Hysteroscopic IUD Removal in Patients with Prior Bradycardia Episodes

Patient Eligibility

The American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) guidelines indicate that a remote, isolated bradycardia episode with a subsequent normal cardiac work‑up and a current asymptomatic status with a normal ECG does not constitute a contraindication to hysteroscopic IUD removal. 1

According to the ACC/AHA/HRS bradycardia guidelines, “symptomatic bradycardia” is defined as a documented bradyarrhythmia that directly causes syncope, presyncope, dizziness, heart‑failure symptoms, or confusional states due to cerebral hypoperfusion. 1
In a patient whose prior bradycardia episode was distant, the cardiology evaluation was unremarkable, and the present ECG is normal, the criteria for active symptomatic bradycardia are not met; therefore, no additional cardiac intervention (e.g., pacemaker evaluation) is required before hysteroscopic IUD removal. 1
The ACC/AHA/HRS emphasizes that a thorough history, physical examination, and a baseline ECG constitute the core of risk assessment for bradyarrhythmia‑related procedural risk. 1

The BJOG outpatient hysteroscopy guidelines require the clinical team to promptly alert the hysteroscopist if the patient appears to be experiencing a vasovagal episode and is unable to communicate, allowing immediate cessation of the procedure. 2
Patients should receive counseling that uterine instrumentation may cause cramping and pain, and that the procedure will be stopped if the discomfort becomes intolerable. 2

Informed consent must explicitly document discussion of vasovagal risk and available pain‑management strategies prior to hysteroscopic IUD removal. 2
Continuous monitoring for vasovagal signs—such as pallor, diaphoresis, nausea, or bradycardia—and immediate termination of the procedure upon their appearance are mandated by the BJOG guidelines. 2