A. X-ray of the abdomen – Explanation

To answer this question accurately, it is essential to know about the management of lost
intrauterine device threads.

How do we manage lost intrauterine device threads?

1. Exclude pregnancy by performing a urine pregnancy test
2. Request a pelvic ultrasound to look for the IUCD
3. If the IUCD is not found on ultrasound, request an abdominal X-ray

Emergency contraceptin is incorrect as there is no evidence of recent sexual
intercourse in the stem. Remember, one needs to know the timing of sexual intercourse
to know which emergency contraception to use. Example, levonorgestrel can be used
for up to 72 hours whereas ulipristal acetate and copper intrauterine device can be used
up to 5 days.

We are not sure if the coil is in place. There is no evidence of sexual intercourse.
A hysteroscopy may be used to remove an IUCD from within the uterine cavity provided
it is proven to be there.

An X-ray of the abdomen would be best to determine if the IUCD is in the abdomen.
This can occur when the IUCD perforates through the uterus during insertion or finds a
way to migrate to the abdominal cavity when initially inserted intrauterine. If the IUCD is
found outside the uterus but inside the abdominal cavity, a laparoscopy can be done to
retrieve it.

MANAGEMENT OF LOST INTRAUTERINE DEVICE THREADS

The explanation below is rather specific and most likely not required for PLAB but they
do help with the understanding of what do you do in situations where the IUD thread is
not found.

Speculum examination reveals no IUD thread

• Take menstrual and sexual history, exclude pregnancy. Provide alternative
  contraception and/or post coital contraception if indicated by history
• If woman is pregnant
  o Refer to Early Pregnancy Unit for rapid access to ultrasound scan. Viabilty of
  pregnancy, site, gestation will need to be determined. The management from
  here on is rather complex and unlikely to be asked in the PLAB test
• If woman is not pregnant
  o Refer for ultrasound scan. Ensure contraception is given until ultrasound scan
  is performed.
  • • If ultrasound scan reports misplaced in cavity, the management depends on
      symptoms and degree of displacement.
    • If ultrasound scan reports device is correctly located in the uterus, leave the
      IUD in situ until it is due to be removed.
    • If IUD not seen in uterus, order a plain abdominal X-ray
      .If abdo X-ray shows IUD is in the abdominal cavity, this may require
      laparoscopic removal
      .If abdo X-ray shwos IUD not located, this implies that IUD has fallen out
      and replacement of IUD can be offered.