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INTRAUTERINE CONTRACEPTIVE DEVICE (IUD): REMOVALDEFINITIONSteps to follow in removing a patient’s Intrauterine Device (IUD).SUBJECTIVEMust include:LNMP and menstrual history.Medical and sexual history update.History of any recent intercourse, if patient not currently menstruating (may want to delay removal if recent exposure).Documentation of reason for IUD removal request.If patient wants to continue IUD use, but is requesting removal because her 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 whenOBJECTIVEPelvic examination. Check for any signs of infection or incorrect IUD placement.LABORATORYMust include:Hemoglobin/hematocrit (if history of excessive bleeding). If anemia noted, consult with MD.Negative sensitive pregnancy test if patient symptomatic (If test positive, see IUD Complications- Delayed Menses protocol.)Consider Zika screening referral if indicated by risk assessmentASSESSMENTCandidate for IUD removalPLANIf IUD strings visible:If there are any signs or symptoms of cervical infection or PID, 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 IUD Complications-Missing String(s) protocol.If patient seeking pregnancy, provide preconception counseling.If patient desires contraception:If patient has re-qualified for an IUD, you may place another IUD this same visit. (See Identification of Intrauterine Contraceptive (IUD) Candidate protocol). If patient desires another method, provide it.If patient 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.If patient with no prior history of hypertension has BP ≥ 140/90 verified at least one additional time this visit with no smoking or caffeine for 30 minutes, follow agency’s hypertension protocol or consider referral for evaluation of possible hypertension.PATIENT EDUCATIONCounsel regarding risk of pregnancy or ectopic pregnancy if IUD removed in absence of menses with recent intercourse; tell patient IUD no longer protects her from pregnancy. Encourage EC use. See Emergency Contraceptive (EC) protocol.Encourage women 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 women 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 strategiesAvoid traveling to impacted areasAvoiding mosquito bites if traveling to impacted areasUsing condoms to prevent transmission of virusAvoiding pregnancy if infected or partner infectedRisk to unborn fetusREFER TO MD/EDA patient with elevated BP or difficult IUD removal.REFERENCESCenters for Disease Control and Prevention (CDC). U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. Available at Centers for Disease Control and Prevention (CDC). US Selected Practice Recommendations for Contraceptive Use, 2016. Available at Hatcher RA, et al (editors). Contraceptive Technology, 21st Ed. Ayer Company Publishers New York, NY 2018: 157-193Centers for Disease Control and Prevention (CDC). Zika Virus Homepage- Mirena website: website: website: Liletta website: Kyleena website: Reviewed/Revised 2019 ................
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