Malpositioning

A malpositioned IUC may be diagnosed in follow-up, either by history (ongoing pelvic pain, dyspareunia, ongoing problematic bleeding), or by ultrasound (when used to investigate positioning, or when found incidentally).

A malpositioned IUC can be further classified and managed as follows:

• Malrotation: The horizontal arms should be pointed towards the tubal ostia (cornua or placement of the fallopian tubes), owing to the ovoid shape of the uterus. If the IUC is rotated to the arms are pointing in a different direction, embedment can occur. If the device is intrauterine, and there is no perforation/embedment, and the woman is asymptomatic, it can be left in situ. More commonly, it should be removed and replaced. as it causes discomfort.
• Partial embedment: A portion of one of the arms of the IUC is in the myometrium. It should be replaced to prevent further migration. If the vertical stem is embedded, removal may be more difficult.
• Low placement – Copper – A low-placed IUD will often migrate into the correct fundal position. If the device is located completely in the uterine cavity (not in the cervix), it should provide adequate contraception, and can be used without backup. There is no data on copper ion concentration with low positioing of the device. In this situation, it is not clear if removal and replacement is helpful. A personalized approached should be taken and women should be informed of the elevated risk of expulsion, advised to perform a string check periodically, and reimage in 3 months.
• Intracervical placement – Copper – If the IUC is in the cervix, then there may not be sufficient copper concentrations to prevent pregnancy. Therefore backup should be used. The clinician and women should determine whether an attempt of adjusting the IUC into the cavity or replacement is the next step in management. If the post is visible at the external os, it should be replaced.
• Low placement – IUS – A low placed IUS will often migrate into the correct fundal position. If the device is located completely in the uterine cavity, even if in the lower segment, it should provide adequate contraception to allow for conservative management and reimaging in 3 months. Discuss the increased risk of expulsion and the role of string checks.
• Intracervical placement – IUS – Previous studies show high effectiveness among intracervically-placed IUS’, likely owing to the fact that the mechanism of action is thickened cervical mucus. If the IUS is located partially in the cervix, and the women is asymptomatic, a discussion should take place as to whether it is left and observed, an attempt is made to move it up into the uterine cavity, or if replacement is performed. All are acceptable options.

Costescu D. and Guilbert E. et al. Preceptorship Program - Module 4
Costescu et al. Levonorgestrel-Releasing Intrauterine Systems for Long-Acting Contraception: Current Perspectives, Safety, and Patient Counseling.Int J Womens Health 2016.