Intrauterine Pregnancy With a Correctly Positioned Levonorgestrel-Releasing Intrauterine System: A Case Report

Intrauterine pregnancy occurring with a correctly positioned levonorgestrel-releasing intrauterine system (LNG-IUS) is extremely rare. Most pregnancies associated with LNG-IUS use result from device malposition, unnoticed expulsion, or insertion during an undiagnosed early pregnancy. Pregnancy with an intrauterine device in situ is associated with an increased risk of miscarriage, preterm delivery, and intra-amniotic infection. We report the case of a 39-year-old gravida 4 para 2 abortus 1 woman with a correctly positioned 52-mg LNG-IUS who presented at 12 weeks' gestation with leakage of amniotic fluid. One week earlier, an ultrasound had confirmed a viable intrauterine pregnancy with correct device positioning in the uterine fundus. Because the IUS strings were not visible on examination, no immediate removal was attempted. The patient wished to continue the pregnancy. During hospitalization, intrauterine fetal demise occurred, followed by pharmacological induction of miscarriage and uterine curettage with device removal. This case highlights the clinical challenges of pregnancy with an LNG-IUS in situ and emphasizes that the lack of visible strings should not preclude consideration of removal. Current evidence suggests that hysteroscopic removal in early pregnancy may reduce adverse outcomes and should be considered in patients wishing to continue pregnancy.