Mirena at caesarean section

Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis

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.

Intrauterine Device Expulsion After Postpartum Placement: A Systematic Review and Meta-analysis

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.

Insertion of intrauterine devices after cesarean section: a systematic review update

Background

Women who undergo a cesarean section (CS) are in a unique position to receive the intrauterine contraceptive device (IUD). They may also want to use the IUD as a long-acting reversible contraceptive method provided the IUD is safe and effective in the presence of a CS scar.

Search strategy

We researched and reviewed the MEDLINE, POPLINE, Google Scholar, and ClinicalTrials.gov databases from January 1968 to June 2015.

Selection criteria

Eligible studies reported event rates or practical problems relating to IUD usage in post-placental or interval insertion (>90 days) after CS. Studies with ≥20 subjects were included.

Data collection and analysis

Analysis of eligible data collected from the search followed the PRISMA guidelines.

Main results

Twelve eligible studies of post-placental IUD insertion after CS included four randomized controlled trials of post-placental versus delayed insertion. Women randomized to delayed insertion were less likely to receive a device. Six studies examined the problem of missing IUD threads at follow-up with only 30%–60% presence of strings observed.

Conclusion

The IUD is a long-acting reversible contraceptive method that is suitable for use in all women undergoing CS. The problems of device expulsion, missing threads at follow-up, and the tendency of increased puerperal bleeding need to be solved. Solutions are proposed.

A randomised clinical trial to assess satisfaction with the levonorgestrel- releasing intrauterine system inserted at caesarean section compared to postpartum placement

Background

Insertion of levonorgestrel‐releasing intrauterine system (LNG‐IUS) at caesarean section (CS) provides contraception prior to resumption of ovulation or sexual activity. Patient satisfaction with insertion at CS has not previously been studied.

Aims

The aim of this study was to compare patient satisfaction with LNG‐IUS inserted at the time of lower uterine segment CS to six weeks postpartum.

Materials and Methods

Open‐label randomised controlled trial. Women booked for elective CS were randomised to LNG‐IUS insertion either at the time of CS (study group) or at six weeks postpartum (control group). The primary outcome measure was patient satisfaction. Outcomes were measured at six weeks, three months and six months postpartum.

Results

Forty‐eight women were randomised into two treatment groups. Twenty‐five women were randomised to have LNG‐IUS inserted at the time of CS, 23 of whom had the planned intervention and two had the LNG‐IUS inserted postpartum. Twenty‐three women were randomised to the control group, four of whom withdrew prior to treatment. The 44 remaining women contributed to data analysis. Patient satisfaction was high and similar in both groups. At six months postpartum, 90.5% of the study group were very satisfied or somewhat satisfied compared with 88.2% of the control group.

Conclusions

Patient satisfaction is high with LNG‐IUS insertion at CS and not different to that with delayed insertion. LNG‐IUS insertion may be an option for women who find postpartum contraception difficult to access.

Expulsion of Nova-T380, Multiload 375, and Copper-T380A contraceptive devices inserted during cesarean delivery

OBJECTIVE

To compare the expulsion rate of Nova-T380, Multiload 375, and Copper-T380A intrauterine contraceptive devices (IUCDs) inserted during cesarean delivery.

METHODS

A comparative randomized study was conducted between January 1, 2013, and June 30, 2014, in three maternity centers in Egypt and Saudi Arabia. All women scheduled for an elective cesarean and accepting intraoperative insertion of an IUCD were randomly allocated to receive the Nova-T380 (group 1), Multiload 375 (group 2), or Cu-T380A (group 3) using a computer-generated table. Researchers and participants were not masked to the type of IUCD. Follow-up was for 1 year. The primary outcome was IUCD expulsion (complete or partial [i.e. displacement]).

RESULTS

Each group contained 40 participants. At 1 year, expulsion had been reported for 5 (13%) women in group 1, 2 (5%) in group 2, and 6 (15%) in group 3 (P>0.05 for all). The frequency of displacement was significantly lower in group 2 (5 [13%] participants) than in group 1 (15 [38%]; P=0.001) and group 3 (14 [35%]; P=0.008).

CONCLUSION

Despite a comparable risk of expulsion following IUCD insertion during cesarean delivery, the Multiload 375 device showed the lowest risk of displacement.

Five-year follow-up of two types of contraceptive device fitted during elective cesarean delivery

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.

Intrauterine contraception after cesarean section and during lactation: a systematic review

BACKGROUND

All postpartum women, including those who are breastfeeding or have had a cesarean section, appear potentially suited to intrauterine contraception, a long acting reversible contraceptive (LARC). Like any other method used after delivery, it should not interfere with lactation or be affected by cesarean section.

STUDY DESIGN

We searched the MEDLINE, PubMed, Popline, Google Scholar, and Clinicaltrials.gov databases from January 1968 through to December 2012. Studies were included if they reported event rates in women who had a cesarean section and event rates and clinical outcomes in lactating women or their infants in the breastfeeding group. Summary odds ratios were not calculated because of the diverse methods of reporting event rates in the cesarean section group and the heterogeneity of the results in the breastfeeding group.

RESULTS

We found 26 articles on event rates in interval and post-placental intrauterine device (IUD) use, and 18 on event rates and clinical outcomes in breastfeeding IUD users. Four prospective studies and one retrospective study showed an increased expulsion rate in interval insertion. There were 19 studies, of which five were controlled in post-placental IUD insertion after cesarean section. Four studies had expulsion rates of 10 or more per 100 woman-years of use and 15 expulsion rates below 10 per 100 woman-years of use. Three studies showed that event rates for lactating IUD users are the same as those for non-lactating users. Fifteen controlled studies showed that the IUD had no effect on milk production and seven of these showed no effect on infant growth. Pharmacovigilance databases report an increased rate of IUD perforations in lactating women, while the event rate studies report that insertion is generally easier and less painful than expected. These were uncontrolled reports.

CONCLUSION

The IUD is a long-acting reversible method of contraception with expulsion rates of 5-15 per 100 woman-years of use when used as a post-placental method immediately after cesarean section. As an interval procedure (6 or more weeks after cesarean section) it appears to have a high expulsion rate (5% or higher) notably in older devices. The IUD does not affect breastfeeding and is easy to insert in these women, but appears to be associated with a higher perforation rate (>1 per 100). Providers should not be deterred from using this contraception method, especially in developing countries, but should be attentive to preventing these potential problems.