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Mohamed HH, Ehresmann K, Seburg EM, Vazquez-Benitez G, Demerath EW, Fields DA, Vesco KK, Kharbanda EO, Palmsten K. Characterisation and validation of lactation information from structured electronic health records for use in pharmacoepidemiological studies. Paediatr Perinat Epidemiol 2024; 38:505-514. [PMID: 38494336 DOI: 10.1111/ppe.13051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/22/2023] [Accepted: 01/22/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Breastfeeding information stored within electronic health records (EHR) has recently been used for pharmacoepidemiological research, however the data are primarily collected for clinical care. OBJECTIVES To characterise breastfeeding information recorded in structured fields in EHR during infant and postpartum health care visits, and to assess the validity of lactation status based on EHR data versus maternal report at research study visits. METHODS We assessed breastfeeding information recorded in structured fields in EHR from one health system for a subset of 211 patients who were also enrolled in a study on breast milk composition between 2014 and 2017 that required participants to exclusively breastfeed their infants until at least 1 month of age. We assessed the frequency of breastfeeding information in EHR during the first 12 months of age and compared lactation status based on EHR with maternal report at 1 and 6-month study visits (reference standard). RESULTS The median number of breastfeeding records in the EHR per infant was six (interquartile range 3) with most observations clustering in the first few weeks of life and around well-infant visits. At the 6-month study visit, 93.8% of participants were breastfeeding and 80.1% were exclusively breastfeeding according to maternal report. Sensitivity of EHR data for identifying ever breastfeeding was at or near 100%, and sensitivity for identifying ever exclusive breastfeeding was 98.0% (95% CI: 95.0%, 99.2%). Sensitivities were 97.3% (95% CI: 93.9%, 98.9%) for identifying any breastfeeding and 94.4% (95% CI: 89.7%, 97.0%) for exclusive breastfeeding, and positive predictive values were 99.5% (95% CI: 97.0%, 99.9%) for any breastfeeding and 95.0% (95% CI: 90.4%, 97.4%) for exclusive breastfeeding. CONCLUSIONS Breastfeeding information in structured EHR fields have the potential to accurately classify lactation status. The validity of these data should be assessed in populations with a lower breastfeeding prevalence.
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Affiliation(s)
- Hibo H Mohamed
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Kirsten Ehresmann
- Pregnancy and Child Health Research Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Elisabeth M Seburg
- Pregnancy and Child Health Research Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Gabriela Vazquez-Benitez
- Pregnancy and Child Health Research Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Ellen W Demerath
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - David A Fields
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Kimberly K Vesco
- Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Elyse O Kharbanda
- Pregnancy and Child Health Research Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Kristin Palmsten
- Pregnancy and Child Health Research Center, HealthPartners Institute, Minneapolis, Minnesota, USA
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Wang Y, Chen Q, Liu Z, Chen Y, Zheng Y, Guo J, Zhou F, Lv N, Zhao J, Shen S, Yuan Q, Tong J. Analgesia efficacy of lidocaine transfused by a novel disposable injectable cervical dilator during intrauterine device removal procedure: A randomized clinical trial. Contraception 2024; 135:110439. [PMID: 38552820 DOI: 10.1016/j.contraception.2024.110439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/19/2024] [Accepted: 03/24/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVE The majority of intrauterine devices (IUDs) inserted in China are tailless, requiring intrauterine manipulations for removal and causing pain. This study aimed to investigate the analgesic efficacy of lidocaine injection into a novel disposable injectable cervical dilator for IUD removal procedures. STUDY DESIGN A double-blinded, placebo-controlled, randomized clinical trial was conducted with women aged 18-65 years old requesting outpatient IUD removal. The study randomly assigned participants to either lidocaine (injecting 5 ml of 2% lidocaine into the injectable cervical dilator) or placebo (injecting 5 ml of normal saline into the device) group. All participants received a standardized paracervical block. The primary outcome was pain reported during IUD removal on a 100 mm Visual Analog Scale (VAS). Intention-to-treat were conducted to evaluate the analgesic effectiveness of injecting lidocaine into the injectable cervical dilators. RESULTS We enrolled seventy-four eligible participants (37 in lidocaine group and 37 in placebo group). The results showed that the median intraoperative VAS score in the lidocaine group was lower than the placebo group (30.0 mm [IQR 20.0-46.0, n = 37] vs 46.0 mm [IQR 30.0-55.0, n = 37], p = 0.01. In subgroup analyses, among participants with IUD removal and without uterine manipulation and additional procedures, there was no statistically significant disparity observed in intraoperative VAS scores between the lidocaine and placebo group (15.0 mm [IQR 10.0-27.5, n = 8] vs 20.0 mm [IQR 20.0-40.0, n = 6]), p = 0.28). Among participants with an IUD removal necessitating intrauterine manipulations and without additional procedures, showing lower intraoperative VAS scores in lidocaine group (25.0 mm [IQR 15.0-40.5, n = 17]) compared to placebo group (46.0 mm [IQR 38.5-50.0, n = 23]), p < 0.01. Among participants with additional procedures in addition to IUD removal, there was no statistically significant disparity observed in intraoperative VAS scores between the lidocaine and placebo group (41.0 mm [IQR 32.5-57.5, n = 12] vs 45.0 mm [IQR 22.5-69.0, n = 8]), p = 0.97). CONCLUSIONS Injecting lidocaine into the novel disposable injectable cervical dilator for cervix dilation can significantly reduce pain during an IUD removal, particularly in patients necessitating intrauterine manipulations during IUD removal. IMPLICATIONS When we have to perform intrauterine manipulations to remove an IUD, surgical pain and narrow cervical canal undoubtedly affect the implementation of the procedure. Injecting lidocaine into the injectable cervical dilator can achieve local anesthesia while dilating the cervix, and might reduce the choice of general anesthesia for IUD removal.
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Affiliation(s)
- Yahui Wang
- Department of Obstetrics and Gynecology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
| | - Qianying Chen
- Department of the Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Zhengnan Liu
- Department of Obstetrics and Gynecology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
| | - Yun Chen
- Department of Obstetrics and Gynecology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
| | - Yingling Zheng
- Department of Obstetrics and Gynecology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
| | - Jialu Guo
- Department of Obstetrics and Gynecology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
| | - Fan Zhou
- Department of Obstetrics and Gynecology, Hangzhou Women's Hospital, Hangzhou, Zhejiang, China
| | - Nengyuan Lv
- Department of the Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jianying Zhao
- Department of Obstetrics and Gynecology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
| | - Siyi Shen
- Department of the Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qiaolei Yuan
- Department of the Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jinyi Tong
- Department of Obstetrics and Gynecology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China.
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Grandi G, Del Savio MC, Tassi A, Facchinetti F. Postpartum contraception: A matter of guidelines. Int J Gynaecol Obstet 2024; 164:56-65. [PMID: 37334892 DOI: 10.1002/ijgo.14928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/19/2023] [Accepted: 05/28/2023] [Indexed: 06/21/2023]
Abstract
The postpartum period is the perfect time to access family planning services. WHO guidelines contraindicate combined hormonal contraceptives postpartum in breastfeeding patients between 6 weeks and 6 months after delivery (Medical Eligibility Criteria category 3). On the contrary, the Faculty of Sexual and Reproductive Healthcare and the Centers for Disease Control and Prevention guidelines do not contraindicate their use in women who breastfeed from 6 weeks to 6 months postpartum. New combined hormonal contraceptives with natural estrogens have never been studied in this setting. Guidelines agree on the prescription of the progestin-only pill postpartum in non-breastfeeding women (category 1). Differences are found in women who breastfeed. In non-breastfeeding women, an implant is considered safe (category 1) by all guidelines, without any distinction in time. Regarding postpartum breastfeeding women, the guidelines for implants give quite different indications but are still permissive. Intrauterine devices are viable options for postpartum contraception but guidelines give different indications about the timing of insertion. Postplacental intrauterine device placement can reduce the subsequent unintended pregnancy rate, particularly in settings at greatest risk of not having recommended postpartum controls. However, it has yet to be understood whether this approach can really have an advantage in high-income countries. Postpartum contraception is not a 'matter of guidelines': it is the best customization for each woman, as early as possible but at the ideal timing.
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Affiliation(s)
- Giovanni Grandi
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Azienda Ospedaliero Universitaria Policlinico, Modena, Italy
| | - Maria C Del Savio
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Azienda Ospedaliero Universitaria Policlinico, Modena, Italy
| | - Alice Tassi
- Clinic of Obstetrics and Gynecology, DAME, University Hospital of Udine, Udine, Italy
| | - Fabio Facchinetti
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Azienda Ospedaliero Universitaria Policlinico, Modena, Italy
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Fassett MJ, Reed SD, Rothman KJ, Pisa F, Schoendorf J, Wahdan Y, Peipert JF, Gatz J, Ritchey ME, Armstrong MA, Raine-Bennett T, Postlethwaite D, Getahun D, Shi JM, Xie F, Chiu VY, Im TM, Takhar HS, Wang J, Anthony MS. Risks of Uterine Perforation and Expulsion Associated With Intrauterine Devices. Obstet Gynecol 2023; 142:641-651. [PMID: 37535968 PMCID: PMC10424817 DOI: 10.1097/aog.0000000000005299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/31/2023] [Accepted: 06/08/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE The APEX-IUD (Association of Perforation and Expulsion of Intrauterine Devices) study evaluated the association of postpartum timing of intrauterine device (IUD) insertion, breastfeeding, heavy menstrual bleeding, and IUD type (levonorgestrel-releasing vs copper) with risks of uterine perforation and IUD expulsion in usual clinical practice. We summarize the clinically important findings to inform counseling and shared decision making. METHODS APEX-IUD was a real-world (using U.S. health care data) retrospective cohort study of individuals aged 50 years and younger with IUD insertions between 2001 and 2018 and with electronic health record data. Cumulative incidences of uterine perforation and IUD expulsion were calculated. Adjusted hazard ratios (aHRs) and 95% CIs were estimated from proportional hazards models with control of confounding. RESULTS Among the study population of 326,658, absolute risk of uterine perforation was low overall (cumulative incidence, 0.21% [95% CI 0.19-0.23%] at 1 year and 0.61% [95% CI 0.56-0.66% at 5 years]) but was elevated for IUDs inserted during time intervals within 1 year postpartum, particularly among those between 4 days and 6 weeks postpartum (aHR 6.71, 95% CI 4.80-9.38), relative to nonpostpartum insertions. Among postpartum insertions, IUD expulsion risk was greatest for insertions in the immediate postpartum period (0-3 days after delivery) compared with nonpostpartum (aHR 5.34, 95% CI 4.47-6.39). Postpartum individuals who were breastfeeding had a slightly elevated risk of perforation and lowered risk of expulsion than those not breastfeeding. Among nonpostpartum individuals, those with a heavy menstrual bleeding diagnosis were at greater risk of expulsion than those without (aHR 2.84, 95% CI 2.66-3.03); heavy menstrual bleeding also was associated with a slightly elevated perforation risk. There was a slightly elevated perforation risk and slightly lower expulsion risk associated with levonorgestrel-releasing IUDs compared with copper IUDs. CONCLUSION Absolute risk of adverse outcomes with IUD insertion is low. Clinicians should be aware of the differences in risks of uterine perforation and expulsion associated with IUD insertion during specific postpartum time periods and with a heavy menstrual bleeding diagnosis. This information should be incorporated into counseling and decision making for patients considering IUD insertion. FUNDING SOURCE Bayer AG. CLINICAL TRIAL REGISTRATION EU PAS register, EUPAS33461.
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Affiliation(s)
- Michael J Fassett
- Department of Obstetrics & Gynecology, Kaiser Permanente West Los Angeles Medical Center, Los Angeles, the Department of Clinical Science and the Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, and the Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, and the Division of Research, Kaiser Permanente Northern California, Oakland, California; the Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington; RTI Health Solutions, Research Triangle Park, North Carolina; Bayer AG, Berlin, Germany; Bayer AG and Bayer OY, Espoo, Finland; Bayer Pharmaceuticals, Whippany, New Jersey, and the Department of Obstetrics and Gynecology, Indiana University School of Medicine, and the Regenstrief Institute, Indianapolis, Indiana
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Quinlan TAG, Lindrooth RC, Guiahi M, McManus BM, Mays GP. Medicaid Payment For Postpartum Long-Acting Reversible Contraception Prompts More Equitable Use. Health Aff (Millwood) 2023; 42:665-673. [PMID: 37126756 DOI: 10.1377/hlthaff.2022.01178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
To increase access to highly effective contraception and improve reproductive autonomy, a growing number of state Medicaid programs pay for the provision of immediate postpartum long-acting reversible contraception (LARC) in addition to providing a global payment for maternity care. Using Pregnancy Risk Assessment Monitoring System data, we examined postpartum LARC use both overall and by race and ethnicity among respondents with Medicaid-paid births during the period 2012-18 in eight states that implemented immediate postpartum LARC payment and eight states without it. Using a quasi-experimental difference-in-differences design, we found that the policy resulted in an overall 2.1-percentage-point increase in postpartum LARC use. Our triple-differences analysis found no significant change among White mothers and a 3.7-percentage-point increase in use among Black mothers compared with White mothers. Additional research is needed to determine whether this increase was aligned with patients' preferences and whether hospitals' immediate postpartum LARC policies and practices take a patient-centered approach that supports reproductive autonomy and equity.
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Affiliation(s)
- Taryn A G Quinlan
- Taryn A. G. Quinlan , Colorado School of Public Health, Aurora, Colorado
| | | | - Maryam Guiahi
- Maryam Guiahi, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Glen P Mays
- Glen P. Mays, Colorado School of Public Health
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Averbach S, Kully G, Hinz E, Dey A, Berkley H, Hildebrand M, Vaida F, Haider S, Hofler LG. Early vs Interval Postpartum Intrauterine Device Placement: A Randomized Clinical Trial. JAMA 2023; 329:910-917. [PMID: 36943214 PMCID: PMC10031390 DOI: 10.1001/jama.2023.1936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/05/2023] [Indexed: 03/22/2023]
Abstract
Importance The early postpartum period, 2 to 4 weeks after birth, may be a convenient time for intrauterine device (IUD) placement; the placement could then coincide with early postpartum or well-baby visits. Objective To determine expulsion rates for IUDs placed early postpartum compared with those placed at the standard interval 6-week visit. Design, Setting, and Participants In this randomized noninferiority trial, people who had a vaginal or cesarean birth were randomly assigned to undergo early (14-28 days) or interval (42-56 days) postpartum IUD placement. Clinicians blinded to participant study group used transvaginal ultrasonography to confirm IUD presence and position at the 6-month postpartum follow-up. The study assessed 642 postpartum people from 4 US medical centers, enrolled a consecutive sample of 404 participants from March 2018 to July 2021, and followed up each participant for 6 months postpartum. Interventions Early postpartum IUD placement, at 2 to 4 weeks postpartum, vs standard interval placement 6 to 8 weeks postpartum. Main Outcomes and Measures The primary outcome was complete IUD expulsion by 6 months postpartum; the prespecified noninferiority margin was 6%. Secondary outcomes were partial IUD expulsion, IUD removal, pelvic infection, patient satisfaction, uterine perforation, pregnancy, and IUD use at 6 months postpartum. IUD malposition was an exploratory outcome. Results Among 404 enrolled participants, 203 participants were randomly assigned to undergo early IUD placement and 201 to undergo interval IUD placement (mean [SD] age, 29.9 [5.4] years; 46 [11.4%] were Black, 228 [56.4%] were White, and 175 [43.3%] were Hispanic). By 6 months postpartum, 53 participants (13%) never had an IUD placed and 57 (14%) were lost to follow-up. Among the 294 participants (73%) who received an IUD and completed 6-month follow-up, complete expulsion rates were 3 of 149 (2.0% [95% CI, 0.4%-5.8%]) in the early placement group and 0 of 145 (0% [95% CI, 0.0%-2.5%]) in the interval placement group (between-group difference, 2.0 [95% CI, -0.5 to 5.7] percentage points). Partial expulsion occurred in 14 (9.4% [95% CI, 5.2%-15.3%]) participants in the early placement group and 11 (7.6% [95% CI, 3.9%-13.2%]) participants in the interval placement group (between-group difference, 1.8 [95% CI, -4.8 to 8.6] percentage points). IUD use at 6 months was similar between the groups: 141 (69.5% [95% CI, 62.6%-75.7%]) participants in the early group vs 139 (67.2% [95% CI, 60.2%-73.6%]) in the interval group. Conclusions and Relevance Early IUD placement at 2 to 4 weeks postpartum compared with 6 to 8 weeks postpartum was noninferior for complete expulsion, but not partial expulsion. Understanding the risk of expulsion at these time points may help patients and clinicians make informed choices about the timing of IUD placement. Trial Registration ClinicalTrials.gov Identifier: NCT03462758.
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Affiliation(s)
- Sarah Averbach
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Complex Family Planning, University of California, San Diego, La Jolla
- Center on Gender Equity and Health, University of California, San Diego, La Jolla
| | - Gennifer Kully
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Complex Family Planning, University of California, San Diego, La Jolla
- Center on Gender Equity and Health, University of California, San Diego, La Jolla
| | - Erica Hinz
- Department of Obstetrics and Gynecology, Division of Complex Family Planning, University of Illinois at Chicago
| | - Arnab Dey
- Center on Gender Equity and Health, University of California, San Diego, La Jolla
| | - Holly Berkley
- Department of Gynecologic Surgery and Obstetrics, Naval Medical Center, San Diego, California
| | - Marisa Hildebrand
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Complex Family Planning, University of California, San Diego, La Jolla
| | - Florin Vaida
- School of Public Health, Division of Biostatistics, University of California, San Diego, La Jolla
| | - Sadia Haider
- Department of Obstetrics and Gynecology, Division of Complex Family Planning, University of Chicago, Chicago, Illinois
- Department of Obstetrics and Gynecology, Division of Complex Family Planning, Rush University, Chicago, Illinois
| | - Lisa G. Hofler
- Department of Obstetrics and Gynecology, Division of Complex Family Planning, University of New Mexico, Albuquerque
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Demographic, Reproductive, and Medical Risk Factors for Intrauterine Device Expulsion. Obstet Gynecol 2022; 140:1017-1030. [PMID: 36357958 PMCID: PMC9665953 DOI: 10.1097/aog.0000000000005000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To explore to what extent intrauterine device (IUD) expulsion is associated with demographic and clinical risk factors. METHODS The APEX-IUD (Association of Perforation and Expulsion of IntraUterine Devices) study was a U.S. cohort study using electronic health records from three integrated health care systems (Kaiser Permanente Northern California, Southern California, and Washington) and a health care information exchange (Regenstrief Institute). These analyses included individuals aged 50 years or younger with IUD insertions from 2001 to 2018. Intrauterine device expulsion cumulative incidence and incidence rates were estimated. Using Cox regression models, hazard ratios with 95% CIs were estimated before and after adjustment for risk factors of interest (age, race and ethnicity, parity, body mass index [BMI], heavy menstrual bleeding, and dysmenorrhea) and potential confounders. RESULTS In total, 228,834 individuals with IUD insertion and no delivery in the previous 52 weeks were identified (184,733 [80.7%] with levonorgestrel-releasing intrauterine system). Diagnosis of heavy menstrual bleeding-particularly a diagnosis in both recent and past periods-was the strongest risk factor for IUD expulsion. Categories with the highest risk of IUD expulsion within each risk factor included individuals diagnosed with overweight, obesity, and morbid obesity; those in younger age groups, especially among those aged 24 years or younger; and in those with parity of four or more. Non-Hispanic White individuals had the lowest incidence and risk, and after adjustment, Asian or Pacific Islander individuals had the highest risk. Dysmenorrhea was not independently associated with expulsion risk when adjusting for heavy menstrual bleeding. CONCLUSION Most risk factors for expulsion identified in this study appear consistent with known physiologic factors that affect uterine anatomy and physiology (age, BMI, heavy menstrual bleeding, parity). The increased risk of IUD expulsion among individuals of color warrants further investigation. Intrauterine devices are an effective long-term contraceptive; expulsion is uncommon, but patients should be counseled accordingly. FUNDING SOURCE Bayer AG. CLINICAL TRIAL REGISTRATION EU PAS register, EUPAS33461.
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Long-Acting Reversible Contraception. Obstet Gynecol 2022; 140:883-897. [DOI: 10.1097/aog.0000000000004967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/09/2022] [Indexed: 11/15/2022]
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Reed SD, Zhou X, Ichikawa L, Gatz JL, Peipert JF, Armstrong MA, Raine-Bennett T, Getahun D, Fassett MJ, Postlethwaite DA, Shi JM, Asiimwe A, Pisa F, Schoendorf J, Saltus CW, Anthony MS. Intrauterine device-related uterine perforation incidence and risk (APEX-IUD): a large multisite cohort study. Lancet 2022; 399:2103-2112. [PMID: 35658995 DOI: 10.1016/s0140-6736(22)00015-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 12/28/2021] [Accepted: 01/04/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Reports of perforation risk related to intrauterine devices (IUDs) inserted immediately post partum and among non-post-partum individuals are scarce, and previous studies with only 12-month follow-ups underestimate the risk. Breastfeeding at IUD insertion and insertion within 36 weeks post partum have been associated with increased risk of uterine perforation. The aim of these analyses was to compare the incidence and risks of IUD-related uterine perforations by non-post-partum and post-partum intervals at IUD insertion, and among post-partum individuals, to assess the impact of breastfeeding on these outcomes. METHODS We did a multisite cohort study in the USA, using electronic health records (EHR). Study sites were three health-care systems and a site that used data from a health-care information exchange. The study population included individuals who were aged 50 years or younger and had an IUD insertion between Jan 1, 2001, and April 30, 2018. Individuals were excluded if they had not been in the health-care system for at least 12 months before IUD insertion. The primary outcome for this analysis was any IUD-related uterine perforation diagnosis for the first IUD insertion in this time period. Both complete and partial IUD-related perforations were identified. Chart abstraction was done to validate EHR-based algorithms or confirm perforations. The crude rate and cumulative incidence of uterine perforation were evaluated by non-post-partum and post-partum intervals at IUD insertion in the full cohort, and by breastfeeding status in a subcohort of post-partum individuals. Cox models estimated crude and adjusted hazard ratios (aHRs). FINDINGS Data from 326 658 individuals in the full cohort and 94 817 individuals in the post-partum subcohort were analysed. In the full cohort, we identified 1008 uterine perforations (51·2% complete), with the 5-year cumulative incidence being the lowest in the non-post-partum group (0·29%, 95% CI 0·26-0·34). The aHR for the post-partum interval relative to non-post partum ranged from 2·73 (95% CI 1·33-5·63; 0 to 3 days post partum) to 6·71 (4·80-9·38; 4 days to ≤6 weeks post partum). The post-partum subcohort of individuals with breastfeeding information had 673 uterine perforations (62% complete), with a 5-year cumulative incidence of 1·37% (95% CI 1·24-1·52) and an increased risk with breastfeeding (aHR 1·37, 95% CI 1·12-1·66). INTERPRETATION Although the risk for uterine perforation with IUD insertion 4 days to 6 weeks or less post partum is nearly seven times that of insertion non-post partum, perforation remains an incredibly rare event for all clinical time points. Despite a slight increased risk of perforation with breastfeeding at IUD insertion, the benefits of breastfeeding and effective contraception generally outweigh risks and should have little clinical impact. Therefore, IUD insertion timing should be based on individual desire for IUD contraception and patient convenience to assure an IUD insertion can occur. Careful follow-up of individuals at higher risk of uterine perforation is warranted. FUNDING Bayer AG.
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Affiliation(s)
- Susan D Reed
- Department of Obstetrics & Gynecology, University of Washington, Seattle, WA, USA.
| | - Xiaolei Zhou
- RTI Health Solutions, Research Triangle Park, NC, USA
| | - Laura Ichikawa
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Jeffrey F Peipert
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, IN, USA
| | - Mary Anne Armstrong
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Tina Raine-Bennett
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; Department of Health Systems Science at the Kaiser Permanente, Bernard J Tyson School of Medicine, Pasadena, CA, USA
| | - Darios Getahun
- Department of Health Systems Science at the Kaiser Permanente, Bernard J Tyson School of Medicine, Pasadena, CA, USA; Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Michael J Fassett
- Department of Obstetrics & Gynecology, Kaiser Permanente West Los Angeles Medical Center, Los Angeles, CA, USA
| | | | - Jiaxiao M Shi
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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Averbach S, Hofler L. Long-Acting Reversible Contraception With Contraceptive Implants and Intrauterine Devices. JAMA 2022; 327:2013-2014. [PMID: 35522320 DOI: 10.1001/jama.2022.5448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sarah Averbach
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego
- Center on Gender Equity and Health, University of California, San Diego
| | - Lisa Hofler
- Department of Obstetrics & Gynecology, University of New Mexico, Albuquerque
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Gatz JL, Armstrong MA, Postlethwaite D, Raine-Bennett T, Chillemi G, Alabaster A, Merchant M, Reed SD, Ichikawa L, Getahun D, Fassett MJ, Shi JM, Xie F, Chiu VY, Im TM, Takhar HS, Wang J, Saltus CW, Ritchey ME, Asiimwe A, Pisa F, Schoendorf J, Wahdan Y, Zhou X, Hunter S, Anthony MS, Peipert JF. Association between intrauterine device type and risk of perforation and device expulsion: results from the Association of Perforation and Expulsion of Intrauterine Devices study. Am J Obstet Gynecol 2022; 227:57.e1-57.e13. [PMID: 35395215 DOI: 10.1016/j.ajog.2022.03.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 03/14/2022] [Accepted: 03/30/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Intrauterine devices, including levonorgestrel-releasing and copper devices, are highly effective long-acting reversible contraceptives. The potential risks associated with intrauterine devices are low and include uterine perforation and device expulsion. OBJECTIVE This study aimed to evaluate the risk of perforation and expulsion associated with levonorgestrel-releasing devices vs copper devices in clinical practice in the United States. STUDY DESIGN The Association of Perforation and Expulsion of Intrauterine Devices study was a retrospective cohort study of women aged ≤50 years with an intrauterine device insertion during 2001 to 2018 and information on intrauterine device type and patient and medical characteristics. Of note, 4 research sites with access to electronic health records contributed data for the study: 3 Kaiser Permanente-integrated healthcare systems (Northern California, Southern California, and Washington) and 1 healthcare system using data from a healthcare information exchange in Indiana (Regenstrief Institute). Perforation was classified as any extension of the device into or through the myometrium. Expulsion was classified as complete (not visible in the uterus or abdomen or patient reported) or partial (any portion in the cervix or malpositioned). We estimated the crude incidence rates and crude cumulative incidence by intrauterine device type. The risks of perforation and expulsion associated with levonorgestrel-releasing intrauterine devices vs copper intrauterine devices were estimated using Cox proportional-hazards regression with propensity score overlap weighting to adjust for confounders. RESULTS Among 322,898 women included in this analysis, the incidence rates of perforation per 1000 person-years were 1.64 (95% confidence interval, 1.53-1.76) for levonorgestrel-releasing intrauterine devices and 1.27 (95% confidence interval, 1.08-1.48) for copper intrauterine devices; 1-year and 5-year crude cumulative incidence was 0.22% (95% confidence interval, 0.20-0.24) and 0.63% (95% confidence interval, 0.57-0.68) for levonorgestrel-releasing intrauterine devices and 0.16% (95% confidence interval, 0.13-0.20) and 0.55% (95% confidence interval, 0.44-0.68) for copper intrauterine devices, respectively. The incidence rates of expulsion per 1000 person-years were 13.95 (95% confidence interval, 13.63-14.28) for levonorgestrel-releasing intrauterine devices and 14.08 (95% confidence interval, 13.44-14.75) for copper intrauterine devices; 1-year and 5-year crude cumulative incidence was 2.30% (95% confidence interval, 2.24-2.36) and 4.52% (95% confidence interval, 4.40-4.65) for levonorgestrel-releasing intrauterine devices and 2.30% (95% confidence interval, 2.18-2.44) and 4.82 (95% confidence interval, 4.56-5.10) for copper intrauterine devices, respectively. Comparing levonorgestrel-releasing intrauterine devices with copper intrauterine devices, the adjusted hazard ratios were 1.49 (95% confidence intervals, 1.25-1.78) for perforation and 0.69 (95% confidence intervals, 0.65-0.73) for expulsion. CONCLUSION After adjusting for potential confounders, levonorgestrel-releasing intrauterine devices were associated with an increased risk of uterine perforation and a decreased risk of expulsion relative to copper intrauterine devices. Given that the absolute numbers of these events are low in both groups, these differences may not be clinically meaningful.
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Affiliation(s)
| | | | | | - Tina Raine-Bennett
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Health Systems Science, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA
| | - Giulia Chillemi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Amy Alabaster
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Maqdooda Merchant
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Laura Ichikawa
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Darios Getahun
- Department of Health Systems Science, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA; Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Michael J Fassett
- Department of Obstetrics and Gynecology, Kaiser Permanente West Los Angeles Medical Center, Los Angeles, CA; Department of Clinical Science, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA
| | - Jiaxiao M Shi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Fagen Xie
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Vicki Y Chiu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Theresa M Im
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Harpreet S Takhar
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Jinyi Wang
- Research Triangle Institute Health Solutions, Research Triangle Park, NC
| | | | - Mary E Ritchey
- Research Triangle Institute Health Solutions, Research Triangle Park, NC
| | | | | | | | | | - Xiaolei Zhou
- Research Triangle Institute Health Solutions, Research Triangle Park, NC
| | - Shannon Hunter
- Research Triangle Institute Health Solutions, Research Triangle Park, NC
| | - Mary S Anthony
- Research Triangle Institute Health Solutions, Research Triangle Park, NC
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