For most women, perfect contraceptive protection is protection that you don’t have to “manage or even think about”. One of the more popular methods of worry free birth control is the Mirena intrauterine device. The Mirena is an intrauterine contraceptive that delivers small amounts of levonorgestrel directly to the uterus. This device is made of soft, flexible plastic that can be placed by your healthcare provider during an office visit. Mirena is birth control that can last up to 5 years, and is also approved to treat heavy periods in women who choose intrauterine contraception. The only maintenance required with this method is checking the threads once a month, if you experience problems finding them back-up contraception is suggested. In the uncommon event you get pregnant while using Mirena, seek emergency care because pregnancy with an intrauterine device can be life threatening and may result in loss of pregnancy or fertility.
I had the opportunity to attend the delivery of a 28 year old G2P1 with a complicated pregnancy due to the findings of the Mirena device as well as an intrauterine pregnancy at 10 weeks gestation. The patient had the device in place for less than one year but assumed that the device had been expelled when her pregnancy test was positive. In serial ultrasounds the device was displaced but present in the uterus. She was closely managed and followed as a complicated ob patient without surgical intervention under the pretense to watch and wait to see how the pregnancy would progress. In the course of the pregnancy the patient did not undergo any significant events and was able to labor and deliver vaginally. During the birthing process there was a period in which forceps or vacuum extraction was considered but was not necessary. The patient did have an uneventful vaginal delivery but the IUD was not noted or recovered in placental contents nor on exam, however there was greater than average degree of post partum bleeding noted. This case was highly unusual and the patient will need to be followed up to determine if indeed the uterus is void of the device.
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Wow. I attended a Centering group and we did talk about the Mirena and Paragard options. The question was asked what would happen if a pregnancy occured with the IUD in. I was surprised by the answer that it is usually left in place---the risk being that removal can induce abortion, leaving in place can cause sepsis/septic abortion, and leaving in place can also proceed with a normal pregnancy.
ReplyDeleteI would b e interested in finding out the results of f/u in this case.
I can't help compare this case w/one I recently saw at the other end of the spectrum...I attended a delivery a few days ago of a G3P3 who was "done" with childbearing. Antenatally with her last pregnancy, she chose to have an IUD placed (Mirena). To my surprise, it was placed immediately post delivery after her uneventful SVD (as opposed to 6 weeks postpartum). The CNM said she'd already done quite a few this year without any complications. Unfortunately, this woman experienced continued uterine bleeding w/MULTIPLE clots (they hesitated to document it as a hemorrhage, but it sure looked like a "slow hemorrhage" to me of approx 800 cc in just over 1 hour after her initial EBL of 200 cc during delivery) after 40 of pit, Cytotec, and frequent fundal massage. The CNM removed the IUD as they couldn't rule this out as the cause of her bleed; and when I left they gave her Methergine. I'll be finding out next week how she did, hopefully they were able to stop the bleed without having to take her back in the OR.
ReplyDeleteI had the opportunity to place a Mirena last week. I understand from the company website that about 8 in 1000 women will get pregnant with the IUD in place over a 5 year period. Had your patient been checking IUD strings on a regular basis? Also I’m wondering if there was any consideration of attempting to remove the device once it was determined that the patient had an intrauterine pregnancy. Women in this situation are at higher risk for infection, miscarriage and preterm delivery, but I know that there is also risks associated with removal. I’ve seen several sources including our textbook list Mirena as a form of emergency contraception; however, the company states that it is not licensed for that purpose. Have you heard of people using it for that reason?
ReplyDeleteI hadn't heard of it used for emergency contraception although I suppose it would be possible. As to my knowledge for this patient, she had been properly checking the IUD strings. Although the device was visible on ultrasound the risks of removing it outweighed just watchful waiting being uncertain of the outcome. The device itself is supposed to irritate the uterine lining enough as to provide a less than ideal area for implantation-which would make it a potentially effective emergency contraceptive method.
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