Chapter 4. IUD Malposition and Management

IUD MALPOSITION

Ultrasound imaging of IUDs has become increasingly common in clinical practice. It is now accepted as the initial step in evaluation and management of malpositioned IUDs.^1,2

The most critical concern for identifying a malpositioned IUD is the risk of undesired pregnancy.² . Other considerations are disruptive pelvic symptoms including pain and bleeding.

One of the issues related to IUD imaging has been lack of consistent terminology for describing IUD position. ACOG (American College of Obstetricians and Gynecologists) suggests that terminology is confusing.³ A proposed classification system has been recommended to provide clearer definitions of types of malpositions and degrees of expulsion. These will be reviewed in this chapter.

Incidence

The overall incidence of IUD malposition and expulsion is relatively high, but there are varying consequences of these related to degree of the malposition. For women who are asymptomatic, many are unaware of the malposition unless incidental imaging identifies the displacement.

General numbers

The cumulative IUD malposition rate is approximately 19%.⁴ Among those with no uterine abnormalities and good uterine position, the risk was not zero, but much lower. See Table____ listing Odds Ratios (OR) for this.⁴

A study by Gerk et al showed that 18.9% of persons undergoing pelvic ultrasound for any indication showed a malposition rate between 10 and 25%.⁴

Stats: IUD malposition has been reported to occur after 10-25% of insertions among cohorts.⁵

Presenting symptoms

Typical symptoms of IUD malposition include bleeding, pain, and missing IUD strings at time of presentation. There is a significant likelihood of a malpositioned IUD in these women.

Location

Of all malpositioned IUDs discovered, most (73.1%) were noted to be in the lower uterine segment or cervix.⁶

Timing of placement

IUD malposition was more commonly seen within 8 weeks of placement – 16.6 %. Those requiring removal occurred in 8.8%.^2, ⁷

One study showed that if malposition occurs, 33% occur within the first 6 wks after insertion.

Those whose IUDs were inserted in the immediate postpartum period (right after placental delivery) or early post-abortion period were more likely to experience expulsion.²

Uterine shape and size

Incidence of malposition associated with All uterine anomalies, including septate and bicornuate uteri and fibroids, is 31.9%.⁴

Retroflexed uterine positions and all uterine malformations are associated with higher incidence of malpositioned intrauterine devices. (7.6% vs 1.8% in controls).⁴

Fibroids

The presence and number of fibroids (specifically submucosal fibroids) were positively associated with intrauterine device malposition.⁴ Those with a greater total number of fibroids had malposition rate of 3.7%.⁴

Uterine Cavity Size

Larger: 37 mm and larger transverse diameter (width) of the uterine cavity in the coronal section had a higher risk for displacement.²

Smaller: Women with small uterine cavity length were reported to have higher malposition rates. For these women, a smaller IUD size is recommended

IUD-endometrium distance (Distance from device tip to endometrium) more than 7.5 mm were much more likely to experience a displaced IUD.²

Expulsion incidence

The copper T have a 6% expulsion rate in the first year of use.⁷

The expulsion rate was more than four times higher for women with a uterine cavity length longer than 45 mm.²

Women with a thicker endometrium had higher expulsion rates. ²

In a review of 2138 women with IUDs, the overall rates of expulsion were:

— 1% at 1 month

—4% at 12 months

— 6% after follow-up (average of 37 months)²

Associated conditions/risk factors

General risk factors ^2,7

Age <20

Morbid obesity

Copper IUD

HMB

Dysmenorrhea

Anatomic distortion of the cavity

Uterine position

Prior uterine window or rupture (C-section scar defect)

Healthcare professionals’ experience

Table 1. Additional variables predicting malpositioned IUD:⁴

Variable	Odds Ratio (OR)
Anterior midline position	0.33
No uterine anomaly	0.59
Vaginal bleeding	2.25
Pain	2.85
Missing IUD string	3.58
IUD placement check*	3.94

*IUD placement check: ultrasound evaluation ordered due to difficult insertion or concern for improper IUD placement, with or without symptoms

Uterine Dimensions and Structure

Women with small uterine cavity distances were reported to have higher malposition. Cavity widths less than 41.5 mm may be recommended smaller size IUD. ^1,2

Shorter uterine length was found to a predictor for menorrhagia in pts with a copper IUD, with menorrhagia being a risk for incidence of malposition. ¹

Conversely, a longer uterine length (greater than 45 mm²presents a higher risk for IUD expulsion.

Figure 1. Illustration of mean uterine dimensions of nulliparous and multiparous women.

Figure (below) is an image of a copper T IUD placed in a nulliparous woman. She presented with dysmenorrhea, pain with intercourse, and pain with bowel movements and exercise. Notice in this image that the lower tip of the IUD is impinging on the internal os, so it was presumed that the tip was exerting pressure on that area causing the pain with cervical flexion. The IUD was removed and replaced with a smaller device (LNG-IUS) and her symptoms resolved.

Figure 2. Image of nulliparous woman with copper T IUD.

Figure 3. Image of nulliparous woman with copper T IUD - sagittal and transverse views.

NOTE: Do not presume that a multiparous uterus is larger and can accommodate a larger IUD. There are cases where a multiparous uterus is smaller than the average nulliparous uterus.

Fibroids

Although uterine fibroids can increase malposition, this is not always the case. In fact, many women with fibroids and dysmenorrhea or menorrhagia find LNG-IUS devices helpful for managing their fibroid-related symptoms.

As previously mentioned, Gerkowicz⁴ found that the incidence of fibroids n both normally placed and malpositioned IUDs, comparable . However, those identified as having malposiitoned IUD’s had higher number of fibroids, and were the only women to have submucosal fibroids. Fibroid size was not statistically significant, but fibroid location (subserosal) was correlated with malpositioned IUDs.

The presenting symptom of HMB or abnormal bleeding was increased in women who had fibroids, and subsequent imaging revealed a higher incidence of malpositioned IUD.⁴

Our study found that women with an IUD-endometrium distance more than 7.5 mm were much more likely to experience a displaced IUD (sensitivity 81%, specificity 37.5%, 95% CI 0.51–0.7) women with IUDs with 7 mm and more distance from the endometrium should be alerted about displacement. Based on our data, uterus width less than 41.5 mm .²

Factors studied were uterine position, uterine flexion, and CS scar defect (CSD) size. Among those, the group with retroflexed ut and a large CSD more likely to have a malpositioned uterus.⁵

Uterine Forces

Cintesun² reported that women with dysmenorrhea demonstrated a downward movement of IUDs inside the uterine cavity and it was previously known that this movement might be related to uterine contractions.

Patients experiencing pelvic cramping with IUD are more susceptible for IUD expulsion as the downward movement of IUD is more prominent in these patients.¹

If an initial ultrasound is performed immediately after insertion, ideally the IUD tip can be seen just below the inner uterine fundus. However, even if the IUD appears to be lower initially, often the intrauterine forces can move the IUD higher into the uterus (as seen in Figure 4 (below, lower illustration).

Figure 4. Illustration describing potential direction of uterine forces with an IUD.

Adenomyosis

Suspected adenomyosis increases the likelihood of IUD malposition. (OR of 3.04).⁸This is potentially due to the distortion of the endometrial cavity, as well as the increased uterine cramping/contraction and bleeding associated with adenomyosis.

Figure 5 (below) shows the anterior “bulging” of the uterus and the diminished view of the upper portion of the endometrium.

Figure 5. Sagittal image of adenomyosis sonographic characterisics

C/Section Scar Defects (CSD)

Findings: Prior CD was significantly associated with increased risk of malposition. The larger the CSD the higher risk for malposition as well as perforation through the scar.⁵

Figure 6. Transabdominal image showing a CSD.

Figure 7. Transvaginal image showing a CSD that is distorting the juncture of the endocervix and endometrium.

Figure 8. Transvaginal images of two uteri with CSDs (highlighted with the white arrows)

Symptoms of Malposition

Common symptoms in women who present with IUD-related complications include: uterine pain, abnormal bleeding, feeling the device at the cervical os, lengthening of strings or inability to feel strings, pain with intercourse, or pain with uterine flexion (associated with bowel bladder and exercise)

Signs of Malposition

NON-VISUALIZED STRINGS

Some asymptomatic women present with inability to feel the IUD strings. For these women the concern is that the IUD has expelled or has become perforated and is no longer protective for pregnancy.

The other situation is where a woman presents for a routine gyn exam or for a timely removal/replacement of the IUD and the strings are not visible to the clinician.

ACOG³ Recommendations for non-visualized IUD strings are listed later in this chapter in the section entitled Management.

Types of Malpositions

Most common malposition: low lying, with higher incidence in copper T devices. LNG-IUS (particularly the 52-mg device) had the highest incidence of correct placement.⁴

Definition of malposition⁹

The malpositioned IUD can be considered a spectrum of abnormal positioning (Table 1). At one end of the spectrum is complete ‘expulsion’ through the external cervical os. At the other end is complete ‘perforation’ through the uterine serosa. ⁹

MALPOSITION: The IUD can be partially expelled, rotated, embedded in myometrium or perforating the uterine serosa. ^5,8

Most malpositioned devices (73.1%) were noted to be in the lower uterine segment or cervix.⁶

Types and degrees of malpositioned IUDs

Figure 9 below represents a chart developed by Tal et al¹⁰ to classify types and degrees of IUD malposition.

Figure 9 Chart illustrating types and degrees of IUD malposition¹⁰

Examples using the Tal chart above:

An IUD that has dropped below the internal os but is not embedded would be classified as B-0 (see chart).
An IUD that is fundal but the arms are extended downward, and appear to be embedded, is classified as A-3 (see chart)

Additional Descriptions of Malposition

Displacement : Rotation or inferior positioning in the lower uterine segment or cervix

Displacement refers to any IUD that is rotated from the normal transverse position or located away from the fundus and within the lower uterine segment or cervix (Fig. 5). Early studies defined displacement as a distance of more than 3 mm between the IUD and the uterine fundus, which was initially thought to be associated with a high risk of expulsion. However, more recent studies have shown that a majority of low IUDs move to a fundal position within a few months after insertion even if they appear low initially. The current expectation is that the IUD should be within 5-7 mm of the fundus.

Non-fundal IUD (ACOG)

A large retrospective study by Fadugla et al (1)was conducted, studying the distance between the tip of the copper IUD and the fundus, myometrium and endometrium, to evaluate the displacement of the IUD. The relationship between the symptoms and IUD displacement diagnosed by ultrasonographic examination were investigated.¹

Findings concluded that women with an IUD-endometrium distance more than 7.5 mm were significantly more likely to experience a displaced IUD , suggesting that women with this finding should be cautioned about displacement.

The distances between the tip of the IUD and the endometrium, myometrium and the uterine fundus, were statistically and significantly longer in patients who experienced pelvic cramping at 3rd month, showing a downward movement of the IUD

Figure 10. Two images of IUDs that are non-fundal

Figure 11. Image of a transvaginal sagittal view of a non-fundal IUD

Figure 12. Image of a transvaginal sagittal view of a non-fundal IUD that is located in the cervix (white arrow)

Figure 13. Image of a transvaginal sagittal view of a non-fundal IUD that is partially in the cervix. Note the thickened endometrium above the IUD tip.

Figure 14. Two transvaginal images of IUDs located in the cervix

Embedment: Penetration of the myometrium of either the stem or arm, without extension through the Embedment

Embedment refers to the penetration of the myometrium by either the arm or stem of the IUD without extension through the serosa. Figure 15 below is an image of an IUD fully embedded into the posterior lower uterine segment and myometrium. Note that it does not penetrate the posterior serosa, but it is creating a small bulge where it impinges.

Figure 15 a . Transvaginal image of an IUD stem embedded in the posterior myometrium

Figure 15.b Transvaginal image of and IUD stem embedded into the anterior myometrium

Perforation

The perforated IUD may penetrate through the serosa, either partially (Fig. 11) or completely with migration into the intraperitoneal cavity (Fig. 12). Perforation can occur at the time of insertion, but not exclusively. Perforation through the serosa occurs in one to two cases per 1,000 insertions and is more often seen with inexperienced operators, early postpartum placement, breastfeeding women, women with either few prior pregnancies or multiple miscarriages, or extreme flexion of uterus (ante or retro).⁹

Significant injury is unlikely and management includes laparoscopic removal.³

Figure 16. Transvaginal image of an IUD stem that is outside and posterior to the uterus

Fracture of IUD

A fractured IUD is fairly uncommon, but it can be difficult to assess with ultrasound. Care must be taken to ascertain what is a piece of the IUD and what could be something else (such as calcifications). Knowing the dimensions of IUDs is helpful for measuring what is seen to compare with the typical length of the IUD stem.

Figure 17. Image of an IUD that has fractured and is seen in 2 pieces..

MANAGEMENT

Management of IUD complications depends on a number of factors, and guidelines have been published by a several ob/gyn authorities for recommendations such as ACOG³ and the CDC (Centers for Disease Control)¹¹

Step 1. Rule out pregnancy

The first evaluation to perform is a pregnancy test. If the test is positive, then an ectopic pregnancy must be excluded.

Step 2. Imaging

The next step is typically imaging assessment, starting with ultrasound. A POCUS is the first line in many practices, however, if there is any question about malposition, a 3-D ultrasound should be performed to evaluate the precise position of the IUD arms.

Once the IUD malposition is identified, then further management requires an individualized approach.

General recommendations by Doulaveris et al:⁵

Conclusion: Providers who place an IUD may consider using ultrasonography to guide the placement and/or confirm the proper location of the IUD in persons with a prior history of cesarean delivery, retroflexed uterus, large CSD, and new onset of pelvic pain.

Reasons to remove and replace IUD

A copper IUD is the most likely to cause decreased contraceptive efficacy if it is not in the fundal portion of the uterus. Copper IUDs noted to be malpositioned should be removed and replaced.

The LNG-IUS has a different mechanism of action, and the local effect of the levonorgestrel is considered adequate for contraception even if the device is not at the fundus.⁶ If the woman is continuing to experience oligomenorrhea or amenorrhea, and is otherwise asymptomatic, it is an indication that the levonorgestrel is continuing to provide contraceptive protection.

NOTE: Having a malpositioned IUD removed or expelled is NOT a contraindication to reinsertion of a new device; however, the risk of expulsion of the second device is higher.

Non-visualized strings

ACOG³

The American College of Obstetricians and Gynecologists’ recommendations for nonvisualized IUD strings:

Pregnancy should be excluded.
POCUS can be performed to confirm that the IUD is in the endometrium
If POCUS fails to identify the IUD, a backup method of contraception and emergency oral contraceptives (if appropriate) should be recommended until further imaging confirms the IUD location.
Figure 18. Decision Tree for management of non-visualized IUD strings.

IUD Strings Are Not Visible and Cannot Be Easily or Safely Retrieved

If ultrasonography is available and determines that the IUD is above the internal os, retrieval may be difficult. Referral for expert removal may be needed, especially if the IUD is a LNG-IUS and has expired, requiring replacement,

If the IUD cannot be located, it might have been expelled or have perforated the uterine wall.

If ultrasound is not possible or available, or the IUD is determined by ultrasound to be inside the uterus, the woman should be advised to seek care promptly if she has heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever.

Non-fundal IUD

Non-fundal IUDs were described earlier in this chapter. ACOG³ has a decision tree (below, Figure ) for considerations in managing a nonfundal device.

Management of the non-fundal IUD depends on the position of the device and the woman’s symptoms. An IUD located in the cervix is considered to be partially expelled. Since this increases the risk of complete expulsion, the IUD should be removed (and replaced if the patient desires). If the woman is asymptomatic and the IUD is above the internal os, it may be preferable to leave the IUD as it is, since removal of the IUD is more likely to lead to pregnancy.

Management of a low-lying IUD is less clear – shared decision making is needed.

1. If asymptomatic and iud is above int os, it is ok to leave in.

2. Many IUDs that are non-fundal shortly after insertion move upward within 3 months due to upward-directing uterine forces (see Figure 4 (in uterine forces section)

Figure 19. Decision Tree for non-fundal IUD

IUD and Pregnancy

If a woman becomes pregnant with an IUD in place, the IUD should be removed if strings are visible or if the IUD is within the cervix (retrievable)³

• Evaluate for possible ectopic pregnancy.

• Advise the patient that they have an increased risk for spontaneous abortion (including septic abortion that might be life threatening) and for preterm delivery if the IUD is left in place. The removal of the IUD reduces these risks but might not decrease the risk to the baseline level of a pregnancy without an IUD.

If the patient does not want to continue the pregnancy, counsel them about options.

If the patient wants to continue the pregnancy, advise them to seek care promptly if they have heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever

Figure 20. Decision Tree for positive pregnancy test with IUD in place.

Removal of IUD

Malpositioned IUDs were more likely to be removed and removed sooner than normally positioned IUDs. Most IUDs, even IUDs labeled as partially perforated or embedded, were removed by a generalist obstetrician and gynecologist, using ring forceps, on first attempt. Ultrasound findings of IUD malposition are not associated with difficult IUD removal.¹²

Should a malpositioned IUD always be removed?

A study by Braaten et al (6) raises questions about the commonly held belief that all malpositioned IUDs should be removed. They demonstrated that after removal, the IUD was not immediately replaced, which increased pregnancy rates.⁶

Asymptomatic low-lying IUDs (those above the internal cervical os) present a particular challenge since there is no clear evidence for their contraceptive effectiveness. The exception to this is the copper IUD which is most effective when in the fundal portion of the uterus. So a copper T device should be removed if malpositioned because of the increased risk of contraceptive failure.

In comparison, a malpositioned LNG-IUS may be left in place if located in the lower uterine segment, as the local effect of the levonorgestrel is likely continuing to be absorbed, providing contraceptive benefit. Rather than being expelled, most low-lying IUDs eventually to a fundal position due to uterine forces. ¹³

Many IUDs, even those that appear embedded, can be removed in the office by grasping the strings with a clamp and applying traction. If removal is unsuccessful with moderate traction or if the strings are not visible, the next step is either ultrasound guided removal or hysteroscopic removal.³

RECOMMENDED POST-INSERTION FOLLOW UP (MMWR)

Despite data presented earlier in the chapter about increased recognition of malpositioned IUDs in early months after insertion, there is no specific recommendation for timing and frequency of follow up visits. Systematic reviews about the effect of a specific follow-up schedule for IUDs is limited and of poor quality. The evidence did not suggest that greater frequency of visits or earlier timing of the first follow-up visit after placement improves continuation of use.

Recommendations for insertion timing to minimize complications¹¹

Timing of LNG-IUD Placement

• The LNG-IUD may be placed at any time if it is reasonably certain that the patient is not pregnant

• If the LNG-IUD is placed within the first 7 days since menstrual bleeding started, no additional contraceptive protection is needed.

• If the LNG-IUD is placed >7 days since menstrual bleeding started, the patient needs to abstain from sexual intercourse or use barrier methods (e.g., condoms) for the next 7 days

Amenorrhea (Not Postpartum)

• Timing: The LNG-IUD may be placed at any time if it is reasonably certain that the patient is not pregnant (Box 3).

• Need for back-up contraception: The patient needs to abstain from sexual intercourse or use barrier methods (e.g., condoms) for the next 7 days.

Postpartum (Including Cesarean Delivery, Breastfeeding, or Non-breastfeeding)

• Timing: The LNG-IUD may be placed at any time postpartum, including immediately postpartum if it is reasonably certain that the patient is not pregnant. Postpartum placement of IUDs is safe. Higher rates of expulsion during the immediate postpartum period, and lower after 4-6 weeks postpartum. The LNG-IUD should not be placed in a patient with postpartum sepsis or chorioamnionitis.

Need for back-up contraception: If the patient is <6 months postpartum, amenorrheic, and fully or nearly fully breastfeeding (exclusively breastfeeding, no additional contraceptive protection is needed. A woman who is ≥21 days postpartum and whose menstrual cycle has not returned needs to abstain from sexual intercourse or use barrier methods (e.g., condoms) for the next 7 days If the patient’s menstrual cycle has returned and it has been >7 days since menstrual bleeding began, the patient needs to abstain from sexual intercourse or use barrier methods (e.g., condoms) for the next 7 days.

Postabortion (Spontaneous or Induced)

• Timing: The LNG-IUD may be placed at any time postabortion, including immediately after abortion completion, if it is reasonably certain that the patient is not pregnant.. The LNG-IUD should not be placed immediately after a septic abortion.

• Need for back-up contraception: The patient needs to abstain from sexual intercourse or use barrier methods (e.g., condoms) for the next 7 days unless the IUD is placed immediately after abortion.

Switching from Another Contraceptive Method

• Timing: The LNG-IUD may be placed immediately if it is reasonably certain that the patient is not pregnant. Waiting for the patient’s next menstrual cycle is unnecessary and can cause a delay of contraception.

Special Considerations

Amenorrhea (Not Postpartum)

• Timing: The LNG-IUD may be placed at any time if it is reasonably certain that the patient is not pregnant.

• Need for back-up contraception: The patient needs to abstain from sexual intercourse or use barrier methods (e.g., condoms) for the next 7 days.

There is no direct evidence that placing LNG-IUDs on different days of the cycle affects short- or long-term outcomes

Recommendations for post-insertion FOLLOW UP (MMWR) (11)

Despite data presented earlier in the chapter about increased recognition of malpositioned IUDs in early months after insertion, there is no specific recommendation for timing and frequency of follow up visits. Systematic reviews about the effect of a specific follow-up visits schedule for IUDs is limited and of poor quality. The evidence did not suggest that greater frequency of visits or earlier timing of the first follow-up visit after placement improves continuation of use.

DOCUMENTATION FOR IUD-RELATED ULTRASOUND

Below is a template for use in documenting an IUD-related POCUS exam. This has the essential elements needed to provide thorough explanation of indications and findings. In addition to the written documentation. there must also be images of what was seen in the uterus and adnexa. This template can be adapted to an institution’s protocol for POCUS documentation.

NOTE: Documentation is required for billing of the POCUS exam.

IUD -- Point of Care Ultrasound IUD location/placement

Indication: IUD check indication, confirm after placement, strings not felt, pain, abnormal bleeding

Type of IUD: Mirena, Skyla, Kyleena, Paragard, other

Method of scanning: Transabdominal, Transvaginal

LMP:

Findings:

Uterus: anteverted, anteflexed, mid-position, retroverted, retroflexed

IUD location:

IUD in acceptable position

IUD low in the uterus

IUD in the cervix

IUD appears imbedded in myometrium

IUD arms not extended

IUD not seen in the uterus

Endometrium: ___cm

Endometrial characteristics:

Hypo echoic (consistent with proliferative phase)

Echogenic (consistent with ovulatory phase)

Hyperechoic (consistent with secretory phase)

Mixed in echogenicity

Impression: IUD in acceptable position, IUD low in the uterus, IUD in the cervix, IUD imbedded in myometrium, IUD arms not extended, IUD not seen in the uterus

Plan:

Routine care and follow up

Rescan in 4-6 weeks

Refer for diagnostic ultrasound

Suboptimal IUD position - consider removal/replacement

Comments:

USD performed by: Name of midwife/sonographer

Suggested ICD10 codes; IUD Localization, 76942 IUD location, Z30.431 IUD location

CODING FOR IUD-RELATED ULTRASOUND¹⁴

Suggested CPT codes;

IUD Localization, 76942 IUD location, Z30.431

Transvaginal GYN exam 76830

Pelvic (complete) 76856

Limited Follow-up Pelvic 76857

Common ICD10 codes to describe indication for scan:

ICD 10 Code	Description
N91.2	Amenorrhea
N91.5	Oligomenorrhea
N92.0	Excessive and frequent menstruation with regular cycle
N92.1	Excessive and frequent menstruation with irregular cycle
N92.2	Excessive menstruation at puberty
N92.3	Ovulation bleeding
N92.4	Excessive bleeding in the premenopausal period
N92.5	Other specified irregular menstruation
N92.6	Irregular menses (irregular menstruation, unspecified)
N94.3	Dysfunctional uterine bleeding
N94.6	Dysmenorrhea
N95.0	Postmenopausal bleeding
N95.8	Other specified menopausal and perimenopausal disorders (ie, perimenopausal bleeding)
N95.9	Unspecified menopausal and perimenopausal disorder

YOU MAY NOW TAKE THE QUIZ AND MOVE TO THE COMPLETION AND EVALUATION SECTION. YOU WILL NOT BE ABLE TO OPEN THE NEXT CHAPTER UNTIL YOU COMPLETE AND PASS THE QUIZ. YOU WILL HAVE AS MANY TRIES AS YOU NEED TO GET ALL THE ANSWERS CORRECT!

YOU SHOULD RECEIVE YOUR CME CERTIFICATE ONCE THESE FIELDS ARE COMPLETE. THANK YOU FOR TAKING THIS COURSE!

Links to Supplemental Materials for POCUS and IUD Evaluation

Iud insertion using ultrasound

https://www.tiktok.com/@drpkobgyn/video/7436184863687855390

Using POCUS to identify IUD placement

https://youtu.be/R0hnHGPMbgw?si=ZUPH4ADmnP869Vwr

Link to article reference: Stalnaker and Kauniz, “How to identify and localize IUDs on ultrasound”

https://blogs.the-hospitalist.org/content/how-identify-and-localize-iuds-ultrasound