Pregnancy with IUD

28-year-old pregnant female with abnormal ultrasound. Next step? • Xray of the Week

Figure 1. Pelvic ultrasound of a 28-year-old female.

Figure 2. Pelvic ultrasound of a 28-year-old female demonstrating an intrauterine pregnancy with an IUD. A. Sagittal view reveals rotated and inferiorly displaced IUD in the lower uterine segment and cervix (orange arrow) and an intact intrauterine gestational sac (yellow arrows). B. Sagittal image confirms an inferiorly displaced IUD (orange arrow) and an intrauterine pregnancy with gestational sac and embryonic pole (yellow arrows).

Discussion:

Ultrasonography is the first-line imaging method for evaluating common gynecologic complaints such as abnormal vaginal bleeding, amenorrhea, pelvic pain, or mispositioning of an intrauterine device (IUD), due to its low-cost and lack of radiation exposure [1]. The IUD is the most widespread form of reversible contraception in reproductive-age women. On a standard 2D transvaginal ultrasound (TVUS), it appears as a linear echogenic structure with posterior shadowing [1,2]. The arms of a copper IUD are fully echogenic with posterior shadowing (Fig. 1,2) compared to a hormone-releasing IUD, which is echogenic only at the proximal and distal ends [2].

Nearly 11% of the patients with IUDs experience some type of malpositioning which includes expulsion, displacement, embedment, and perforation. When an IUD is partially or completely out of the external cervical os, it is termed expulsion. Embedment is when an IUD penetrates the myometrium but not the serosa, while perforation is when it penetrates both [1,3]. The copper IUD is rotated and inferiorly displaced >3mm in the lower uterine segment and is no longer touching the fundus of the uterus, a likely cause of the pictured intrauterine pregnancy with gestational sac and fetal pole (Figs. 1,2). The risk of intrauterine pregnancy is higher in a copper IUD than in a hormone-releasing IUD due to copper’s decreased efficacy when displaced. According to a case-control study, approximately 64% of patients with displaced copper IUDs became pregnant compared to only 11% of non-pregnant patients in the control group [1,4,5].

If an IUD cannot be visualized on an ultrasound, an abdominal radiograph can be used to evaluate its position due to its radiopacity. A CT/MRI can be used when suspecting uterine or bowel perforation, pelvic abscesses, or other complications of IUD expulsion or migration. Copper and hormone-releasing IUDs are safe up to 3-T MRI, but more investigation is needed for stainless steel IUDs [1,6].

Pregnancies with an IUD are at a heightened risk for preterm delivery, spontaneous abortion, placental abruption, chorioamnionitis, and vaginal bleeding. Removing the IUD earlier in the pregnancy, especially first trimester when its filaments are visible, decreases the risk of miscarriage [7,8].

References:

1. Nowitzki KM, Hoimes ML, Chen B, Zheng LZ, Kim YH. Ultrasonography of intrauterine devices. Ultrasonography. 2015;34(3):183-194. doi:10.14366/usg.15010

2. Boortz HE, Margolis DJ, Ragavendra N, Patel MK, Kadell BM. Migration of intrauterine devices: radiologic findings and implications for patient care. Radiographics. 2012;32(2):335-352.doi:10.1148/rg.322115068

3. Braaten KP, Benson CB, Maurer R, Goldberg AB. Malpositioned intrauterine contraceptive devices: risk factors, outcomes, and future pregnancies. Obstet Gynecol. 2011;118(5):1014-1020. doi:10.1097/AOG.0b013e3182316308

4. Anteby E, Revel A, Ben-Chetrit A, Rosen B, Tadmor O, Yagel S. Intrauterine device failure: relation to its location within the uterine cavity. Obstet Gynecol. 1993;81(1):112-114. PMID: 8416443.

5. Pakarinen P, Luukkainen T. Five years' experience with a small intracervical/intrauterine levonorgestrel-releasing device. Contraception. 2005;72(5):342-5. doi:10.1016/j.contraception.2005.05.013

6. Berger-Kulemann V, Einspieler H, Hachemian N, Prayer D, Trattnig S, Weber M, Ba-Ssalamah A. Magnetic field interactions of copper-containing intrauterine devices in 3.0-Tesla magnetic resonance imaging: in vivo study. Korean J Radiol. 2013;14(3):416-22. doi:10.3348/kjr.2013.14.3.416

7. Kim SK, Romero R, Kusanovic JP, Erez O, Vaisbuch E, Mazaki-Tovi S, Gotsch F, Mittal P, Chaiworapongsa T, Pacora P, Oggé G, Gomez R, Yoon BH, Yeo L, Lamont RF, Hassan SS. The prognosis of pregnancy conceived despite the presence of an intrauterine device (IUD). J Perinat Med. 2010;38(1):45-53. doi:10.1515/jpm.2009.133

8. Schiesser M, Lapaire O, Tercanli S, Holzgreve W. Lost intrauterine devices during pregnancy: maternal and fetal outcome after ultrasound-guided extraction. An analysis of 82 cases. Ultrasound Obstet Gynecol. 2004;23(5):486-489. doi:10.1002/uog.1036

Mounica Chidurala is a medical student at Marian University College of Osteopathic Medicine in Indianapolis, IN. Prior to medical school, she graduated from Oklahoma State University with a Bachelor of Science degree in Chemical Engineering, minor in Chemistry, and an Honors College Degree. She also obtained her Master of Science degree in Chemical Engineering from the University of Oklahoma where she defended her master’s thesis in biofuels and heterogeneous catalysis. She is excited to pursue a career in Diagnostic Radiology with interests in Interventional Radiology or Nuclear Medicine. She is passionate about research and innovation in medicine and hopes to teach/mentor students in the future.

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Kevin M. Rice, MD is the president of Global Radiology CME

Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.

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