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The most appropriate management for a lost intrauterine device (IUD) is to perform an ultrasound followed by an X-ray. This approach allows for accurate localization of the IUD by visualizing its position within the uterus or outside of it. Ultrasound is a non-invasive imaging technique that helps determine if the IUD is still within the uterine cavity. If it cannot be found via ultrasound, an X-ray can then provide additional clarity on its location, especially if the IUD has migrated outside the uterus into the abdominal cavity.

Waiting for natural expulsion might seem reasonable in some cases, but it does not provide timely interventions or address potential complications like perforation or migration. Hysteroscopy is a method used to directly visualize the uterine cavity and remove an IUD if it is misplaced, but it is typically performed after identification of the IUD's location through imaging. Immediate removal is not the standard first step because it is crucial to ascertain where the IUD is located to ensure safe and effective removal without causing injury or complications. Therefore, employing imaging studies is the established first step in managing a lost IUD.