July 2023: Improving IUD Insertion Care with POCUS

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The use of Point-of-Care Ultrasound (POCUS) has been well established in emergency medicine. However, what is less known is the utility of POCUS in the Primary Care and outpatient setting. This month’s newsletter aims to explore how POCUS can improve healthcare delivery in primary care and outpatient settings, with a specific focus on guiding the insertion of intrauterine devices (IUDs). As more outpatient providers are trained in POCUS, the applications for its benefits in improving overall patient care continue to expand.

POCUS and IUD Insertions

According to the CDC, 10.4% of women aged 15-49 use long-acting reversible contraception (IUD’s or contraceptive implants).

In recent years, pain associated with IUD insertion has gained more visibility across popular media channels.  

Is there a more patient-centered approach to improve how IUD insertions are performed?

The Journal of Ultrasound in Medicine published a groundbreaking meta-analysis this month comparing ultrasound-guided IUD insertion to traditional techniques.

The authors Baradwan et al., concluded that ultrasound-guided IUD insertion compared to traditional technique led to the following:

  • Significantly less discomfort with insertion

  • Significantly less time required to perform IUD insertion

  • Significantly increased patient satisfaction

  • Significantly fewer malpositioned IUDs

  • Significantly fewer procedural complications

As medical providers, we strive to continue to improve how medical care is delivered.  POCUS has the potential to improve healthcare delivery by improving the patient experience to decrease discomfort, save time, increase patient satisfaction and decrease complications.  Ultrasound-guided IUD insertions are one of many applications in the outpatient setting in which POCUS can benefit patient care. Therefore, it is important for us to consider how we can incorporate POCUS into our daily practice to improve the quality of care we deliver.

“Technology has the potential to improve patient care, but only if it is seamlessly integrated into the healthcare workflow” — Bill Maris

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9b5f6a67 8dc9 da2d 6182 60fc8db953c2Case Study #1

A 38-year-old woman presents for follow-up 6 weeks after routine placement of a copper IUD. She reports some intermittent spotting and mild pelvic discomfort over the past month.

Exam demonstrates the IUD string extending 4 cm from cervical os (2 cm length documented on insertion). The IUD was removed and re-placement of the displaced IUD was recommended. However, the patient expresses concern about the discomfort and inconvenience of another follow-up pelvic exam, and the risk of having this happen again.  She worries that an IUD may not be her best choice for contraception.

POCUS exam was offered, which demonstrated:

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A markedly anteflexed uterus.  Implications of this anatomical variation were discussed and options offered including:

  1. Traditional IUD placement—with the knowledge that the clinician will need to provide cervical traction to straighten the angle, use a curved uterine sound directed upward, and guide the IUD in a similar upward direction
  2. Ultrasound-guided IUD insertion – which allows direct visualization as uterine instrumentation occurs for additional guidance and safety.
  3. Consideration of alternative contraception, as the anatomy as discovered by POCUS predicts a more difficult IUD insertion.

Through shared decision making, the patient elects to have a contraceptive subdermal implant placed instead.

9b5f6a67 8dc9 da2d 6182 60fc8db953c2Case Study #2

A 26-year-old G2P2 patient presents to discuss contraception.  She likes the convenience and reliability of an IUD, but is apprehensive because her sister told her that having her IUD placed was horribly painful.

You discuss the literature surrounding IUD insertion discomfort and decide to proceed with IUD insertion under ultrasound guidance based on its proven success in reducing pain during this procedure.

POCUS reveals a mid- position relatively straight uterus:

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Her cervical os is slightly patulous after 2 previous vaginal deliveries, so you elect to proceed with IUD insertion by the Uterine Sound Sparing Approach (UUSA)—which can also decrease pain with insertion. Learn more:  Ali MK, Ramadan AK, Abu-Elhassan AM, Sobh AMA. Ultra[1]sound-guided versus uterine sound-sparing approach during copper intrauterine device insertion: a randomized clinical trial. Eur J Contracept Reprod Health Care 2022; 27:3–8)

After sonographically measuring the distance from os to internal fundus, the IUD was inserted to the correct depth, under ultrasound observation, and was confirmed to be in correct position.  The patient was pleased with the procedure and reported her discomfort as “one and a half” on a 0-10 VAS pain scale.

She returned for follow-up visit in 6 weeks, and a brief POCUS exam again confirmed the IUD to be well positioned—which avoided the need for the traditional speculum exam for an IUD string check.

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(Case contributions by GUSI Lead Faculty Dr. Stephen Erickson, MD  FAAFP  RMSK)

If you’d like to contribute great learning cases for us to share and offer suggestions for future POCUS topics you’d like to see in our monthly newsletters, write to gusi@globalultrasoundinstitute.com (subject line: Newsletter)

Faculty Spotlight

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Emory Williams, MD is a family physician currently providing primary care with obstetrics in an FQHC system near Seattle, WA. After finishing residency at Swedish First Hill Family Medicine Residency in Seattle, they completed UCSF’s HEAL Initiative Global Health Fellowship where they worked on the Navajo Nation and in Liberia. Emory has been interested in what POCUS can offer resource deprived settings since residency. Internationally, they have used POCUS to connect patients with US-based consultants. Domestically, they have used POCUS to aid in their hospitalist and obstetrics practice and to provide comprehensive reproductive health care in the outpatient setting.

GUSI in the Community

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GUSI led a transformative 3-day Obstetric POCUS Training in Sarara, Kenya. Sarara, the Samburu word for ‘the meeting place,’ is a nomadic community located in Samburu.

The Sarara Foundation’s mobile clinic plays a crucial role in providing healthcare for the nomads. However, in cases where referrals are required, pregnant mothers face a 16-mile journey to the nearest facility in Wamba, while complex cases require a daunting 62-mile trip to the Samburu County hospital.

OB POCUS eliminates the need for these risky trips, ensuring the well-being of both mother and baby. Our POCUS training holds immense significance, promising to enhance outcomes and transform maternal and fetal health. We would love to come and teach at your institution!

We would love to come teach at your institution! Click here to contact us.

GUSI Software Updates

Are you a GUSI Group Leader and want to assign course content to your learners?  You can do it now through your group leader dashboard!

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Best wishes,

Kevin, Mena, & the GUSI Education Team



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