IUD issues

Difficult insertion:

30 yo, G2/T 2, P2, A, 0, L 2, cesarean section for both births presents to WHNP after two unsuccessful attempts at IUD placement. Pt relates history of abnormal PAP smears, laser cone and cold knife procedures, suspected stenoic os. The patient underwent two attempts at IUD placement via two different clinicians both of which were unsuccessful despite attempts at sequential dilation. Management options of the patient include attempted placement in the clinic post intravaginal Cytotech 200mg x 2, or placement in outpatient surgery. Patient elects outpatient surgery option due to concerns about further discomforts expected without anesthesia.

Post insertion cramping and bleeding:

35 you G3/T 2, P 1, A 0, L3. Patient presents 6 days after initial IUD placement with complaints of bleeding (now stopped) and abdominal pain and cramping which is rated by the patient at 7/10. The patient denies fever chills, other signs/symptoms of infection. To this point abdominal pain has not been responsive to NSAID therapy. On physical exam the vault and os are free of blood. Strings to the copper IUD are evident at approximately 3 cm in length. There is no cervical motion tenderness, but the patient’s abdomen is tender to palpation. An ultrasound was performed that demonstrated the presence of the IUD inside the uterus. The patient was discharged with a 5 day supply of Percocet and instructed again concerning signs and symptoms of infection. The patient was also instructed to schedule a routine appointment in approximately 3 months.

Observations:

IUD placement is a common procedure but not best for every patient. Based on the first patient’s past history of Laser cone and cold knife procedures primary care providers would probably have be justified in referring the patient to the WHNP or obstetrician. Additionally, it is necessary to educate patient thoroughly concerning what symptoms to expect post insertion. Bleeding and cramping may persist for some time post insertion and patients need a warning in advance while at the same time being instructed concerning signs of complication e.g. infection, insertion though of the IUD through the wall of the uterus.