Comparison of C-reactive protein levels in pregnancies with retained and removed intrauterine device

Pregnancy with retained intrauterine device: national-level assessment of characteristics and outcomes

BACKGROUND

Although intrauterine devices provide effective contraceptive protection, unintentional pregnancy can occur. Previous studies have shown that a retained intrauterine device during pregnancy is associated with adverse pregnancy outcomes but there is a paucity of nationwide data and analysis.

OBJECTIVE

This study aimed to describe characteristics and outcomes of pregnancies with a retained intrauterine device.

STUDY DESIGN

This serial cross-sectional study used data from the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population comprised 18,067,310 hospital deliveries for national estimates from January 2016 to December 2020. The exposure was retained intrauterine device status, identified by the World Health Organization's International Classification of Diseases, Tenth Revision, code O26.3. The co-primary outcome measures were incidence rate, clinical and pregnancy characteristics, and delivery outcome of patients with a retained intrauterine device. To assess the pregnancy characteristics and delivery outcomes, an inverse probability of treatment weighting cohort was created to mitigate the prepregnant confounders for a retain intrauterine device.

RESULTS

A retained intrauterine device was reported in 1 in 8307 hospital deliveries (12.0 per 100,000). In a multivariable analysis, Hispanic individuals, grand multiparity, obesity, alcohol use, and a previous uterine scar were patient characteristics associated with a retained intrauterine device (all P<.05). Current pregnancy characteristics associated with a retained intrauterine device included preterm premature rupture of membrane (9.2% vs 2.7%; adjusted odds ratio, 3.15; 95% confidence interval, 2.41-4.12), fetal malpresentation (10.9% vs 7.2%; adjusted odds ratio, 1.47; 95% confidence interval, 1.15-1.88), fetal anomaly (2.2% vs 1.1%; adjusted odds ratio, 1.71; 95% confidence interval, 1.03-2.85), intrauterine fetal demise (2.6% vs 0.8%; adjusted odds ratio, 2.21; 95% confidence interval, 1.37-3.57), placenta malformation (1.8% vs 0.8%; adjusted odds ratio, 2.12; 95% confidence interval, 1.20-3.76), placenta abruption (4.7% vs 1.1%; adjusted odds ratio, 3.24; 95% confidence interval, 2.25-4.66), and placenta accreta spectrum (0.7% vs 0.1%; adjusted odds ratio, 4.82; 95% confidence interval, 1.99-11.65). Delivery characteristics associated with a retained intrauterine device included previable loss at <22 weeks' gestation (3.4% vs 0.3%; adjusted odds ratio, 5.49; 95% confidence interval, 3.30-9.15) and periviable delivery at 22 to 25 weeks' gestation (3.1% vs 0.5%; adjusted odds ratio, 2.81; 95% confidence interval, 1.63-4.86). Patients in the retained intrauterine device group were more likely to have a diagnosis of retained placenta at delivery (2.5% vs 0.4%; adjusted odds ratio, 4.45; 95% confidence interval, 2.70-7.36) and to undergo manual placental removal (3.2% vs 0.6%; adjusted odds ratio, 4.81; 95% confidence interval, 3.11-7.44).

CONCLUSION

This nationwide analysis confirmed that pregnancy with a retained intrauterine device is uncommon, but these pregnancies may be associated with high-risk pregnancy characteristics and outcomes.

Pregnancy outcomes with a copper 380 mm2 intrauterine device in place: A retrospective cohort study in Turkey, 2011-2021

OBJECTIVES

To investigate pregnancy outcomes in patients with pregnancies with a copper 380 mm2 intrauterine device (IUD) in situ at conception.

STUDY DESIGN

In this retrospective study, we identified patients with pregnancies with a copper 380 mm2 IUD between 2011 and 2021 from the electronic health record system. According to their initial diagnosis, we classified the patients as having nonviable intrauterine pregnancies (IUPs), viable IUPs, or ectopic pregnancies. Among the viable IUPs, we divided the ongoing pregnancies into two subgroups as IUD-removed and IUD-retained. We compared the pregnancy loss (miscarriage before 22 weeks) rates and adverse pregnancy outcomes (at least one of preterm birth, preterm premature rupture of membranes, chorioamnionitis, placental abruption, or postpartum hemorrhage) of IUD-removed and IUD-retained pregnancies.

RESULTS

We identified a total of 246 patients with pregnancies with an IUD. We excluded six (2.4%) patients without follow-up data and seven (2.8%) patients with levonorgestrel-IUD and included the remaining 233 (44 [18.9%] ectopic pregnancy, 31 [13.3%] nonviable IUP, and 158 [67.5%] viable IUP) patients. Among the 158 women with viable IUP, 21 (13.3%) underwent abortion, leaving 137 (86.7%) who elected to continue the pregnancy. A total of 54 (39.4%) patients with ongoing pregnancy had the IUD removed. We found a lower rate of pregnancy loss among those who underwent removal (18/54 [33.3%]) compared to those with a retained IUD (51/83 [61.4%], p < 0.001). After accounting for pregnancy loss, adverse pregnancy outcomes remained increased in the IUD-retained group (17/32 [53.1%]) compared to the IUD-removed group (10/36 [27.8%], p = 0.03).

CONCLUSIONS

Pregnancy in the setting of a copper 380 mm2 IUD is high risk. Our results demonstrate that pregnancy outcomes improve by removal of the copper 380 mm2 IUD.

IMPLICATIONS

Prior studies have suggested that the removal of the IUD improves outcomes, but all have limitations. Our results from a very large series with care in a single institution provide contemporary evidence to support copper 380 mm2 IUD removal to reduce the risk of both early pregnancy loss and later adverse outcomes.

Outpatient hysteroscopic removal of intrauterine devices in early pregnancy: feasibility and outcomes

OBJECTIVE

To describe our experience with outpatient hysteroscopy for removal of intrauterine devices (IUDs) in pregnant patients, along with the pregnancy-related outcomes.

DESIGN

Retrospectively and prospectively collected data between January 2015 and April 2021.

SETTING

Hysteroscopic outpatient clinic (See and Treat Clinic) at a university affiliated, tertiary medical center.

PATIENT(S)

Forty-one patients with an inadvertent but desired pregnancy up to 12 weeks + 6 days gestational age with an IUD in situ, with documented failed attempts of IUD removal.

INTERVENTION(S)

After ultrasonographic confirmation of IUD location, gestational age, and viability, a small-caliber hysteroscope was introduced via a vaginoscopic approach. The uterus was distended using 0.9% normal saline until a clear view was achieved. On visualization, the IUD was grasped by its strings, tail, or lateral arm using a semirigid hysteroscopic grasper. Oral antibiotic prophylaxis was prescribed in all cases.

MAIN OUTCOME MEASURE(S)

The primary outcome of interest was term delivery, from 37 weeks of gestation. Secondary outcomes included patient-reported tolerability and satisfaction, and procedure-related and pregnancy related complications.

RESULT(S)

The procedure was completed successfully in all 41 patients. Thirty-three patients continued their pregnancies, resulting in 32 full-term singleton deliveries and 1 singleton preterm delivery at 33 + 4 weeks. Median gestational age at delivery was 39 weeks, with a median birthweight of 3,450 grams. Eight patients (19.5%) miscarried, 4 of these within a week of the procedure.

CONCLUSION(S)

In cases of desired pregnancy with an IUD, outpatient hysteroscopic removal of the IUD is a safe and effective management option. Broader uptake of outpatient hysteroscopy and development of hysteroscopic skills will allow more clinicians to offer patients this effective solution.

History of IUD utilization and the risk of preterm birth: a cohort study

OBJECTIVE

To explore whether a history of IUD use could increase the risk of subsequent preterm birth.

METHODS

We performed a cohort study of 24,496 multipara aged 19-48 years in Dongguan City. Each subject was followed up for 1 year, and 12,508 women obtained pregnancy outcomes. They were divided into 2 groups: 2130 subjects with IUD use history (exposure group), and 10,378 subjects without IUD use history (control group). The exposure group will remove the IUD before pregnancy. The primary outcomes were preterm birth (less than 37 weeks of gestation) and early preterm birth (less than 34 weeks of gestation). We used log-binomial regression to estimate adjusted risk ratios (aRR) of preterm birth and early preterm birth for women with a history of IUD. According to the different adjusted baseline data, three regression models were established, and the propensity matching score method was also used to verify the stability of the results.

RESULTS

The delivery rate of women with IUD history was 51.24%, and that of women without IUD was 51.03% (² = 0.063, P = 0.802). Six hundred and eighty-five women had preterm birth (5.48%, 95% CI 5.08-5.88) and 133 women had early preterm birth (1.06%, 95% CI 0.83-1.24). Compared with the control group, the incidence of preterm birth and early preterm birth in the exposure group were significantly lower. The results are stable in all four models. Subgroup analysis also supported the result. This study also found that the longer the women used IUD before pregnancy, the younger the age of first using IUD, and the shorter the time from condom removal to pregnancy, the lower the incidence of premature birth.

CONCLUSION

The women with a history of IUD use are less likely to have premature birth after the IUD is removed. More prospective studies are needed to confirm it.

The diagnostic performance of the beta-glucan assay in the detection of intra-amniotic infection with Candida species

INTRODUCTION

A bioassay based on the detection of beta-glucan, a constituent of the cell wall of fungi, has been successfully used to diagnose fungal infections in a variety of biological fluids but not yet in the amniotic fluid.

OBJECTIVE

To determine the diagnostic performance of a beta-glucan bioassay in the detection of Candida species in the amniotic fluid of women who either did or did not have an intrauterine contraceptive device (IUD) in place during an episode of spontaneous preterm parturition.

METHODS

The study population comprised women who had a singleton pregnancy without congenital or chromosomal abnormalities, who experienced preterm labor or preterm prelabor rupture of the fetal membranes, and who underwent a transabdominal amniocentesis for clinical indications. Samples of amniotic fluid were cultured for aerobic and anaerobic bacteria, genital mycoplasmas, and Candida species, and assayed for beta-glucan, using the (1→3)-beta-d-glucan-specific Limulus amebocyte lysate test (beta-glucan assay) in all cases. Amniotic fluid interleukin (IL)-6 assay results were also available for all cases. The beta-glucan assay takes about 1 hour to run: a concentration >80 pg/mL was considered positive for fungi. Sterile intra-amniotic inflammation of the amniotic cavity was defined by the presence of an amniotic fluid IL-6 concentration ≥2.6 ng/mL and a negative amniotic fluid culture.

RESULTS

(1) One hundred ninety-seven (197) women met the study criteria, of whom 58 (29.4%) had an IUD in place; (2) 20 (10.2%) women had a culture of proven intra-amniotic Candida species-related infection, 19 of whom had a positive beta-glucan assay [sensitivity, 95% (19/20; 95% confidence interval (CI): 75.1-99.9%)]; and (3) the specificity of the beta-glucan assay was 75.1% [133/177; 95% CI: 68.1-99.9%]. It was affected by the presence of nonfungal intra-amniotic infections and an IUD, but not by the presence of sterile intra-amniotic inflammation, and there was a significant interaction between the presence of an IUD and nonfungal intra-amniotic infections (estimated for the interaction effect = 2.1923, p value =.026). The assay's specificity was reduced when nonfungal intra-amniotic infections were diagnosed but only in women who did not have an IUD. Among women without an IUD, the assay's specificity was 91.4% (117/128); it was 93% (106/114) for those without intra-amniotic infection, and 78.6% (11/14) for those with a nonfungal intra-amniotic infection; the difference was not significant (p = .09). Among women with an IUD, the assay's specificity was 32.7% (16/49); 42.9% (9/21) for those with a nonfungal intra-amniotic infection; and 25% (7/28) for those without intra-amniotic infection; and the difference was significant (p = .03).

CONCLUSIONS

The beta-glucan assay is a sensitive, rapid, point-of-care test used to diagnose intra-amniotic Candida species-related infection, and it has a high specificity in pregnant women who did not have an IUD in place.

Pregnant with a perforated levonorgestrel intrauterine system and visible threads at the cervical os

We present a case in which a patient presented with a pregnancy of unknown location and normally rising human chorionic gonadotropin (hCG) levels but with a levonorgestrel intrauterine device (LNG-IUD) present. The LNG-IUD had been placed 4.5 years ago. Although unintended, this pregnancy was desired. Strings were clearly visible and initial 2D ultrasound suggested intrauterine location of the LNG-IUD. The LNG-IUD could not be removed however. The patient was managed expectantly with close follow-up, serial beta-hCGs and serial ultrasounds until definitive diagnosis of the location of the pregnancy. The patient was diagnosed with an ectopic pregnancy and during laparoscopy the body of the IUD was noted in the posterior cul-de-sac. When patients present with multiple competing clinical problems it is important to look at the patient as a whole, taking into account their desires, in order to construct a cohesive management plan.

Transabdominal collection of amniotic fluid "sludge" and identification of Candida albicans intra-amniotic infection

A G3P2 patient who conceived while using an intrauterine contraceptive device (IUD) presented at 20 weeks of gestation with mild irregular uterine contractions and vaginal bleeding. Sonographic examination at admission showed the presence of dense amniotic fluid "sludge" and a long sonographic uterine cervix (42 mm). To assess the microbiologic significance of amniotic fluid "sludge", we performed a transabdominal amniocentesis. The procedure was performed under real-time ultrasound, and fluid resembling pus at gross examination was noted. Rapid amniotic fluid analysis showed the presence of a high white blood cell count and structures resembling hyphae. Amniotic fluid cultures were positive for Candida albicans. Treatment was begun with broad-spectrum antibiotics, including Fluconazole, upon the visualization of pus in the "sludge" material because of the presence of hyphae in the Gram stain. Despite treatment, the patient went into spontaneous preterm labor and delivered five days after admission. Placental examination revealed acute fungal histologic chorioamnionitis and funisitis. This represents the first report of transabdominal collection and analysis of amniotic fluid "sludge" and the microbiologic detection of Candida albicans in this material. This report provides evidence that transabdominal retrieval of "sludge" is possible and may be of significant value for patient management and selection of antimicrobial agents.

Saline Hysteroscopy for Removal of Retained Intrauterine Contraceptive Devices in Early Pregnancy

OBJECTIVE

Pregnancies complicated by a retained intrauterine device (IUD) are at increased risk for adverse outcomes such as miscarriage and preterm labour. There is limited evidence to guide the management of retained IUDs in pregnancy when the strings are not visible at the external cervical os. We describe a method for IUD retrieval in such cases.

METHODS

Twenty-six patients underwent saline hysteroscopy with or without concurrent ultrasound guidance for retrieval of a retained IUD in early pregnancy between 2002 and 2015. We retrospectively evaluated procedural and pregnancy-related outcomes in this case series.

RESULTS

The average gestational age at the time of the procedure was 11+0 weeks. Successful IUD retrieval occurred in 22 of 26 cases (84.6%). There were 23 live births, including 20 full term and three preterm deliveries. The average gestational age at delivery was 38+4 weeks. There was one miscarriage and one elective termination of pregnancy following the procedure. There were no complications directly related to the procedure.

CONCLUSION

Saline hysteroscopy is a safe and effective method for retrieval of a retained IUD in early pregnancy. It appears that concurrent ultrasound guidance can facilitate IUD localization, but more cases are needed to confirm this. Pregnancy outcomes after IUD retrieval were favourable, with a low rate of miscarriage and preterm labour.