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Nguyen AT, Curtis KM, Tepper NK, Kortsmit K, Brittain AW, Snyder EM, Cohen MA, Zapata LB, Whiteman MK. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep 2024; 73:1-126. [PMID: 39106314 PMCID: PMC11315372 DOI: 10.15585/mmwr.rr7304a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2024] Open
Abstract
The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1-103). Notable updates include 1) the addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and 3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.
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Affiliation(s)
- Antoinette T. Nguyen
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Kathryn M. Curtis
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Naomi K. Tepper
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Katherine Kortsmit
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Anna W. Brittain
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Emily M. Snyder
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Megan A. Cohen
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Lauren B. Zapata
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Maura K. Whiteman
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
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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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Ultrasound-Guided Compared With Non–Ultrasound-Guided Placement of Immediate Postpartum Intrauterine Contraceptive Devices. Obstet Gynecol 2022; 140:91-93. [DOI: 10.1097/aog.0000000000004828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 11/26/2022]
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Marchin A, Moss A, Harrison M. A Meta-Analysis of Postpartum Copper IUD Continuation Rates in Low- and Middle-Income Countries. ACTA ACUST UNITED AC 2021; 4:36-46. [PMID: 33860278 DOI: 10.26502/fjwhd.2644-28840059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Long-acting reversible contraception (LARC) initiated immediately postpartum can reduce unintended or mistimed pregnancies, and contribute to proper pregnancy spacing. Data on use and continuation of postpartum LARC in low- and middle-income countries (LMIC) is limited. Methods We searched PubMed, OVID, Embase, Google Scholar, Cochrane, POPLINE, Global Health (CABI), and LILACS databases for relevant terms. Studies of any design, published in English, were screened for relevance based on six-month continuation rates of postpartum LARC, location of study, and LARC insertion within 48 hours after vaginal or cesarean birth. We found no relevant studies of implant or hormonal intrauterine device (IUD). Therefore, analysis was limited to studies of the copper IUD only. Two authors used the Cochrane Public Health Group Data Extraction and Assessment Template to guide data extraction to estimate pooled six-month continuation rates, and the Cochrane Risk of Bias Tool for Randomized Controlled Trials and the National Heart, Lung, and Blood Institute (NHLBI) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies to rate the quality of the studies. A random-effects meta-analysis of proportions was performed. Results Immediate-postpartum copper IUDs have a six-month continuation rate of 87% (95% CI 80-92%) in LMIC. The pooled estimated rates of six-month adverse outcomes were 6% (95% CI 5-9%) for expulsion, 5% (95% CI 4-7%) for removal, and 0.2% (95% CI 0.0-0.9%) for infection. Conclusions High six-month continuation rates and a low rate of adverse outcomes suggest immediate postpartum copper IUD insertion is a feasible and acceptable postpartum contraceptive option for women living in LMIC.
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Affiliation(s)
- Angela Marchin
- Planned Parenthood Federation of America, CO, United States
| | - Angela Moss
- University of Colorado School of Medicine, Colorado, United States
| | - Margo Harrison
- University of Colorado School of Medicine, Colorado, United States
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Muhumuza J, Migisha R, Ngonzi J, Kayondo M, Mugyenyi G. Risk factors for postpartum intrauterine device expulsion among women delivering at a tertiary Hospital in Uganda: a prospective cohort study. Contracept Reprod Med 2021; 6:7. [PMID: 33648587 PMCID: PMC7923832 DOI: 10.1186/s40834-021-00153-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 02/05/2021] [Indexed: 11/21/2022] Open
Abstract
Background Postpartum intrauterine device (PPIUD) use refers to intrauterine device (IUD) insertion after delivery but within 48 h of birth. In Uganda, the general use of modern methods of contraception is low with < 1% of the women adopting the IUD as a method of contraception. An important limiting factor to increased uptake of immediate postpartum IUD insertion may be its expulsion rates which vary widely. There is minimal documentation PPIUD expulsion rates and factors associated with PPIUD expulsion during puerperium in Uganda. Objective We aimed to determine the proportion of TCu380A (copper) intrauterine devices expelled by 6 weeks postpartum, and identify risk factors for expulsion among women delivering at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda. Methods We conducted a prospective cohort study from September 1, 2014 to January 31, 2015 at MRRH. We administered a structured questionnaire to all participants, to capture data on their baseline demographic, clinical and obstetric characteristics. We followed up women who accepted the PPIUD insertions at 6 weeks post insertion for any IUD expulsion. We fit multivariable log binomial regression models to identify risk factors for IUD expulsion. Results We enrolled 167 women who had PPIUDs inserted. Of the144 women who returned at 6 weeks for follow up, 13 (9%; 95%CI:4.9–15%) of them had the IUDs expelled. In the multivariable model, the significant risk factors for PPIUD expulsion were: IUD insertion more than 10 min post-delivery (aRR 8.1, 95%CI 1.26–51.98, p = 0.027) and bloody lochia flow of ≥15 days (aRR 8.5, 95%CI 1.47–48.47, p = 0.017). Conclusion The cumulative expulsion rate of postpartum IUDs among women delivering at MRRH was low and comparable to expulsion rates in interval insertions. Longer duration from delivery to IUD insertions and longer duration of bloody lochia flow were key risk factors for postpartum IUD expulsion. More emphasis should be put on prenatal counseling for postpartum family planning to allow for postplacental IUD insertions, which are associated with lower expulsion rates.
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Affiliation(s)
- Joy Muhumuza
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda.,Department of Obstetrics and Gynecology, Kampala International University, Kampala, Uganda
| | - Richard Migisha
- Department of Physiology, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda.
| | - Joseph Ngonzi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Musa Kayondo
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Godfrey Mugyenyi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
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Averbach SH, Ermias Y, Jeng G, Curtis KM, Whiteman MK, Berry-Bibee E, Jamieson DJ, Marchbanks PA, Tepper NK, Jatlaoui TC. Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis. Am J Obstet Gynecol 2020; 223:177-188. [PMID: 32142826 DOI: 10.1016/j.ajog.2020.02.045] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/13/2020] [Accepted: 02/24/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To provide updated and more detailed pooled intrauterine device expulsion rates and expulsion risk estimates among women with postpartum intrauterine device placement by timing of insertion, delivery type, and intrauterine device type to inform current intrauterine device insertion practices in the United States. DATA SOURCES We searched PubMed, Cochrane Library, and ClinicalTrials.gov through June 2019. STUDY ELIGIBILITY CRITERIA We included all studies, of any study design, that examined postpartum placement of Copper T380A (copper) or levonorgestrel-containing intrauterine devices that reported counts of expulsion. STUDY APPRAISAL AND SYNTHESIS METHODS We evaluated intrauterine device expulsion among women receiving postpartum intrauterine devices in the "immediate" (within 10 minutes), "early inpatient" (>10 minutes to <72 hours), "early outpatient" (72 hours to <4 weeks), and interval (≥4 weeks) time periods after delivery. We assessed study quality using the US Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of partial and complete intrauterine device expulsion separately and estimated adjusted relative risks by the timing of postpartum placement, delivery type, and intrauterine device type using log-binomial multivariable regression. RESULTS We identified 48 level I to II-3 studies of poor to good quality that reported a total of 7661 intrauterine device placements. Complete intrauterine device expulsion rates varied by timing of placement as follows: 10.2% (range, 0.0-26.7) for immediate; 13.2% (3.5-46.7) for early inpatient; 0% for early outpatient; and 1.8% (0.0-4.8) for interval placements. Complete intrauterine device expulsion rates also varied by delivery type: 14.8% (range, 4.8-43.1) for vaginal and 3.8% (0.0-21.1) for cesarean deliveries. Among immediate postpartum vaginal placements, the expulsion rate for levonorgetrel intrauterine devices was 27.4% (range, 18.8-45.2) and 12.4% (4.8-43.1) for copper intrauterine devices. Compared with interval placement, immediate and early postpartum placements (inpatient and outpatient combined) were associated with greater risk of complete expulsion (adjusted risk ratio, 8.33; 95% confidence interval, 4.32-16.08, and adjusted risk ratio, 5.27; 95% confidence interval, 2.56-10.85, respectively). Among immediate postpartum placements, risk of expulsion was greater for placement after vaginal compared with cesarean deliveries (adjusted risk ratio, 4.57; 95% confidence interval, 3.49-5.99). Among immediate placements at the time of vaginal delivery, levonorgestrel intrauterine devices were associated with a greater risk of expulsion compared with copper intrauterine devices (adjusted risk ratio, 1.90; 95% confidence interval, 1.36-2.65). CONCLUSION Although intrauterine device expulsion rates vary by timing of placement, type, and mode of delivery, intrauterine device insertion can take place at any time. Understanding the risk of intrauterine device expulsion at each time period will enable women to make an informed choice about when to initiate use of an intrauterine device in the postpartum period based on their own goals and preferences.
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Affiliation(s)
- Sarah H Averbach
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California San Diego, San Diego, CA.
| | - Yokabed Ermias
- School of Medicine, University of California San Diego, San Diego, CA
| | - Gary Jeng
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kathryn M Curtis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Maura K Whiteman
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Erin Berry-Bibee
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Denise J Jamieson
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA
| | - Polly A Marchbanks
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Naomi K Tepper
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Tara C Jatlaoui
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
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Kutlucan H, Karabacak RO, Wildemeersch D. Considerations on a new, frameless copper-releasing intrauterine system for intracesarean insertion and its future clinical significance: A review. J Turk Ger Gynecol Assoc 2020; 21:130-133. [PMID: 32517439 PMCID: PMC7294833 DOI: 10.4274/jtgga.galenos.2020.2020.0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Family planning is a system for attaining the desired number of children and enabling a desired spacing between pregnancies. Family planning can be achieved through both the use of contraceptive methods and the treatment of infertility. A woman’s ability to limit her pregnancy has a significant effect on her health.While family planning reduces the rate of unintented pregnancies, it also reduces the number of unsafe abortions. Contraception is an important component of family planning and reproductive health. Among various contraceptive methods, intrauterine devices (IUDs) are very popular because of some of the features of IUDs including being affordable, simplicity of insertion, long duration of action and reversibility. Modern, frameless, copper IUDs contain more copper and their copper content is contained in the solid tubular sleeves rather than in the wire which increases efficacy and lifespan. Immediate postpartum intrauterine device insertion (IPPI) during cesarean section can be considered in women who desire long acting, reversible contraception. Fertility returns instantly after removal of the device and pregnancy rate is not affected. IPPI is a very attractive method, especially for women who have undergone cesarean and require an interval of contraception before getting pregnant again. However, IPPI needs more clinical attention due to many aspects. The advantages remain including the prevention of unintended short interval pregnancies and, by providing an optimal timeframe for post-cesarean uterine recover, can reduce the incidence of the next cesarean delivery. With the publication of international IPPI studies, it will take a place in the range of globally available contraceptive methods, which in this author’s opinion, it deserves.
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Affiliation(s)
- Hazal Kutlucan
- Department of Gynecology and Obstetrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Recep Onur Karabacak
- Department of Gynecology and Obstetrics, Gazi University Faculty of Medicine, Ankara, Turkey
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Intrauterine Device Expulsion After Postpartum Placement: A Systematic Review and Meta-analysis. Obstet Gynecol 2019; 132:895-905. [PMID: 30204688 DOI: 10.1097/aog.0000000000002822] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To estimate expulsion rates among women with postpartum intrauterine device (IUD) placement by timing of insertion, IUD type, and delivery method. DATA SOURCES We searched PubMed, Cochrane Library, and ClinicalTrials.gov from 1974 to May 2018. METHODS OF STUDY SELECTION We searched databases for any published studies that examined postpartum placement of a copper IUD or levonorgestrel intrauterine system and reported counts of expulsions. We assessed study quality using the U.S. Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of IUD expulsion and estimated adjusted relative risks (RRs) for timing of postpartum placement, delivery method, and IUD type using log-binomial multivariable regression model. TABULATION, INTEGRATION, AND RESULTS We identified 48 level I to II-3 studies of poor to good quality. Pooled rates of expulsion varied by timing of IUD placement, ranging from 1.9% with interval placements (4 weeks postpartum or greater), 10.0% for immediate placements (10 minutes or less after placental delivery), and 29.7% for early placements (greater than 10 minutes to less than 4 weeks postpartum). Immediate and early postpartum placements were associated with increased risk of expulsion compared with interval placement (adjusted RR 7.63, 95% CI 4.31-13.51; adjusted RR 6.17, 95% CI 3.19-11.93, respectively). Postpartum placement less than 4 weeks after vaginal delivery was associated with an increased risk of expulsion compared with cesarean delivery (adjusted RR 5.19, 95% CI 3.85-6.99). Analysis of expulsion rates at less than 4 weeks postpartum also indicated that the levonorgestrel intrauterine system was associated with a higher risk of expulsion (adjusted RR 1.91, 95% CI 1.50-2.43) compared with CuT380A. CONCLUSION Postpartum IUD expulsion rates vary by timing of placement, delivery method, and IUD type. These results can aid in counseling women to make an informed choice about when to initiate their IUD and to help institutions implement postpartum contraception programs.
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Abdelhakim AM, Sunoqrot M, Amin AH, Nabil H, Raslan AN, Samy A. The effect of early vs. delayed postpartum insertion of the LNG-IUS on breastfeeding continuation: a systematic review and meta-analysis of randomised controlled trials. EUR J CONTRACEP REPR 2019; 24:327-336. [DOI: 10.1080/13625187.2019.1665175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Ahmed Mohamed Abdelhakim
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohammad Sunoqrot
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Hussein Amin
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hala Nabil
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ayman N. Raslan
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Samy
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Thompson EL, Vamos CA, Logan RG, Bronson EA, Detman LA, Piepenbrink R, Daley EM, Sappenfield WM. Patients and providers’ knowledge, attitudes, and beliefs regarding immediate postpartum long-acting reversible contraception: a systematic review. Women Health 2019; 60:179-196. [DOI: 10.1080/03630242.2019.1616042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Erika L. Thompson
- Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center, Fort Worth, USA
- The Chiles Center, College of Public Health, University of South Florida, Tampa, USA
| | - Cheryl A. Vamos
- The Chiles Center, College of Public Health, University of South Florida, Tampa, USA
| | - Rachel G. Logan
- The Chiles Center, College of Public Health, University of South Florida, Tampa, USA
| | - Emily A. Bronson
- Florida Perinatal Quality Collaborative & The Chiles Center, College of Public Health, University of South Florida, Tampa, USA
| | - Linda A. Detman
- Florida Perinatal Quality Collaborative & The Chiles Center, College of Public Health, University of South Florida, Tampa, USA
| | - Rumour Piepenbrink
- The Chiles Center, College of Public Health, University of South Florida, Tampa, USA
| | - Ellen M. Daley
- The Chiles Center, College of Public Health, University of South Florida, Tampa, USA
| | - William M. Sappenfield
- Florida Perinatal Quality Collaborative & The Chiles Center, College of Public Health, University of South Florida, Tampa, USA
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Vricella LK, Gawron LM, Louis JM, Louis JM. Society for Maternal-Fetal Medicine (SMFM) Consult Series #48: Immediate postpartum long-acting reversible contraception for women at high risk for medical complications. Am J Obstet Gynecol 2019; 220:B2-B12. [PMID: 30738885 DOI: 10.1016/j.ajog.2019.02.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Reproductive planning is essential for all women and most important for those with complex health conditions or at high risk for complications. Pregnancy planning can allow these high-risk women the opportunity to receive preconception counseling, medication adjustment, and risk assessment related to health conditions that have a direct impact on maternal morbidity and mortality risk. Despite the need for pregnancy planning, medically complex women face barriers to contraceptive use, including systemic barriers, such as underinsurance for women at increased risk for complex medical conditions as well as low uptake of effective postpartum contraception. Providing contraceptive counseling and a full range of contraceptive options, including immediate postpartum long-acting reversible contraception (LARC), is a means of overcoming these barriers. The purpose of this document is to educate all providers, including maternal-fetal medicine subspecialists, about the benefits of postpartum contraception, and to advocate for widespread implementation of immediate postpartum LARC placement programs. The following are Society for Maternal-Fetal Medicine recommendations: we recommend that LARC be offered to women at highest risk for adverse health events as a result of a future pregnancy (GRADE 1B); we recommend that obstetric care providers discuss the availability of immediate postpartum LARC with all pregnant women during prenatal care and consult the U.S. Medical Eligibility Criteria for Contraceptive Use guidelines to determine methods most appropriate for specific medical conditions (GRADE 1C); we recommend that women considering immediate postpartum intrauterine device insertion be counseled that although expulsion rates are higher than with delayed insertion, the benefits appear to outweigh the risk of expulsion, as the long-term continuation rates are higher (GRADE 1C); we recommend that obstetric care providers wishing to utilize immediate postpartum LARC obtain training specific to the immediate postpartum period (BEST PRACTICE); for women who desire and are eligible for LARC, we recommend immediate postpartum placement after a high-risk pregnancy over delayed placement due to overall superior efficacy and cost-effectiveness (GRADE 1B); we recommend that women considering immediate postpartum LARC be encouraged to breastfeed, as current evidence suggests that these methods do not negatively influence lactation (GRADE 1B); for women who desire and are eligible for LARC, we suggest that early postpartum LARC placement be considered when immediate postpartum LARC placement is not feasible (GRADE 2C); and we recommend that contraceptive counseling programs be patient-centered and provided in a shared decision-making framework to avoid coercion (BEST PRACTICE).
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Affiliation(s)
| | | | | | - Judette M Louis
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Whitaker AK, Chen BA. Society of Family Planning Guidelines: Postplacental insertion of intrauterine devices. Contraception 2018; 97:2-13. [DOI: 10.1016/j.contraception.2017.09.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 09/27/2017] [Accepted: 09/28/2017] [Indexed: 01/09/2023]
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Postpartum LARC: Best Practices, Policy and Public Health Implications. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0225-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Practice Bulletin No. 186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Obstet Gynecol 2017; 130:e251-e269. [PMID: 29064972 DOI: 10.1097/aog.0000000000002400] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Intrauterine devices and contraceptive implants, also called long-acting reversible contraceptives (LARC), are the most effective reversible contraceptive methods. The major advantage of LARC compared with other reversible contraceptive methods is that they do not require ongoing effort on the part of the patient for long-term and effective use. In addition, after the device is removed, the return of fertility is rapid (1, 2). The purpose of this Practice Bulletin is to provide information for appropriate patient selection and evidence-based recommendations for LARC initiation and management. The management of clinical challenges associated with LARC use is beyond the scope of this document and is addressed in Committee Opinion No. 672, Clinical Challenges of Long-Acting Reversible Contraceptive Methods (3).
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Moniz MH, Roosevelt L, Crissman HP, Kobernik EK, Dalton VK, Heisler MH, Low LK. Immediate Postpartum Contraception: A Survey Needs Assessment of a National Sample of Midwives. J Midwifery Womens Health 2017; 62:538-544. [PMID: 28881464 PMCID: PMC5924570 DOI: 10.1111/jmwh.12653] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/05/2017] [Accepted: 06/13/2017] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Immediate postpartum long-acting, reversible contraception (LARC)-providing intrauterine devices (IUDs) and contraceptive implants immediately following birth-is an effective strategy to prevent unintended pregnancies and improve birth spacing. We measured US certified nurse-midwives' (CNMs') and certified midwives' (CMs') knowledge, training needs, current practice, and perceived barriers to providing immediate postpartum LARC. METHODS We invited currently practicing CNM and CM members of the American College of Nurse-Midwives to complete an online survey about their knowledge and experience with the use of LARC and analyzed eligible questionnaires using descriptive statistics. RESULTS Of 4609 eligible midwives, 794 responded (17% response rate). Most were female (99.5%) and non-Hispanic white (92.1%), with 45.0% attending births in urban settings. Responses revealed multiple knowledge gaps related to IUD expulsion rates and appropriateness of immediate postpartum LARC in certain clinical scenarios. Only 10.1% of respondents reported feeling confident to insert an immediate postpartum IUD and 43.3% an implant. Many reported desiring additional training in immediate postpartum IUD (63.5%) and implant (22.8%) insertion; few reported access to such training (IUD, 19.9%; implant, 15.2%). Most respondents had never inserted an immediate postpartum IUD (90.7%) or implant (86.8%). The most commonly cited barriers to immediate postpartum LARC provision were that it is not standard practice (IUD, 40.9%; implant, 39.0%) or is not available (IUD, 27.8%; implant, 34.8%) at one's institution and feeling inadequately trained (IUD, 26.5%; implant, 10.7%). DISCUSSION Nine in 10 midwife respondents have never inserted an IUD or implant immediately postpartum, but more than half indicated they would like the opportunity to provide these services. Our findings highlight opportunities to enhance the immediate postpartum LARC-related knowledge and skills of the midwife workforce. They also suggest that logistic and institutional barriers to immediate postpartum LARC access must be removed in order to make this evidence-based reproductive health service available to all women who desire it.
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Eggebroten JL, Sanders JN, Turok DK. Immediate postpartum intrauterine device and implant program outcomes: a prospective analysis. Am J Obstet Gynecol 2017; 217:51.e1-51.e7. [PMID: 28342716 DOI: 10.1016/j.ajog.2017.03.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 03/07/2017] [Accepted: 03/14/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND In-hospital placement of intrauterine devices and contraceptive implants following vaginal and cesarean delivery is increasingly popular and responds to maternal motivation for highly effective postpartum contraception. Immediate postpartum intrauterine device insertion is associated with higher expulsion than interval placement, but emerging evidence suggests that the levonorgestrel intrauterine device may have a higher expulsion rate than the copper intrauterine device. OBJECTIVE This study evaluated in-hospital provision, expulsion, and 6-month continuation of immediate postpartum copper T380 intrauterine devices, levonorgestrel intrauterine devices, and contraceptive implants. STUDY DESIGN We offered enrollment in this prospective observational trial to women presenting to the University of Utah labor and delivery unit from October 2013 through February 2016 who requested an intrauterine device or implant for postpartum contraception during prenatal care or hospitalization at the time of delivery. Following informed consent, participants completed questionnaires prior to hospital discharge and at 3 and 6 months postpartum. Data on expulsions at 6 months were validated by chart abstraction. RESULTS During the study period, 639 patients requested a postpartum intrauterine device or implant and 350 patients enrolled in prospective follow-up prior to discharge from the hospital. Among enrollees, 325 (93%) received their preferred contraceptive device prior to hospital discharge: 88 (27%) copper intrauterine device users, 123 (38%) levonorgestrel intrauterine device users, and 114 (35%) implant users. Participants predominantly were Hispanic (90%), were multiparous (87%), reported a household income <$24,000 per year (87%), and underwent a vaginal delivery (77%). At 6 months postpartum, 289 of 325 device recipients (89%) completed follow-up. Among levonorgestrel intrauterine device users 17% reported expulsions relative to 4% of copper intrauterine device users. The adjusted hazard ratio for expulsion was 5.8 (confidence interval, 1.3-26.4). There was no statistically significant difference in expulsions by delivery type or continuation by device type. Among the 21 women who experienced intrauterine device expulsions, 14 (67%) requested a replacement long-acting reversible contraception device for contraception. The 6-month device continuation was ≥80% for all device types. CONCLUSION An immediate postpartum long-acting reversible contraception program effectively provides women who desire highly effective reversible contraceptive devices with their method of choice prior to hospital discharge. Immediate postplacental levonorgestrel intrauterine device users have higher expulsion rates than copper intrauterine device users, but >8 of 10 women initiating an intrauterine device or implant continue use at 6 months postpartum.
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Affiliation(s)
| | - Jessica N Sanders
- University of Utah Department of Obstetrics and Gynecology, Salt Lake City, UT
| | - David K Turok
- University of Utah Department of Obstetrics and Gynecology, Salt Lake City, UT
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Abstract
Immediate postpartum long-acting reversible contraception (LARC) has the potential to reduce unintended and short-interval pregnancy. Women should be counseled about all forms of postpartum contraception in a context that allows informed decision making. Immediate postpartum LARC should be offered as an effective option for postpartum contraception; there are few contraindications to postpartum intrauterine devices and implants. Obstetrician-gynecologists and other obstetric care providers should discuss LARC during the antepartum period and counsel all pregnant women about options for immediate postpartum initiation. Education and institutional protocols are needed to raise clinician awareness and to improve access to immediate postpartum LARC insertion. Obstetrician-gynecologists and other obstetric care providers should incorporate immediate postpartum LARC into their practices, counsel women appropriately about advantages and risks, and advocate for institutional and payment policy changes to support provision.
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Taub RL, Jensen JT. Advances in contraception: new options for postpartum women. Expert Opin Pharmacother 2017; 18:677-688. [DOI: 10.1080/14656566.2017.1316370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Zerden ML, Stuart GS, Charm S, Bryant A, Garrett J, Morse J. Two-week postpartum intrauterine contraception insertion: a study of feasibility, patient acceptability and short-term outcomes. Contraception 2017; 95:65-70. [DOI: 10.1016/j.contraception.2016.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 08/15/2016] [Accepted: 08/16/2016] [Indexed: 10/21/2022]
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Elsedeek MS. Comparison between the traditional non-guided and a novel ultrasound-guided technique for office fitting of intrauterine contraceptive devices. Int J Gynaecol Obstet 2016; 133:338-41. [DOI: 10.1016/j.ijgo.2015.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/01/2015] [Accepted: 02/10/2016] [Indexed: 12/17/2022]
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Abstract
As birth spacing has demonstrated health benefits for a woman and her children, contraception after childbirth is recognized as an important health issue. The potential risk of pregnancy soon after delivery underscores the importance of initiating postpartum contraception in a timely manner. The contraceptive method initiated in the postpartum period depends upon a number of factors including medical history, anatomic and hormonal factors, patient preference, and whether or not the woman is breastfeeding. When electing a contraceptive method, informed choice is paramount. The availability of long-acting reversible contraceptive methods immediately postpartum provides a strategy to achieve reductions in unintended pregnancy.
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Elsedeek MSE. Five-year follow-up of two types of contraceptive device fitted during elective cesarean delivery. Int J Gynaecol Obstet 2015; 130:179-82. [PMID: 25957802 DOI: 10.1016/j.ijgo.2015.02.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 02/05/2015] [Accepted: 04/17/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To present follow-up data for patients fitted with a copper intrauterine contraceptive device (IUCD) or the levonorgestrel intrauterine system (IUS) during cesarean delivery. METHODS Between March 2006 and December 2011, a prospective study was undertaken of women who were scheduled to have a repeat cesarean for a singleton pregnancy and had chosen to undergo intraoperative fitting of an IUCD or the IUS. Participants were followed up for up to 5 years using transvaginal ultrasonography, clinical evaluation, and a questionnaire. RESULTS Among 143 participants, 63 requested the IUCD and 80 the IUS. Misalignment was more common at 6 weeks with the IUS (37 [46.3%] patients) than with the IUCD (22 [34.9%]; P=0.06). Spontaneous expulsion occurred in the IUCD group only (4 [6.3%] patients). No pregnancies were reported in the IUS group, whereas 4 (6.3%) women with the IUCD became pregnant. CONCLUSION Although misalignment of an IUCD or the IUS is fairly common after intraoperative insertion, the contraceptive performance and menstrual pattern are not affected. Therefore, there is no need to remove or replace a misaligned IUCD or IUS.
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Affiliation(s)
- Mervat S E Elsedeek
- Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Alexandria, Egypt; Shatby Maternity University Hospital, Alexandria, Egypt.
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Stuart GS, Lesko CR, Stuebe AM, Bryant AG, Levi EE, Danvers AI. A randomized trial of levonorgestrel intrauterine system insertion 6 to 48 h compared to 6 weeks after vaginal delivery; lessons learned. Contraception 2015; 91:284-8. [DOI: 10.1016/j.contraception.2014.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 12/16/2014] [Accepted: 12/21/2014] [Indexed: 10/24/2022]
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Kaneshiro B, Salcedo J. Contraception for Adolescents: Focusing on Long-Acting Reversible Contraceptives (LARC) to Improve Reproductive Health Outcomes. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015; 4:53-60. [PMID: 27635305 PMCID: PMC5021306 DOI: 10.1007/s13669-015-0112-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Adolescent pregnancy rates in the U.S. have reached an all-time low from their peak in the 1980s and 1990s. However, the U.S. maintains the highest rate of teenage pregnancy among developed nations. Adolescents experience higher typical use failure rates for user-dependent contraceptives compared to their adult counterparts. Long-acting reversible contraception (LARC), IUDs and implants, have failure rates that are both very low and independent of user age. In settings where the most effective methods are prioritized and access barriers are removed, the majority of adolescents initiate LARC. Use of LARC by adolescents significantly reduces rates of overall and repeat teen pregnancy. All methods of contraception are safe for use in teens, including IUDs and DMPA. Dual use of LARC and barrier methods to reduce risk of sexually transmitted infection, is the optimal contraceptive strategy for most adolescents. Adolescent access to evidence-based and confidential contraceptive services, provided in a manner that respects autonomy, is a vital public health goal.
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Affiliation(s)
- Bliss Kaneshiro
- Department of Obstetrics, Gynecology and Women’s Health University of Hawaii John A. Burns School of Medicine, 1319 Punahou Street #824, Honolulu, HI 96826, Phone: (808) 203-6500, Fax: (808) 955-2175
| | - Jennifer Salcedo
- Department of Obstetrics, Gynecology and Women’s Health University of Hawaii John A. Burns School of Medicine, 1319 Punahou Street #824, Honolulu, HI 96826, Phone: (808) 203-6500, Fax: (808) 955-2175
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Singal S, Bharti R, Dewan R, Divya, Dabral A, Batra A, Sharma M, Mittal P. Clinical Outcome of Postplacental Copper T 380A Insertion in Women Delivering by Caesarean Section. J Clin Diagn Res 2014; 8:OC01-4. [PMID: 25386484 DOI: 10.7860/jcdr/2014/10274.4786] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 07/17/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Short interconception period after caesarean section and its associated risk of increased morbidity, mortality and surgical interventions could be avoided by postplacental IUCD insertion during the procedure. Despite the safety reports on intracaesarean IUCD insertion, obstetricians are still hesitant to extend the benefit of this long acting reversible contraception to women undergoing operative delivery. OBJECTIVE To study the clinical outcome (safety, efficacy, expulsion and continuation rates) of postplacental Copper T 380A insertion in primiparous women undergoing caesarean section. MATERIALS AND METHODS This study was a prospective observational study, carried out in the Department of Obstetrics and Gynaecology, Safdarjung hospital, which is a tertiary care hospital of Northern India. Primiparous women who delivered by caesarean section over a period of six months (July 2012 to December 2012), willing for postplacental intracaesarean IUCD insertion, and willing to comply with the study protocol, were recruited for the study. All these subjects fulfilled the WHO Standard Medical Criteria for PPIUCD insertion; follow up visits were scheduled at 1, 3, 6 and 12 months. RESULTS A total of 300 primiparous women underwent postpartum intracaesarean insertion of Copper T 380A. The mean age of women included in the study was 23.12 ± 2.42 years. Most common postinsertion complication observed in the immediate postoperative period was febrile morbidity (2%). Majority of women (94.33%) had hospital stay of less than 4 days. The common adverse events observed during follow-up of 12 months were menstrual complaints, excessive vaginal discharge and persistent pelvic pain. At the end of one year, there were 16 expulsions, 21 removals, and 2 pregnancies with gross cumulative expulsion, removal, failure and continuation rates of 5.33%, 7%, 0.67% and 91%, respectively. CONCLUSION Postplacental intracaesarean Copper T 380A insertion in primiparous women is a safe and effective method of reversible contraception, with low expulsion and high continuation rates.
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Affiliation(s)
- Sunita Singal
- Ex Chief Medical Officer (SAG), Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital , New Delhi, India
| | - Rekha Bharti
- Assistant Professor, Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital New Delhi, India
| | - Rupali Dewan
- Consultant & Professor, Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital New Delhi, India
| | - Divya
- Postgraduate Student, Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital New Delhi, India
| | - Anjali Dabral
- Chief Medical Officer (SAG), Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital New Delhi, India
| | - Achla Batra
- Consultant & Associate Professor, Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital New Delhi, India
| | - Manjula Sharma
- Consultant & Professor, Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital New Delhi, India
| | - Pratima Mittal
- Head of Department, Consultant & Professor, Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital New Delhi, India
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Jatlaoui TC, Marcus M, Jamieson DJ, Goedken P, Cwiak C. Postplacental intrauterine device insertion at a teaching hospital. Contraception 2013; 89:528-33. [PMID: 24565735 DOI: 10.1016/j.contraception.2013.10.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 10/11/2013] [Accepted: 10/16/2013] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine whether postplacental intrauterine device (IUD) insertion can be safely and effectively performed within a teaching program. STUDY DESIGN This was a prospective cohort of 177 subjects planning vaginal delivery enrolled antenatally who desired postplacental IUD insertion of either the copper T380A IUD or levonorgestrel IUS. Insertions were performed primarily by resident physicians following a training session. Follow-up included a 4- to 8-week visit and telephone calls at 3 and 6 months. RESULTS Ninety-nine subjects underwent successful postplacental IUD insertion of 100 attempts. Seventeen expulsions (17%) were noted: 10 complete and 7 partial. The study identified no differences in outcome by training level; however, the study lacked statistical power to evaluate anything other than large differences. CONCLUSION Postplacental IUD insertions can be safely and effectively performed within a training program. IMPLICATIONS A training protocol may safely and feasibly be initiated among physicians, advanced practice clinicians or trainees with no prior experience with postplacental IUD insertion. By initiating this practice, access to highly effective contraception may increase for patients who have difficulty returning for a visit or otherwise receiving effective methods.
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Affiliation(s)
- Tara C Jatlaoui
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA.
| | - Michele Marcus
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Denise J Jamieson
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Peggy Goedken
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Carrie Cwiak
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
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Prescott GM, Matthews CM. Long-Acting Reversible Contraception: A Review in Special Populations. Pharmacotherapy 2013; 34:46-59. [DOI: 10.1002/phar.1358] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Gina M. Prescott
- Department of Pharmacy Practice; University at Buffalo School of Pharmacy and Pharmaceutical Sciences; Buffalo New York
| | - Christina M. Matthews
- Department of Pharmacy Practice; University at Buffalo School of Pharmacy and Pharmaceutical Sciences; Buffalo New York
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Cappiello J, Bosak J. IUDs: beyond the basics. Nurse Pract 2013; 38:40-46. [PMID: 23958671 DOI: 10.1097/01.npr.0000433075.30022.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This article reviews the changes in patient selection for intrauterine devices (IUDs) and evidence-based practices regarding counseling and management of common IUD issues. Where evidence-based research is lacking, expert opinion and common standards of practice are reviewed, and current clinical resources are identified.
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Simmons KB, Edelman AB, Li H, Yanit KE, Jensen JT. Personalized contraceptive assistance and uptake of long-acting, reversible contraceptives by postpartum women: a randomized, controlled trial. Contraception 2013; 88:45-51. [DOI: 10.1016/j.contraception.2012.10.037] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 10/26/2012] [Accepted: 10/31/2012] [Indexed: 11/29/2022]
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Mwalwanda CS, Black KI. Immediate post-partum initiation of intrauterine contraception and implants: a review of the safety and guidelines for use. Aust N Z J Obstet Gynaecol 2013; 53:331-7. [PMID: 23635040 DOI: 10.1111/ajo.12095] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 03/24/2013] [Indexed: 10/26/2022]
Abstract
Women are particularly susceptible to unintended pregnancies in the first year after birth, with 10-44% of pregnancies being unintended. In many settings, post-partum birth control is initiated at the six-week post-partum visit but most women are sexually active by this time, and ovulation can occur as early as day 28. There are many potential advantages of initiating intrauterine contraception (IUC) and implants use in the immediate post-partum period, including their high efficacy and reversibility which rivals sterilisation as well as ease of access to providers trained in their insertion. This review aims to describe the benefits and risks of use of IUC and implants in the immediate post-partum period. It discusses the maternal and infant health safety issues of early initiation of the progestogen containing methods and provides a critical review of existing international guidelines. Overall low rates of adverse effects such as pain, bleeding, infection and perforation, are documented to occur in all studies regardless of the timing or route of IUC insertion. Expulsion rates are significantly higher immediately after vaginal delivery compared to interval insertions, but are no higher after insertion at caesarean section. Post-partum implants appear to have the same side effects as interval insertions, and to date, no adverse impact on breast milk or infant growth has been demonstrated. Most international evidence-based guidelines support the initiation of IUC and progestogen containing contraceptive methods in the immediate post-partum period as they regard the advantages of provision at this time to outweigh the risks.
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Affiliation(s)
- Carolyn S Mwalwanda
- Discipline of Obstetrics, Gynaecology and Neonatology, University of Sydney, Sydney, New South Wales, Australia
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Eisenberg D, McNicholas C, Peipert JF. Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents. J Adolesc Health 2013; 52:S59-63. [PMID: 23535059 DOI: 10.1016/j.jadohealth.2013.01.012] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 01/02/2013] [Accepted: 01/03/2013] [Indexed: 01/31/2023]
Abstract
Cost is a major barrier to adolescents' ability to obtain long-acting reversible contraception (LARC). By reviewing the available literature on this issue, we provide a framework to understand how insurance coverage, out-of-pocket expenses, parental involvement, and recent pregnancy can impact access. We provide examples of cost-free access to LARC for adolescents, such as the Contraceptive CHOICE Project. Universal coverage for contraception, without cost-sharing, could increase use of LARC among adolescents resulting in fewer unintended pregnancies, improved health outcomes, and considerable cost savings to the healthcare system.
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Affiliation(s)
- David Eisenberg
- Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, Missouri 63110, USA.
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Attia AM, Ibrahim MM, Abou-Setta AM. Role of the levonorgestrel intrauterine system in effective contraception. Patient Prefer Adherence 2013; 7:777-85. [PMID: 23990713 PMCID: PMC3749061 DOI: 10.2147/ppa.s36948] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Norgestrel, a synthetic progestin chemically derived from 19-nortestosterone, is six times more potent than progesterone, with variable binding affinity to various steroid receptors. The levonorgestrel-releasing intrauterine system (LNG IUS) provides a long-acting, highly effective, and reversible form of contraception, with a pearl index of 0.18 per 100 women-years. The locally released hormone leads to endometrial concentrations that are 200-800 times those found after daily oral use and a plasma level that is lower than that with other forms of levonorgestrel-containing contraception. The contraceptive effect of the LNG IUS is achieved mainly through its local suppressive effect on the endometrium, leading to endometrial thinning, glandular atrophy, and stromal decidualization without affecting ovulation. The LNG IUS is generally well tolerated. The main side effects are related to its androgenic activity, which is usually mild and transient, resolving after the first few months. Menstrual abnormalities are also common but well tolerated, and even become desirable (eg, amenorrhea, hypomenorrhea, and oligomenorrhea) with proper counseling of the patient during the choice of the method of contraception. The satisfaction rates after 3 years of insertion are high, reaching between 77% and 94%. The local effect of the LNG IUS on the endometrium and low rates of systemic adverse effects have led to its use in other conditions rather than contraception, as for the treatment of endometrial hyperplasia, benign menorrhagia, endometriosis, adenomyosis, and uterine fibroids.
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Affiliation(s)
| | - Magdy M Ibrahim
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
| | - Ahmed M Abou-Setta
- George and Fay Yee Centre for Healthcare Innovation, University of Manitoba/Winnipeg Regional Health Authority, Winnipeg, MB, Canada
- Correspondence: Ahmed M Abou-Setta George and Fay Yee, Center for Healthcare Innovation, University of Manitoba/Winnipeg Regional Health Authority, GH-714–820 Sherbrook Street, Winnipeg, MB R3A 1R9, Canada, Tel +1 204 787 8707, Fax +1 204 787 7567, email
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Stuart GS, Bryant AG, O'Neill E, Doherty IA. Feasibility of postpartum placement of the levonorgestrel intrauterine system more than 6 h after vaginal birth. Contraception 2011; 85:359-62. [PMID: 22067759 DOI: 10.1016/j.contraception.2011.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Revised: 07/21/2011] [Accepted: 08/10/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND The objective of this study was to determine the feasibility of postpartum levonorgestrel intrauterine system (LNG-IUS) placement on the postpartum ward. STUDY DESIGN This case-series study took place in a teaching hospital in North Carolina. Women were followed for 6 months, and data on method satisfaction, study design satisfaction and expulsion were collected. Descriptive statistics were used. RESULTS Forty women enrolled. Twenty-nine women (73%) received the LNG-IUS at a median of 20 h (range 7-48 h) after delivery, and all reported that they would recommend this method of contraception to a friend. Eleven women had a spontaneous expulsion (38%; 95% confidence interval 21, 58). CONCLUSION Placement of LNG-IUS more than 6 h postpartum was acceptable to women in this study. The expulsion rate of 38% had statistical instability and should be interpreted with caution. However, our report may assist with individual counseling of women interested in postpartum LNG-IUS placement, or in future study designs.
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Affiliation(s)
- Gretchen S Stuart
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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GEMZELL-DANIELSSON KRISTINA, INKI PIRJO, HEIKINHEIMO OSKARI. Recent developments in the clinical use of the levonorgestrel-releasing intrauterine system. Acta Obstet Gynecol Scand 2011; 90:1177-88. [DOI: 10.1111/j.1600-0412.2011.01256.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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The benefits and risks of using a levonorgestrel-releasing intrauterine system for contraception. Contraception 2011; 85:224-34. [PMID: 22067761 DOI: 10.1016/j.contraception.2011.08.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 08/05/2011] [Accepted: 08/05/2011] [Indexed: 11/24/2022]
Abstract
The contraceptive profile of the levonorgestrel-releasing intrauterine system (LNG-IUS; Mirena®) is well established, with efficacy similar to that achieved with sterilization and rapid return to fertility after discontinuation of use. The LNG-IUS is typically associated with transient menstrual disturbance during the first few months of use, but this usually settles with continued use, with a concomitant decrease in menstrual blood loss. Overall, the safety profile of the LNG-IUS has been well established across a wide population of women, and the available data do not suggest that the LNG-IUS adversely affects bone health or increase the risk of adverse cardiovascular events or breast and uterine cancers. This article reviews the literature to provide updated information on the risks and benefits associated with the LNG-IUS, particularly focusing on its use in contraception.
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Norman WV, Kaczorowski J, Soon JA, Brant R, Bryan S, Trouton KJ, Dicus L. Immediate vs. delayed insertion of intrauterine contraception after second trimester abortion: study protocol for a randomized controlled trial. Trials 2011; 12:149. [PMID: 21672213 PMCID: PMC3141529 DOI: 10.1186/1745-6215-12-149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 06/14/2011] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND We describe the rationale and protocol for a randomized controlled trial (RCT) to assess whether intrauterine contraception placed immediately after a second trimester abortion will result in fewer pregnancies than current recommended practice of intended placement at 4 weeks post-abortion. Decision analysis suggests the novel strategy could substantially reduce subsequent unintended pregnancies and abortions. This paper highlights considerations of design, implementation and evaluation of a trial expected to provide rigorous evidence for appropriate insertion timing and health economics of intrauterine contraception after second trimester abortion. METHODS/DESIGN Consenting women choosing to use intrauterine contraception after abortion for a pregnancy of 12 to 24 weeks will be randomized to insertion timing groups either immediately (experimental intervention) or four weeks (recommended care) post abortion. Primary outcome measure is pregnancy rate at one year. Secondary outcomes include: cumulative pregnancy rates over five year follow-up period, comprehensive health economic analyses comparing immediate and delayed insertion groups, and device retention rates, complication rates (infection, expulsion) and, contraceptive method satisfaction. Web-based Contraception Satisfaction Questionnaires, clinical records and British Columbia linked health databases will be used to assess primary and secondary outcomes. Enrolment at all clinics in the province performing second trimester abortions began in May 2010 and is expected to complete in late 2011. Data on one year outcomes will be available for analysis in 2014. DISCUSSION The RCT design combined with access to clinical records at all provincial abortion clinics, and to information in provincial single-payer linked administrative health databases, birth registry and hospital records, offers a unique opportunity to evaluate such an approach by determining pregnancy rate at one through five years among enrolled women. We highlight considerations of design, implementation and evaluation of a trial expected to provide rigorous evidence for appropriate insertion timing and health economics of intrauterine contraception after second trimester abortion.
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Affiliation(s)
- Wendy V Norman
- Contraception & Abortion Research Team, Women's Health Research Institute, Vancouver, British Columbia, V6H 1G3, Canada
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Janusz Kaczorowski
- Contraception & Abortion Research Team, Women's Health Research Institute, Vancouver, British Columbia, V6H 1G3, Canada
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Judith A Soon
- Contraception & Abortion Research Team, Women's Health Research Institute, Vancouver, British Columbia, V6H 1G3, Canada
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Rollin Brant
- Contraception & Abortion Research Team, Women's Health Research Institute, Vancouver, British Columbia, V6H 1G3, Canada
- Department of Statistics, University of British Columbia, Vancouver, British Columbia, V6H 3V4, Canada
| | - Stirling Bryan
- Contraception & Abortion Research Team, Women's Health Research Institute, Vancouver, British Columbia, V6H 1G3, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada
- The Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, V5Z 1M9, Canada
| | - Konia J Trouton
- Contraception & Abortion Research Team, Women's Health Research Institute, Vancouver, British Columbia, V6H 1G3, Canada
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada
- Vancouver Island Women's Clinic, Victoria, British Columbia, V9B 1T2, Canada
| | - Lyda Dicus
- Contraception & Abortion Research Team, Women's Health Research Institute, Vancouver, British Columbia, V6H 1G3, Canada
- CARE Program, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, V6H 3N1, Canada
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Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol 2010; 116:1079-87. [PMID: 20966692 DOI: 10.1097/aog.0b013e3181f73fac] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To estimate whether 6-month use of the levonorgestrel-releasing intrauterine device (IUD) would be higher when insertion occurred within 10 minutes of placental delivery compared with 6-8 weeks postpartum. METHODS We enrolled pregnant women planning vaginal deliveries and desiring a postpartum levonorgestrel-releasing IUD. Patients were randomly assigned when admitted in labor to postplacental or delayed IUD insertion. The women followed up in person at 6-8 weeks and 6 months and were contacted by telephone at 3 months. Women were ineligible for a study IUD postenrollment for intrapartum events including infection, hemorrhage, and cesarean delivery; these women were contacted by phone at 3 and 6 months. Expelled IUDs were replaced per patient preference. RESULTS Successful IUD placement occurred in 50 of 51 participants (98.0%) and 46 of 51 participants (90.2%) in the postplacental and delayed groups, respectively (P=.2). Expulsion within 6 months occurred in 12 of 50 (24.0%; 95% confidence interval [CI], 13.1-38.2) and two of 46 (4.4%; 95% CI 0.5-14.8) participants, respectively (P=.008). Intrauterine device use at 6 months was 43 of 51 (84.3%; 95% CI 71.4-93.0) and 39 of 51 (76.5%; 95% CI 62.5-87.2), respectively (P=.32). For ineligible patients, only 11 of 41 (26.8%) women were using IUDs at 6 months and two (4.9%) had become pregnant. CONCLUSION Intrauterine device use 6 months after delivery is similar in women who have postpartum or scheduled delayed IUD placement through a study after replacement of expelled IUDs. Expulsions are significantly higher with postplacental compared with delayed IUD placement. Women asked to follow up with their own health care providers for delayed insertion are significantly less likely to receive an IUD. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT00476021. LEVEL OF EVIDENCE I.
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Bednarek PH, Jensen JT. Safety, efficacy and patient acceptability of the contraceptive and non-contraceptive uses of the LNG-IUS. Int J Womens Health 2010; 1:45-58. [PMID: 21072274 PMCID: PMC2971715 DOI: 10.2147/ijwh.s4350] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Indexed: 11/23/2022] Open
Abstract
Intrauterine devices (IUDs) provide highly effective, long-term, safe, reversible contraception, and are the most widely used reversible contraceptive method worldwide. The levonorgestrel-releasing intrauterine system (LNG-IUS) is a T-shaped IUD with a steroid reservoir containing 52 mg of levonorgestrel that is released at an initial rate of 20 μg daily. It is highly effective, with a typical-use first year pregnancy rate of 0.1% - similar to surgical tubal occlusion. It is approved for 5 years of contraceptive use, and there is evidence that it can be effective for up to 7 years of continuous use. After removal, there is rapid return to fertility, with 1-year life-table pregnancy rates of 89 per 100 for women less than 30 years of age. Most users experience a dramatic reduction in menstrual bleeding, and about 15% to 20% of women become amenorrheic 1 year after insertion. The device's strong local effects on the endometrium benefit women with various benign gynecological conditions such as menorrhagia, dysmenorrhea, leiomyomata, adenomyosis, and endometriosis. There is also evidence to support its role in endometrial protection during postmenopausal estrogen replacement therapy, and in the treatment of endometrial hyperplasia.
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Affiliation(s)
- Paula H Bednarek
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
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Rodriguez MI, Caughey AB, Edelman A, Darney PD, Foster DG. Cost–benefit analysis of state- and hospital-funded postpartum intrauterine contraception at a university hospital for recent immigrants to the United States. Contraception 2010; 81:304-8. [DOI: 10.1016/j.contraception.2009.11.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Revised: 10/27/2009] [Accepted: 11/05/2009] [Indexed: 11/16/2022]
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Allen RH, Goldberg AB, Grimes DA. Expanding access to intrauterine contraception. Am J Obstet Gynecol 2009; 201:456.e1-5. [PMID: 19527902 DOI: 10.1016/j.ajog.2009.04.027] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Revised: 03/05/2009] [Accepted: 04/16/2009] [Indexed: 11/30/2022]
Abstract
The intrauterine device is a safe, highly effective, long-lasting, yet reversible method of contraception. Expanding access to intrauterine contraception is an important measure to reduce the rate of unintended pregnancy in the United States. Clinicians should consider intrauterine contraception in appropriate candidates, including women who are nulliparous, adolescent, immediately postpartum or postabortal, and desiring emergency contraception, and as an alternative to permanent sterilization. Barriers to intrauterine contraception such as requiring cervical cancer screening before insertion, routine testing for gonorrhea and chlamydial infection in low-risk women, or scheduling insertion only during menses are unnecessary.
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Affiliation(s)
- Rebecca H Allen
- Department of Obstetrics and Gynecology, Women & Infants Hospital, Providence, RI, USA
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Verkuyl DAA. Intention-to-treat studies crucial for contraception research. Contraception 2009; 80:234-6. [PMID: 19698814 DOI: 10.1016/j.contraception.2009.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Accepted: 03/09/2009] [Indexed: 10/20/2022]
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Beatty MN, Blumenthal PD. The levonorgestrel-releasing intrauterine system: Safety, efficacy, and patient acceptability. Ther Clin Risk Manag 2009; 5:561-74. [PMID: 19707273 PMCID: PMC2724187 DOI: 10.2147/tcrm.s5624] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The levonorgestrel-releasing intrauterine system (LNG-IUS) is a safe, effective and acceptable form of contraception used by over 150 million women worldwide. It also has a variety of noncontraceptive benefits including treatment for menorrhagia, endometriosis, and endometrial hyperplasia. The LNG-IUS has also been used in combination with estrogen for hormone replacement therapy and as an alternative to hysterectomy. Overall, the system is very well tolerated and patient satisfaction is quite high when proper education regarding possible side effects is provided. However, despite all of the obvious benefits of the LNG-IUS, utilization rates remain quite low in the developed countries, especially in the United States. This is thought to be largely secondary to the persistent negative impressions from the Dalkon Shield intrauterine experience in the 1970s. This history continues to negatively influence the opinions of both patients and health care providers with regards to intrauterine devices. Providers should resolve to educate themselves and their patients on the current indications and uses for this device, as it, and intrauterine contraception in general, remains a largely underutilized approach to a variety of women’s health issues.
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Affiliation(s)
- Megan N Beatty
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA
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Nelson AL, Chen S, Eden R. Intraoperative placement of the Copper T-380 intrauterine devices in women undergoing elective cesarean delivery: a pilot study. Contraception 2009; 80:81-3. [PMID: 19501220 DOI: 10.1016/j.contraception.2009.01.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Revised: 01/27/2009] [Accepted: 01/27/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND The purpose of this pilot project was to test the feasibility of a technique designed to place a copper intrauterine device (IUD) through the hysterotomy incision of an elective cesarean delivery to minimize possible contamination and to guarantee that tailstrings were visible in the vagina for easy removal should complications occur. STUDY DESIGN Women were monitored in the hospital for signs of infection or excessive blood loss. At the time of hospital discharge and at 2 and 6 weeks postpartum, they were examined to determine the status of the tailstrings. The position of the IUD was assessed by ultrasound at week 6. RESULTS All seven of the subjects had successful placement. The sutures tied to the IUD strings were visible on vaginal examination in each case. The original tailstrings were visible in the vagina at 6 weeks and each IUD was fundally positioned. CONCLUSION Successful intraoperative placement of Copper T-380A IUDs through incision at the time of cesarean birth is possible.
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Affiliation(s)
- Anita L Nelson
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90509-2910, USA.
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