The intrauterine device and ectopic pregnancy

Caesarean section and subsequent ectopic pregnancy: a systematic review and meta-analysis

BACKGROUND

Caesarean section rates are increasing worldwide, and the long-term effects are unknown.

OBJECTIVE

To evaluate the risk of subsequent ectopic pregnancy in women with a previous caesarean section, compared with vaginal delivery.

SEARCH STRATEGY

Systematic review of the literature using CINAHL, the Cochrane Library, Embase, Medline, PubMed, SCOPUS and Web of Knowledge, published from 1945 until 17 July 2011.

SELECTION CRITERIA

Cohort and case-control designs reporting on the mode of delivery and subsequent ectopic pregnancy. Two reviewers independently assessed the titles, abstracts, and full articles to identify eligible studies, using a standardised data collection form, and also assessed the study quality. Reference lists of the studies included were also cross-checked.

DATA COLLECTION AND ANALYSIS

Odds ratios (ORs) were combined using a random-effect model to estimate the overall association between caesarean section delivery and the risk of subsequent ectopic pregnancy.

MAIN RESULTS

Thirteen studies were included, which recruited a total of 61,978 women. Five studies reported adjustment for confounding factors, and the pooled OR of subsequent ectopic pregnancy following a caesarean section was 1.05 (95% CI 0.51-2.15). The removal of one study that reported outlier results yielded a pooled OR of 0.82 (95% CI 0.42-1.61). The pooled crude OR for all 13 studies was 1.36 (95% CI 0.99-1.88).

AUTHOR'S CONCLUSIONS

This review found no evidence of an association between prior caesarean section delivery and the occurrence of a subsequent ectopic pregnancy, but the studies included were of poor or variable quality, and only a small number adjusted for potential confounding factors. Further research of a higher methodological quality is required to assess any potential association between mode of delivery and subsequent ectopic pregnancy.

Copper intrauterine contraceptive device and pregnancy rate

Between August 1983 and August 1992, 1995 women aged 20-43 years were fitted with 2736 copper intrauterine contraceptive devices (MLCu250, MLCu375, Nova-T, Gravigard, Anticon). Insertion of the IUD was performed during menstruation by a skilled team of gynecologists. The women were instructed to self-check the IUD tail after each menstrual period. All the women were examined after one month and were followed-up every six months. The 1995 acceptors accumulated a total use of 69,350 months. During this period 39 accidental pregnancies occurred (Pearl Index 0.62, cumulative net pregnancy 1.95 per 100 women). Thirty-six pregnancies were intrauterine and three were ectopic. Most of the accidental pregnancies occurred during the first 12 months of use. The pregnancy rate of IUD users was negatively correlated with age. It is concluded that fitting the Cu-IUD intramenstrually, teaching the user to self-check herself and having frequent re-examinations seems to decrease the pregnancy rate in Cu-IUD users.

The pathology of intra-uterine contraceptive devices

The IUCD is a simple and effective way of producing contraception without the need for patient compliance. It is not rendered ineffective by other drugs, as may be steroid contraceptives, and its side-effects, for carefully selected patients, are considered by most practitioners to be acceptably low (Van Kets et al. 1989).

Safety of intrauterine contraception

Some of the risks which have been associated with the use of intrauterine contraception are reviewed. For users of copper-releasing IUDs, such as the Multiload Cu375 and TCu380, uterine perforations are rare, there is no evidence of an increased risk of infertility, and there probably is no increased risk of ectopic pregnancy after IUD removal. Any increased risk of pelvic inflammatory disease may be limited to the initial months of IUD use. The safety of intrauterine contraception needs to be re-evaluated for the newer IUDs, since most of the information relating to IUD safety is based on studies of devices which are no longer used or which are not in widespread use.

A prospective New Zealand study of fertility after removal of copper intrauterine contraceptive devices for conception and because of complications: a four-year study

A prospective New Zealand study was started in 1982 to determine fertility rates and pregnancy outcomes after removal of copper intrauterine contraceptive devices to allow conception or because of complications. In a combined 4-year study, there were 887 removals to allow conception and 164 due to complications. Participants were 375 (35.7%) nulligravid and 676 (64.3%) gravid women. Within 48 months, 91.5% of the nulligravid and 95.7% of the gravid women had conceived. A 2-year combined study, with regard to longer use of intrauterine contraceptive devices (greater than 2 years), did not show any significant reduction in fertility or increase in ectopic gestation within 24 months. However, in gravid women of similar age distribution, there was a significant increase in the miscarriage rate, compared with use of intrauterine contraceptive devices for less than 2 years or compared with nulligravid women. In a 1-year study, removals because of complications did not cause a significant reduction in fertility or an increase in ectopic gestation, miscarriage, or preterm delivery rates within 12 months, compared with removals to allow conception.

Ectopic pregnancy: a case-control study of aetiological risk factors

Aetiological risk factors for ectopic pregnancies were evaluated in a prospective study of 86 consecutive patients with ectopic pregnancy and two age- and parity-matched control groups of women in normal early pregnancy; those with planned pregnancy (65 pairs) and those having legal abortion (51 pairs). Compared with women with planned pregnancy, the patients with ectopic pregnancy more often had an IUD in situ, they had less frequently used hormonal contraception, and they had more legal abortions, curettages, previous ectopic pregnancies, gynaecological operations and salpingo-oophoritis. Compared with women having legal abortion, the patients with ectopic pregnancy had favoured IUD-usage, or they had been without any contraception, and they had an increased frequency of previous ectopic pregnancies. The frequency of fertility problems was also increased in patients with ectopic pregnancy. Our results show that gynaecological pelvic operations, endometrial curettage and evacuation, gynaecological infections, and usage of IUD are important risk factors for ectopic pregnancy, and that infertility seems to be a sign of this risk. In addition, the clinical characteristics of the patients with ectopic pregnancy were similar to those of the patients having legal abortion.

Clinical performance of copper-T-200, multiload-250 and Nova-T: A comparative multicentre study

A randomized multicentre study of Copper-T-200 (CuT), Multiload-250 (ML) and Nova-T (NoT) was conducted to evaluate the clinical performance of these three IUDs in the hands of general practitioners with varying experience in the different insertion techniques. After 36 months of use a total of 19,821 treatment cycles was accumulated. The continuation rate was 69.7% for CuT, 60.9% for ML and 61.8% for NoT. The cumulative expulsion rate after 36 months was 5.0% and equally distributed among centres and types of IUD. Removal for medical reasons was 11.4% and also equally distributed among the centres and the types of IUD. The pregnancy rate was insignificantly higher for the NoT compared with the two other types.