD has been in place for the number of years for which it is recommended, consult with MD to determine if an off-label extension of years of use is possible.Zika Risk Assessment- As per current CDC guideline- and partner(s)Past travel – where and whenPlans for future travel – where and when CLIENT EDUCATION Reinforce IUD education, including signs and symptoms of possible IUD complications (e.g. infection, expulsion, perforation, pregnancy).Instruct client to seek urgent care if any symptoms of PID, pregnancy, expulsion or experiences heavy vaginal bleeding or severe cramping.Instruct client on recommended removal date based on type of IUDEncourage routine health rm client that Mirena is the most effective medical treatment for heavy menstrual bleeding and can reduce symptoms of endometriosis and problems with anemia. By providing progestin, Mirena also helps reduce the risk of endometrial cancer and precancer, especially in clients with anovulatory cycles.Discuss the expected short-term side effects following placement, including unscheduled bleeding and cramping. Advise that many of these symptoms may subside over time.Discuss the intermediate and longer-term effects of each IUD.ParaGard: Monthly bleeding will may increase by an average of 30-50 %, but that increase can usually be reversed by the use of NSAIDs during menses. (See IUD Issues)Mirena:Unscheduled bleeding and spotting may be frequent in the first 4 months of use but will diminish over time.Total blood loss will be significantly reduced with longer use of Mirena.15-24% of client will have no spotting or bleeding at all by 12 months year 1 of use; 10-26% by 2 years of use Some clients experience headaches or breast tenderness, especially with early use, but usually the symptoms are only temporary or are due to other causes.Mirena is an effective IUD medical therapy for heavy or prolonged menstrual bleeding. It may also help reduce dysmenorrhea.Skyla:Unscheduled bleeding and spotting may be frequent in the first 4 months of use but will diminish over time.Total blood loss will be significantly reduced with longer use.6% of clients will have no spotting or bleeding at all in year 1of use; 10% by 2 years of useSome clients experience headaches or breast tenderness, especially with early use, but usually the symptoms are only temporary or are due to other causes.Liletta Unscheduled bleeding and spotting may be frequent in the first 4 months of use but will diminish over time. Total blood loss will be significantly reduced with longer use. 15-24% of clients will have no spotting or bleeding at all in year 1 of use; 10% by 2 years of useKyleena Spotting and irregular or heavy bleeding may occur during the first 3 to 6 months. Periods may become shorter and/or lighter thereafter. Cycles may remain irregular, become infrequent, or even cease. 13% of clients will have no spotting or bleeding at all by 1 year of use; 20% by 2 years Consider pregnancy if menstruation does not occur within 6 weeks of the onset of previous menstruation.Remind client that the pregnancy protection, non-contraceptive benefits and the side effects disappear almost immediately following IUD removal. Counsel regarding risk of pregnancy or ectopic pregnancy if IUD removed in absence of menses with recent intercourse; tell client IUD no longer protects from pregnancy. Encourage EC use. See Emergency Contraceptive (EC) protocol.Encourage clients who desire IUD removal in order to become pregnant to use folic acid supplements for at least 1-3 months prior to removal or at least prior to conception.Advise clients who have IUD removed but are not seeking pregnancy to immediately initiate another effective method. Remind them that the IUD provides no residual contraceptive protection once it is removed.Zika virus education and prevention strategies Avoid traveling to impacted areas Avoiding mosquito bites if traveling to impacted areas Using condoms to prevent transmission of virus Avoiding pregnancy if infected or partner infectedRisk to unborn fetusREFER TO MD/EDAny client who has difficult placement or removal.Any client with elevated blood pressure or US MEC category 3 or 4 conditions not previously evaluated and approved for IUD by MD.Any client who is unstable after uterine perforation or other complication of IUD placement.MANAGEMENT OF IUD COMPLICATIONSABNORMAL BLEEDINGSUBJECTIVEAssessment must include:Acute vaginal bleeding.Prolonged and/or heavy menses.Intermenstrual bleeding or post-coital bleeding.Symptoms of anemia.Symptoms of pregnancyOBJECTIVEAssessment must include:Signs of anemia and/or hypovolemia (e.g., orthostatic BP or pulse changes).Pelvic examBlood from cervical os.IUD string(s) length increased.IUD in cervical canal.Missing IUD strings.Signs of infection and/or lesionSigns of pregnancy LABORATORYMust include:Sensitive urine pregnancy test. If positive pregnancy test, consider Zika screening referral if indicated by Zika Risk Assessment.Hemoglobin/hematocrit, if heavy bleeding seen or if client symptomatic.Tests to rule out STIs, cervicitis or trichomonal vaginitis, if indicated.ASSESSMENTAbnormal bleeding with IUD and:PREGNANT CLIENTRefer to Medical Emergency Department (ED) to rule out ectopic pregnancy, threatened spontaneous miscarriage or PID in pregnancy if:Client is unstable or is experiencing excessive blood loss or if hemoglobin <8. (May remove IUD first if it is obviously expelling in cervical os.) Arrange ED transportation appropriate to client’s clinical status.Cervical os open (inevitable spontaneous miscarriage).Client complaining of pelvic pain, has cervical motion or uterine/adnexal tenderness, has an adnexal mass or is currently bleeding.If client is stable with no symptoms or signs of ectopic pregnancy see Delayed MensesClient EducationAdvise client to tell care provider about the IUD whether or not it is removed.Refer to MD/EDAll pregnant clients with an IUD.NON-PREGNANT CLIENTRefer to ED if client unstable, severely anemic or is experiencing excessive blood loss. (May remove IUD first if it is obviously expelling.) Arrange transportation appropriate to client’s clinical status.If client is stable and has an expelling IUD, remove IUD according to manufacturer’s instructions with the client’s consent. Provide birth control. The client may be a candidate for placement of another IUD at this visit.If IUD string is visible, the choice of other actions depends on the client’s preferences and presenting complaint:If the client requests IUD removal, see IUD Removal.For post-coital bleeding: test for other causes of post coital bleeding, such as cervical infection, cervical polyps or cervical dysplasia/cancer.For heavy or prolonged bleeding:Offer NSAIDs to start at onset of each menses to reduce menstrual blood loss, (e.g., Ibuprofen 800 mg orally 3 times a day for first 3-5 days each cycle). Contraindicated in clients with gastric ulcers, renal failure or other problems using ASA.Have client keep a menstrual calendar, with pad count for 2 cycles.Instruct client to RTC to evaluate effectiveness of treatment.Provide FeS04 325 mg 1 to 3 times a day, if anemic. FeSO4 is most effective if taken on an empty stomach, if tolerated. Constipation can be a side effect For spotting and bleeding with LNG IUDIf in the first 4-6 months of use, reassure client that bleeding pattern should soon improveIf client requests treatment may use one of the following: See Table 1 for medical interventionsIf bleeding is persistent accompanied by cramping, consider referral for evaluation and possible ultrasound Client EducationReinforce IUD education as appropriate.Remind client to bring menstrual calendar to next visit.Refer to MD/EDClient with intermenstrual bleeding/spotting not explained at this visit.Client with abnormal physical findings.Client with persistent bleeding/spotting.Client who by protocol should have IUD removed but declines to have it removedTable 1 Efficacy of medical interventions for irregular bleeding/spotting in LNG IUD usersMedication ClassMedicationDose (mg)FrequencyLength of TimeDecreased bleedingNSAIDNaproxen5002 Times daily5 dAntifibrinolyticTranexamic acid5003 Times dailyUntil bleeding stopsAntiprogestinMifepristone100OnceMonthlyNo effect on bleedingNSAIDMefenamic acid5003 Times dailyUntil bleeding stopsIncreased bleedingEstrogenEstradiol0.1TransdermalChanged weeklySPRMUlipristal acetate50Daily3 d (Starting 21?d after insertion)Friedlander E, Kaneshiro B. Obstet Gynecol Clin North Am. 2015 Dec; 42(4):593-603Historically, clinicians prescribed cyclic combined oral contraceptive pills in addition to the IUD if bothersome unscheduled bleeding occurred. This prescription provided endometrial stabilization with estrogen while maintaining the superior contraceptive efficacy of the IUD. Although this was shown to be beneficial in levonorgestrel implant (Norplant) users, no data currently support this practice with the LNG DELAYED MENSESSUBJECTIVEAssessment must include:Last menstrual period (LMP), previous menstrual period (PMP) and menstrual history.Client denies IUD expulsion.Pregnancy symptoms. OBJECTIVEAssessment must include:IUD strings visible from cervical os. If strings not visible, see IUD Missing String(s).Bimanual exam LABORATORYPregnancy test.ASSESSMENTDelayed menses-Pregnant IUD user with visible IUD strings.If client has complaint of abdominal pain or has an adnexal mass or tenderness, refer immediately to Emergency Department (ED) to rule out ectopic pregnancy or other pregnancy complication. Using a client-centered approach, discuss pregnancy options and refer for appropriate pregnancy care.If dates and size consistent with intrauterine pregnancy (IUP) in the first trimester and client considering pregnancy continuation:Advise client that the risks of removal of IUD (infection, spontaneous miscarriage, preterm delivery, bleeding) at this gestational age are less than the risks of retaining the IUD. Recommend IUD removal.If experienced in IUD removal in this circumstance and able to handle possible hemorrhage, obtain the client’s informed consent and remove IUD. Give client spontaneous miscarriage precautions.If clinician decides not to remove IUD, refer to appropriate facility for prompt removal.If client declines IUD removal, obtain a signed statement acknowledging risks for IUD continuation and stating reasons for declining IUD removal. Give ectopic, spontaneous miscarriage, and PID precautions.If dates or size consistent with intrauterine pregnancy (IUP) beyond first trimester, advise client of need for prompt evaluation of IUD position with pregnancy care provider.CLIENT EDUCATIONReinforce ectopic pregnancy precautions, if applicable.Educate regarding signs and symptoms of infections and spontaneous miscarriage.Instruct client to tell pregnancy care provider about IUD and/or this removal procedure.REFER TO MD/EDUnsuccessful IUD removal.Client with suspected ectopic pregnancy.Client seeking to continue pregnancy.Client seeking to terminate pregnancy.DELAYED MENSES-NON-PREGNANT CLIENTNon-pregnant IUD user with delayed mensesCopper IUD user:If LMP less than 2 months ago or only slightly more than the usual interval, reassure client and urge return in 2 weeks for repeat pregnancy test.If LMP more than 2 months ago or more than twice usual interval, reassure and urge return in 2 weeks for repeat pregnancy test.Levonorgestrel-releasing IUD userReassure client that amenorrhea and oligomenorrhea are known side effects (and health benefits) of the hormonal IUD.Encourage client to RTC if any other symptoms of pregnancy develop or notes a change in the length of IUD strings.CLIENT EDUCATIONAdvise client that lack of menses with LNG IUD is healthy and that menses will resume after IUD removal.Remind LNG-users that pregnancy testing is appropriate if other symptoms of pregnancy develop but is not needed on a routine basis once amenorrhea has been established.Copper IUD users should be advised that the copper IUD does not cause decrease in menses and any decrease in menses should be evaluated.REFER TO ED/MDClient with suspected ectopic pregnancy.MISSING STRING(S)SUBJECTIVEAssessment must include:Denies knowledge of IUD expulsionIUD strings not felt by clientLNMP and menstrual historyRecent coital historyNo abnormal vaginal bleeding or uterine crampingOBJECTIVEAssessment must include:IUD strings are not visiblePelvic exam may be consistent with pregnancy or active cervicitis or upper tract infectionsLABORATORYPregnancy testASSESSMENTMissing IUD strings in a pregnant clientIf client has any signs or symptoms of an ectopic pregnancy, refer to ED.Provide routine pregnancy options counseling.Refer for care with a note of possible IUD in uteroCLIENT EDUCATIONStress importance of follow-rm client that the most likely reason for the pregnancy was that the IUD was expelled but may be malpositioned. IUD localization is important to determine possible risks to pregnancy and to guide the provider in follow-up care.Advise client to tell prenatal clinician that there may have be an IUD present.Advise client considering pregnancy termination that IUD may be removed at time of procedure.Advise client considering pregnancy continuation of risks of infection later in pregnancy and premature delivery if IUD is in utero. Describe warning signs such as fever, lower abdominal pain or flu-like symptoms.Reassure client that copper IUD is not known to cause fetal malformation. Impact of LNG IUS not well known.Zika virus education and prevention strategiesAvoid traveling to impacted areasAvoiding mosquito bites if traveling to impacted areaUsing condoms to prevent transmission of virusAvoiding pregnancy if infected or partner infectedRisk to unborn fetusREFER TO MD/EDClients with any signs or symptoms of ectopic pregnancy or threatened abortion.Missing IUD strings in endocervix of non-pregnant client If there are any signs or symptoms of cervical infection or PID, provide appropriate antibiotics (See Gonorrhea Cervicitis or Chlamydia Cervicitis protocols) prior to attempted retrieval of strings, if possible.If IUD not in endocervical canal, gently withdraw the strings into the vagina and assess their length. If no evidence of significant lengthening suggestive of partial expulsion, IUD may be left in place. If significant lengthening, consider an ultrasound prior to removalIf any part of the IUD itself is found to be in the endocervical canal:Offer/ provide hormonal method of emergency contraception (EC) (See protocol by same name) if client has had any intercourse within last 5 days.Obtain client’s informed consent to remove IUD.Remove IUD. See IUD Removal protocol for guidance.Provide contraception (may place another IUD, if client requests and still a candidate). Non-pregnant-Strings not in endocervical Management depends upon client preference and pregnancy risk. Two options exist after treatment for cervicitis or PID, if indicated:Option 1: Refer for managementOption 2: If client requests IUD removal, locate the IUD with appropriate radiologic studies prior to attempting to remove IUD. Note: LNG-IUS is more difficult to visualize on ultrasound than is the copper IUD.If ultrasound available, use it to localize IUD.If IUD is in uterine cavity (endometrium), allow client to continue to use if client chooses to retain IUD or have it removedIf embedment (intramural IUD) or perforation suspected, refer to MD.If no IUD seen on ultrasound, provide contraception and refer to MDIf ultrasound not available, provide other contraception, offer EC and refer for one of these studies:Ultrasound is preferred because it can define where the IUD is located (within or outside the uterus). Following ultrasound, manage as described above.X-ray studies can verify presence of copper IUD in pelvis, but cannot localize it in the intrauterine cavity. Markers must be placed in the uterine cavity and both anterior- posterior and lateral x-ray views are needed. The absence of any evidence of an IUD on abdominopelvic films supports the diagnosis of expulsion.REFER TO MD/ERIUD imaged in extrauterine or intramural location.Removal of IUD in endometrial cavity if clinician is not experienced with removal techniques.Difficult IUD removal.Client declines permission for IUD removal.UTERINE PERFORATIONSUBJECTIVEAssessment must include:During procedure:Sudden onset of intense pelvic painCrampingDizzinessPost procedure:Missing IUD strings.Unexplained bleeding, cramping or painPregnancy symptomsOBJECTIVEAssessment must include:During procedure:Excessive uterine depth (greater than expected from bimanual exam) on sounding or with introduction of IUD.Abrupt loss of uterine resistance during sounding or during IUD placement. Tachycardia, diaphoresis, hypotension, or syncope Post procedure:Imaging studies showing IUD outside endometrium cavityMissing IUD stringsLABORATORYHemoglobin, if excessive bleeding reportedPregnancy test if uterine instrumentation plannedASSESSMENTPossible uterine perforation.PLANIf acute perforation:Attempt to gently retract and remove uterine sound or IUD (whichever is involved in suspected perforation).If excessive resistance is encountered with attempted removal or if complications encountered, STOP and:Provide supportive care.Consult MD and/or refer to ED immediately.Arrange transportation appropriate to client’s condition.If removal successful (instrument removed, no excessive bleeding, no evidence of bowel injury and client’s symptoms resolved):Provide supportive care, observe closely and call MDIf MD advises further evaluation in an ED, arrange transportation appropriate to client’s condition. Provide alternative contraceptive.If MD advises that client may go home after prolonged evaluation on site with serial measurements of vital signs and hemoglobin:Provide alternative method of birth control.Advise strict pelvic rest for 48 hoursHave client return to clinic in 1-2 weeks. May consider another IUD placement attempt at that time.If non-acute perforation noted in stable client (IUD thought to be outside endometrial cavity)Perform UCG if indicated.Provide another method of contraception.Obtain ultrasound for localization/confirmation.Refer for IUD surgical removal.If embedment suspected by imaging studies, provide alternative contraceptive and refer for hysteroscopic removal.CLIENT EDUCATIONReinforce importance of ED referral and/or follow-up care.Counsel client about importance of using alternative method until evaluation and treatment complete.REFER TO MD/EDClient with unresolved perforation and stable (MD) or complicated acute uterine perforation (ED)Client with suspected embedmentREFERENCES ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol. 2011, reaffirmed 2015; 118(1):184-96.Centers for Disease Control and Prevention (CDC). U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. Available at Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines. Available at for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. Available at Centers for Disease Control and Prevention (CDC). Zika Virus Homepage- Hatcher RA, et al (editors). Contraceptive Technology, 21st Ed. Ayer Company Publishers New York, NY 2018: 157-193, 520-521Kyleena website: Liletta website: website: website: website: Friedlander E, Kaneshiro B. Obstet Gynecol Clin North Am. 2015 Dec; 42(4):593-603Reviewed/Revised 2021 ................
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