Mar 5, 2009 0
Abdominal pain: “But I have an IUD, doctor”
A 22 year old female G6P6 presented with abdominal pain and discomfort for four weeks. Past medical history was significant for three cesarean sections. She had undergone IUD insertion one year ago for purposes of birth control. She took no medicines, and was allergic to penicillin.
Physical Exam:
Gen: WD/WN/WH, mildly anxious
HEENT: NC/AT, PERRLA, EOMI,
CV: RRR, no M/R/G
Lungs: CTA bilaterally
Abd: Soft, NT/ND, no masses, no HSM, mildly TTP at suprapubic abdomen, L>R
Ext: no C/C/E, equal bilateral pedal pulses
Labs:
WBC: 5.6
H/H: 12.6/ 36.0
Platelets: 220
Na: 137
K: 4.2
Cl: 112
HCO3: 24
BUN: 12
Cr: 1.2
While a urine pregnancy test was pending, the physician performed a transabdominal ultrasound:
Figure 1: Longitudinal still shot of the uterus demonstrating an IUP with FHR at 167. Nrml FHR generally ranges from 120-160.
Figure 2: Using the OB presets on the machine allows measurement of the crown rump length and estimates of gestational age.
Figure 3: This transverse view of uterus demonstrates the IUP. Watch for the bright, “T”-shapes object which appears as the operator scans through the uterus in the last 2 seconds of the clip.
Figure 4: The green arrow on this longitudinal view of the uterus demonstrates the presence of the IUD.
Intrauterine devices have until recently been considered a poor choice of birth control for nulliparous women due to a concern for increased rates of PID and subsequent increased risk for ectopic pregnancy. In 1974, the CDC raised questions about the Dalkon Shield, an IUD marketed between 1970 and 1974, and found an excess risk of complicated pregnancies among the Dalkon Shield users compared with users of other IUDs. The manufacturer withdrew the device from the market in 1974. While this device is still more commonly placed in multips, the IUD is now considered safe for all women as a pregnancy prevention device provided there is no increased risk of exposure to STDs. In the United States there are two commercially available IUDs: a copper device which may be left in place for 10 years, and a hormonal device which must be replaced every five years. While the presence of an IUD alone does not confer an increased risk of ectopic pregnancy, pregnancies which occur with an IUD in place (failure rate < 1% in first year) are more likely to be ectopic. The presence of an IUD with an intrauterine pregnancy is usually grounds for removal as the presence of the IUD may cause complications with the developing pregnancy.
Recommended reading: Nagamani P, Graham D, Levine D. Imaging of intrauterine contraceptive devices. Journal of ultrasound medicine, 2007. 26: 1389-1401.
Special thanks to Dr. Kerri Layman for her scanning skills and excellent clinical care!
