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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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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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Armstrong MA, Raine-Bennett T, Reed SD, Gatz J, Getahun D, Schoendorf J, Postlethwaite D, Fassett MJ, Peipert JF, Saltus CW, Merchant M, Alabaster A, Zhou X, Ichikawa L, Shi JM, Chiu VY, Xie F, Hunter S, Wang J, Ritchey ME, Chillemi G, Im TM, Takhar HS, Pisa F, Asiimwe A, Anthony MS. Association of the Timing of Postpartum Intrauterine Device Insertion and Breastfeeding With Risks of Intrauterine Device Expulsion. JAMA Netw Open 2022; 5:e2148474. [PMID: 35226086 PMCID: PMC8886522 DOI: 10.1001/jamanetworkopen.2021.48474] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Intrauterine device (IUD) expulsion increases the risk of unintended pregnancy; how timing of postpartum IUD insertion and breastfeeding are associated with risk of expulsion is relevant to the benefit-risk profile. OBJECTIVE To evaluate the association of postpartum timing of IUD insertion and breastfeeding status with incidence and risk of IUD expulsion. DESIGN, SETTING, AND PARTICIPANTS The Association of Perforation and Expulsion of Intrauterine Devices (APEX-IUD) cohort study included women aged 50 years or younger with an IUD insertion between 2001 and 2018. The breastfeeding analysis focused on a subcohort of women at 52 or fewer weeks post partum with known breastfeeding status. The study was conducted using data from electronic health records (EHRs) at 4 research sites with access to EHR: 3 Kaiser Permanente sites (Northern California, Southern California, Washington) and the Regenstrief Institute (Indiana). Data analysis was conducted from June to November 2019. EXPOSURES Timing of IUD insertion post partum was categorized into discrete time periods: 0 to 3 days, 4 days to 6 or fewer weeks, more than 6 weeks to 14 or fewer weeks, more than 14 weeks to 52 or fewer weeks, and non-post partum (>52 weeks or no evidence of delivery). Breastfeeding status at the time of insertion was determined from clinical records, diagnostic codes, or questionnaires from well-baby visits. MAIN OUTCOMES AND MEASURES Incidence rates and adjusted hazard ratios (aHRs) were estimated using propensity scores to adjust for confounding. RESULTS The full cohort included 326 658 women (mean [SD] age, 32.0 [8.3] years; 38 911 [11.9%] Asian or Pacific Islander; 696 [0.2%] Hispanic Black; 56 180 [17.2%] Hispanic other; 42 501 [13.0%] Hispanic White; 28 323 [8.7%] non-Hispanic Black; 137 102 [42.0%] non-Hispanic White), and the subcohort included 94 817 women. Most IUDs were levonorgestrel-releasing (259 234 [79.4%]). There were 8943 expulsions. The 5-year cumulative incidence of IUD expulsion was highest for insertions 0 to 3 days post partum (10.73%; 95% CI, 9.12%-12.61%) and lowest for insertions more than 6 weeks to 14 or fewer weeks post partum (3.18%; 95% CI, 2.95%-3.42%). Adjusted HRs using women with non-post partum IUD insertion as the referent were 5.34 (95% CI, 4.47-6.39) for those with postpartum insertion at 0 to 3 days; 1.22 (95% CI, 1.05-1.41) for those with postpartum insertion at 4 days to 6 or fewer weeks; 1.06 (95% CI, 0.95-1.18) for those with postpartum insertion at more than 6 to 14 or fewer weeks; and 1.43 (95% CI, 1.29-1.60) for those with postpartum insertion at more than 14 to 52 or fewer weeks. In the subcohort, 5-year cumulative incidence was 3.49% (95% CI, 3.25%-3.73%) for breastfeeding women and 4.57% (95% CI, 4.22%-4.95%) for nonbreastfeeding women; the adjusted HR for breastfeeding vs not breastfeeding was 0.71 (95% CI, 0.64-0.78). CONCLUSIONS AND RELEVANCE In this study of real-world data, IUD expulsion was rare but more common with immediate postpartum insertion. Breastfeeding was associated with lower expulsion risk.
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Affiliation(s)
| | - Tina Raine-Bennett
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Health Systems Science, the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | | | | | - Darios Getahun
- Department of Health Systems Science, the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | | | - Michael J. Fassett
- Department of Obstetrics & Gynecology, Kaiser Permanente West Los Angeles Medical Center, Los Angeles, California
- Department of Clinical Science, the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | | | | | - Maqdooda Merchant
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Amy Alabaster
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Xiaolei Zhou
- RTI Health Solutions, Research Triangle Park, North Carolina
| | - Laura Ichikawa
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Jiaxiao M. Shi
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Vicki Y. Chiu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Fagen Xie
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Shannon Hunter
- RTI Health Solutions, Research Triangle Park, North Carolina
| | - Jinyi Wang
- RTI Health Solutions, Research Triangle Park, North Carolina
| | - Mary E. Ritchey
- RTI Health Solutions, Research Triangle Park, North Carolina
| | - Giulia Chillemi
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Theresa M. Im
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Harpreet S. Takhar
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | | | - Mary S. Anthony
- RTI Health Solutions, Research Triangle Park, North Carolina
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The role of cine MR imaging in the assessment of uterine function. Arch Gynecol Obstet 2019; 300:545-553. [DOI: 10.1007/s00404-019-05222-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 06/19/2019] [Indexed: 11/26/2022]
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Qu Y, Xiao Z, Liu L, Lv F, Sheng B, Li J. Uterine Peristalsis Before and After Ultrasound-Guided High-Intensify Focused Ultrasound (USgHIFU) Treatment for Symptomatic Uterine Fibroids. Med Sci Monit 2019; 25:2553-2560. [PMID: 30955023 PMCID: PMC6698095 DOI: 10.12659/msm.913392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background This study investigated uterine peristalsis before and after ultrasound-guided high-intensify focused ultrasound (USgHIFU) treatment for symptomatic uterine fibroids by cine magnetic resonance imaging (cine MRI). Material/Methods A total of 30 patients with symptomatic uterine fibroids were treated by USgHIFU, who were subjected to cine MRI before and after USgHIFU treatment in the periovulatory phase. The images were analyzed for the existence, direction, and frequency of uterine peristalsis. The effects of uterine volume, the largest fibroid volume and location, and the fibroid number were examined before and after USgHIFU treatment. Results The incidence of uterine peristalsis was significantly increased after USgHIFU treatment. The main direction of uterine peristalsis before and after USgHIFU was cervix-to-fundus. In 12 cases, uterine peristalsis newly emerged after USgHIFU, and the largest fibroid volumes in these 12 cases were significantly smaller than in the remaining 18 cases before and after USgHIFU. The reduction rates of the largest fibroid volume in the 12 cases were significantly higher than in the remaining 18 cases. The largest fibroids were mainly located in the intramural area before and after USgHIFU. Conclusions USgHIFU treatment may contribute to the recovery of uterine peristalsis in patients with symptomatic fibroids, as detected by cine MRI. Uterine peristalsis recovery was related to the largest fibroid volume, especially for intramural fibroids.
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Affiliation(s)
- Yalin Qu
- Department of Radiology, Chongqing Dazu District People's Hospital, Chongqing, China (mainland)
| | - Zhibo Xiao
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Liuheng Liu
- Department of Radiology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China (mainland)
| | - Furong Lv
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Bo Sheng
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Jia Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
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van den Beukel BAW, Stommel MWJ, van Leuven S, Strik C, IJsseldijk MA, Joosten F, van Goor H, Ten Broek RPG. A Shared Decision Approach to Chronic Abdominal Pain Based on Cine-MRI: A Prospective Cohort Study. Am J Gastroenterol 2018; 113:1229-1237. [PMID: 29946174 DOI: 10.1038/s41395-018-0158-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 05/11/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Chronic abdominal pain develops in 11-20% of patients undergoing abdominal surgery, partly owing to post-operative adhesions. In this study we evaluate results of a novel diagnostic and therapeutic approach for pain associated with adhesions. METHODS Prospective cohort study including patients with a history of abdominal surgery referred to the outpatient clinic of a tertiary referral center for the evaluation of chronic abdominal pain. Subgroups were made based on outcome of adhesion mapping with cine-MRI and shared decision making. In operatively managed cases, anti-adhesion barriers were applied after adhesiolysis. Long-term results for pain were evaluated by a questionnaire. RESULTS A total of 106 patients were recruited. Seventy-nine patients had adhesions on cine-MRI, 45 of whom underwent an operation. Response rate to follow-up questionnaire was 86.8%. In the operative group (Group 1), the number of negative laparoscopies was 3 (6%). After a median of 19 (range 6-47) months follow-up, 80.0% of patients in group 1 reported improvement of pain, compared with 42.9% in patients with adhesions on cine-MRI who declined surgery (group 2), and 26.3% in patients with no adhesions on cine-MRI (group 3), P = 0.002. Consultation of medical specialists was significantly lower in group 1 compared with groups 2 and 3 (35.7 vs. 65.2 vs. 58.8%; P = 0.023). CONCLUSION We demonstrate long-term pain relief in two-thirds of patients with chronic pain likely caused by adhesions, using cine-MRI and a shared decision-making process. Long-term improvement of pain was achieved in 80% of patients who underwent surgery with concurrent application of an anti-adhesion barrier.
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Affiliation(s)
- Barend Arend Willem van den Beukel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands. Rijnstate Hospital Department of Radiology, Arnhem, The Netherlands. These authors jointly supervised: Harry van Goor H, Richard PG ten Broek
| | - Martijn Willem Jan Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands. Rijnstate Hospital Department of Radiology, Arnhem, The Netherlands. These authors jointly supervised: Harry van Goor H, Richard PG ten Broek
| | - Suzanne van Leuven
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands. Rijnstate Hospital Department of Radiology, Arnhem, The Netherlands. These authors jointly supervised: Harry van Goor H, Richard PG ten Broek
| | - Chema Strik
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands. Rijnstate Hospital Department of Radiology, Arnhem, The Netherlands. These authors jointly supervised: Harry van Goor H, Richard PG ten Broek
| | - Michiel Andreas IJsseldijk
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands. Rijnstate Hospital Department of Radiology, Arnhem, The Netherlands. These authors jointly supervised: Harry van Goor H, Richard PG ten Broek
| | - Frank Joosten
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands. Rijnstate Hospital Department of Radiology, Arnhem, The Netherlands. These authors jointly supervised: Harry van Goor H, Richard PG ten Broek
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands. Rijnstate Hospital Department of Radiology, Arnhem, The Netherlands. These authors jointly supervised: Harry van Goor H, Richard PG ten Broek
| | - Richard Peter Gerardus Ten Broek
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands. Rijnstate Hospital Department of Radiology, Arnhem, The Netherlands. These authors jointly supervised: Harry van Goor H, Richard PG ten Broek
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