Management of a Malpositioned IUD in the Emergency Room Setting

Assessment and Decision Algorithm

A malpositioned IUD that is low-lying and potentially extending into the cervix should be removed in the emergency room without requiring an updated ultrasound, especially when associated with persistent pelvic pain, as recommended by the Centers for Disease Control and Prevention (CDC) 1, 2
The patient, a young female with worsening pelvic pain since IUD placement, is at risk for complications related to IUD positioning, with previous ultrasound showing the IUD significantly low-lying, located in the lower half of the endometrium, and at least abutting or minimally extending into the cervix 1, 2

The CDC guidelines state that malpositioned IUDs should be removed as soon as possible when strings are visible or can be safely retrieved, with a high rate of recovery for clinical symptoms among women who have the IUD removed compared to those who do not 1, 2
The procedure for removal involves gently pulling on the strings if visible, with no additional imaging typically required before removal when previous imaging already confirms malposition and the patient has persistent symptoms 2

The patient should be advised to return promptly if she experiences heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever, and discuss alternative contraceptive options if desired, with consideration for scheduling follow-up to ensure resolution of symptoms 2
If strings are not visible and the IUD cannot be safely retrieved, referral for ultrasound-guided removal would be appropriate, and if there are signs of infection, appropriate antibiotic treatment should be initiated 2, 3