Pregnancies associated with etonogestrel implants in the UK: comparison of two 5-year reporting periods

OBJECTIVES

(1) To identify pregnancies associated with the use of the contraceptive implants Implanon and Nexplanon in the UK during two 5-year reporting periods. (2) To classify the possible reasons for device failure in cases reported for each implant. (3) To examine any differences between reasons for pregnancies associated with these products.

STUDY DESIGN

Extraction of data from the UK spontaneous reporting system for adverse drug reactions in relation to etonogestrel implants. Reports indicating pregnancy were identified for the periods 2005-2009 (Implanon) and 2012-2016 (Nexplanon). Possible reasons for failure of the method in each reported case were assigned to one of eight predetermined categories.

RESULTS

After exclusions, 229 Implanon and 234 Nexplanon cases contained sufficient information for analysis. True method failures accounted for a majority of the pregnancies in those using contraceptive implants (58%); the next most common cause was missing implants (26% of pregnancies). In all categories of cases, there was no difference in frequency of pregnancy when the two time periods were compared.

CONCLUSIONS

There is still potential for greater avoidance of pregnancies associated with etonogestrel implant use.

IMPLICATIONS

This study underscores the continuing need for taking a full drug history, timing the insertion on days 1-5 or according to recommended quick starting routines and palpating the arm after implant insertion.

How to improve communication for the safe use of medicines?: Discussions on social marketing and patient-tailored approaches at the annual meetings of the WHO Programme for International Drug Monitoring

Over the past decade, the annual meetings of national centres participating in the WHO Programme for International Drug Monitoring have increasingly included discussions on how to improve communication between national pharmacovigilance centres, patients, healthcare professionals, policy makers and the general public, with the aim of promoting the safe use of medicines. At the most recent meetings, working groups were dedicated to discuss possible applications and implementation of social marketing and patient-tailored approaches. This article provides the history and a summary of the recent discussions and recommendations to support progress in this respect at national and global level. Recommendations are made to investigate and pilot these approaches in small-scale projects at national pharmacovigilance centres. Applying elements from the social marketing and patient-tailored approaches to support behaviours of safe medicines use in patients and healthcare professionals should give the pharmacovigilance community new tools to achieve their goal to minimize risks with medicines and improve patient safety.

Nocturnal enuresis in patients taking clozapine, risperidone, olanzapine and quetiapine: comparative cohort study

BACKGROUND

Nocturnal enuresis has been reported in patients taking clozapine, but the incidence has not been accurately established. The incidence of enuresis in patients taking risperidone, olanzapine or quetiapine is unknown. Aims To compare nocturnal enuresis in patients taking clozapine with that in patients taking risperidone, olanzapine or quetiapine.

METHOD

Observational cohort study using prescription event monitoring methods. Patients prescribed atypical antipsychotic medicines were followed up by questionnaires that were sent to their medical practitioner. Practitioners were asked to directly ask their patients about bed-wetting.

RESULTS

Nocturnal enuresis was reported by 17 of 82 (20.7%) patients taking clozapine, 11 of 115 (9.6%) taking olanzapine, 7 of 105 (6.7%) taking quetiapine and 12 of 195 (6.2%) taking risperidone. Compared with clozapine, the risk of nocturnal enuresis was significantly lower in patients taking olanzapine (odds ratio, OR = 0.43, 95% CI 0.19-0.96), quetiapine (OR = 0.33, 95% CI 0.13-0.59) or risperidone (OR = 0.27, 0.12-0.59), with odds ratios adjusted for age, gender and duration of treatment.

CONCLUSIONS

Approximately one in five patients prescribed clozapine experienced bed-wetting. This was significantly higher than the rate of nocturnal enuresis in patients taking olanzapine, quetiapine or risperidone.

Uterine perforation with the levonorgestrel-releasing intrauterine device: analysis of reports from four national pharmacovigilance centres

BACKGROUND

Levonorgestrel-releasing intrauterine devices (LNG-IUD) are commonly used for contraception and other indications in many countries. National pharmacovigilance centres have been receiving reports from healthcare professionals and patients of uterine perforation associated with the use of these LNG-IUDs.

METHODS

National pharmacovigilance centres in the Netherlands, New Zealand, Switzerland and Germany did a search on their adverse drug reaction databases for reports of cases of uterine perforation after insertion of a LNG-IUD received between the introduction of the LNG-IUD onto the market in the late 1990s and 15 July 2007. The number of women affected and patient characteristics such as age, parity and breastfeeding status were examined. In addition, the method of detection of the perforation and the time until discovery of the perforation were analysed.

RESULTS

Between the introduction of the LNG-IUD onto the market in each country and 15 July 2007, 701 cases of uterine perforation with a LNG-IUD were reported; 8.5% of the perforations were detected at the time of insertion. Abdominal pain and control/check-up visits were the most common events that lead to the detection of a perforation. Of 462 women known to be parous, 192 (42%) were breastfeeding at the time the perforation was discovered.

CONCLUSIONS

Uterine perforations can be asymptomatic and may remain undetected for a long time after IUD insertion. Abdominal pain, control/check-up visits or changes in bleeding patterns are triggers for detection of perforation and should therefore be taken seriously.

Electronic capture of dispensing data by the New Zealand Intensive Medicines Monitoring Programme: a consultation study of community and hospital pharmacists

OBJECTIVE

To obtain pharmacists' views on proposals for electronic transmission of dispensing data to the New Zealand Intensive Medicines Monitoring Programme (IMMP).

METHODS

Consultation with a randomly selected group of 100 community pharmacists and all 28 hospital pharmacies in New Zealand was conducted by postal survey. A specific questionnaire was designed to obtain pharmacists' views on several aspects of electronic data transmission including willingness to co-operate with a new system, awareness of other electronic systems and views on security.

KEY FINDINGS

Survey response rates were 95% for community pharmacists and 73% for hospital pharmacists. Ninety (95%) of the community pharmacists and 18 (95%) of the hospital pharmacists who responded stated they would use the IMMP proposed method of electronic data transmission. Some 91% of community pharmacists and 100% of hospital pharmacists considered the proposed new method would be equally or more secure than the present hard-copy system of posting dispensing records.

CONCLUSIONS

There is a high level of support from New Zealand pharmacists for electronic capture of prescription dispensing data for medicines monitored by the IMMP. This electronic method will now be implemented. Development of such systems is important for enhancing patient safety and pharmacovigilance programmes worldwide.

Fatal and non-fatal cardiovascular events in a general population prescribed sibutramine in New Zealand: a prospective cohort study

BACKGROUND

The cardiovascular safety of sibutramine is currently under review by medicines regulatory authorities worldwide after the SCOUT (Sibutramine Cardiovascular Outcome Trial) showed an increased risk of cardiovascular events in patients taking sibutramine. Further data regarding the cardiovascular safety of sibutramine in a general population are now required.

OBJECTIVE

To quantify the risk of fatal and non-fatal cardiovascular adverse events in a general population prescribed sibutramine in postmarketing use.

STUDY DESIGN

Observational prospective cohort study of patients dispensed sibutramine during a 3-year period (2001-4) and followed up for at least 1 year after their last prescription. The study included record-linkage to national mortality datasets to identify fatal events.

SETTING

Postmarketing 'real-life' use of sibutramine in a general population in New Zealand.

PATIENTS

All New Zealand patients dispensed a prescription for sibutramine in a 3-year period (for whom a National Health Identification number could be validated). 15 686 patients were included in the record linkage study for fatal events. A subgroup of 9471 patients was followed up by intensive methods for non-fatal events.

MAIN OUTCOME MEASURES

(i) Rate of death from all causes and from cardiovascular events; and (ii) rates of non-fatal cardiovascular adverse events.

RESULTS

Total exposure to sibutramine for 15 686 patients in the validated cohort was 5431 treatment-years. The rate of death from all causes in this cohort was 0.13 (95% CI 0.05, 0.27) per 100 treatment-years exposure. The rate of death from a cardiovascular event was 0.07 (95% CI 0.02, 0.19) per 100 treatment-years exposure. The most frequent non-fatal cardiovascular events in the intensively followed up cohort were hypertension, palpitations, hypotensive events and tachycardia.

CONCLUSIONS

Risk of death from a cardiovascular event in this general population of patients prescribed sibutramine was lower than has been reported in other overweight/obese populations. The results of this study suggest that further evaluation of the benefit-risk profile of sibutramine is now required.

Clozapine and myocarditis: a case series from the New Zealand Intensive Medicines Monitoring Programme

AIM

To examine a New Zealand case series of clozapine-associated myocarditis.

METHODS

All cases of myocarditis in the Intensive Medicines Monitoring Programme's (IMMP) clozapine database were identified and reviewed.

RESULTS

25 cases of myocarditis associated with the use of clozapine have been reported to the IMMP. The majority of cases (84%) were male and the mean age was 35.5 years. Myocarditis occurred at daily clozapine doses ranging from 12.5 mg to 500 mg. Eighty percent of the cases developed within 1 month of starting the medicine, although in three cases the onset was more than a year after commencing clozapine. Of the 25 cases, 2 patients died.

CONCLUSIONS

This New Zealand case series of clozapine-associated myocarditis is similar to a recent Australian case series. Clozapine-associated myocarditis most often occurs within 1-2 months of starting clozapine, but it may develop at any time while on the medicine, and can occur even at very low doses. A data-linkage study using national morbidity and mortality datasets could estimate the incidence of clozapine-associated myocarditis in New Zealand.

Pharmacovigilance in New Zealand: the role of the New Zealand Pharmacovigilance Centre in facilitating safer medicines use

The New Zealand Pharmacovigilance Centre (NZPhvC) is the national centre responsible for monitoring adverse reactions to therapeutic products in New Zealand(NZ). The NZPhvC operates three pharmacovigilance programmes and this article explains how each of these programmes operate, focuses on their strengths and limitations, and looks to the future for medicines safety monitoring in NZ.

Life-threatening clozapine-induced gastrointestinal hypomotility: an analysis of 102 cases

OBJECTIVE

To raise awareness of potentially lethal clozapine-induced gastrointestinal hypomotility (CIGH) by reviewing cases from the literature and unpublished pharmacovigilance data and to offer strategies aimed at prevention and early treatment.

METHOD

Databases (PsycINFO, 1967-2007; MEDLINE, 1950-2007; and EMBASE, 1988-2007) were searched using the term clozapine together with each of the following: gastrointestinal, dysmotility, constipation, obstipation, fecal impaction, fecaloma, paralytic ileus, adynamic ileus, subileus, ischemic colitis, colon ischemia, bowel ischemia, gastrointestinal ischemia, gut ischemia, obstruction, necrosis, gangrene, bowel perforation, micro-perforation, megacolon, toxic megacolon, acquired megacolon, pseudo-obstruction, Ogilvie, and Ogilvie's syndrome. We analyzed the electronic database entries held by the Adverse Drug Reactions Advisory Committee and the New Zealand Intensive Medicines Monitoring Program, which cited suspected clozapine-related gastrointestinal side effects, as well as all relevant published case reports. We reviewed the literature on the treatment of gastrointestinal hypomotility and constipation.

RESULTS

We compiled a database of 102 cases of suspected life-threatening CIGH. There was a mortality rate of 27.5% and considerable morbidity, largely due to bowel resection. Within Australasia, at least 15 patients have died of CIGH. Probable risk factors are identified as recent instigation of clozapine, high clozapine dose or serum level, concomitant anticholinergic use, or intercurrent illness.

CONCLUSION

The paucity of literature on CIGH suggests that the significance of this uncommon but important and frequently fatal side effect has not been recognized. Clozapine can affect the entire gastrointestinal system, from esophagus to rectum, and may cause bowel obstruction, ischemia, perforation, and aspiration. The mechanism is likely to be anticholinergic and antiserotonergic. Clozapine prescribing should be accompanied by regular physical monitoring, appropriate and timely use of laxatives, and early referral of constipated patients--before life-threatening pathologic processes develop.

Sibutramine usage in New Zealand: an analysis of prescription data by the Intensive Medicines Monitoring Programme

PURPOSE

To describe patterns of sibutramine usage in New Zealand during the first 3 years of marketing using data acquired during post-marketing safety surveillance.

METHODS

Demographic and prescription data were examined from a nationwide cohort of 17 298 patients prescribed sibutramine between 1 February 2001 and 31 March 2004. Outcome measures were age and sex distribution of the cohort; period prevalence of sibutramine usage for each ethnic group; duration of treatment and reasons for cessation of therapy. Limited BMI data were also examined.

RESULTS

About 0.5% of the NZ population were prescribed sibutramine in the period studied. Overwhelmingly, the highest users of sibutramine were NZ European women aged 30-59 years. Maori and Pacific Peoples were under-represented in the cohort, despite the higher prevalence of obesity among these populations. Sibutramine usage was predominantly short-term: 59% of the cohort used sibutramine for 90 days or less, half of whom used it for only 1 month.

CONCLUSIONS

There has been extensive use of sibutramine in New Zealand. Sibutramine has been relatively under-utilised by Maori and Pacific ethnic groups, compared to New Zealand Europeans, despite their higher prevalence of obesity. A number of factors may have contributed to the predominantly short-term use of this medicine, including the cost of the medicine to the consumer, weight loss not meeting expectations and adverse effects of the medicine.

Hair loss with use of the levonorgestrel intrauterine device

BACKGROUND

The levonorgestrel intrauterine device (IUD) has associated systemic side effects. However, there is little published information about the risk of alopecia.

STUDY DESIGN

Review of both the New Zealand Intensive Medicines Monitoring Programme (IMMP) data on alopecia associated with levonorgestrel IUD and the international evidence.

METHODS

The IMMP uses Prescription Event Monitoring to study the safety of medicines during the postmarketing period. All reported cases of alopecia with levonorgestrel IUD use were identified in the IMMP databases and assessed for causality. World Health Organization (WHO) spontaneous reporting data were also obtained.

RESULTS

Five reports of alopecia associated with the levonorgestrel IUD were identified in the IMMP database. From the cohort of insertions during 2000-2001, the estimated cumulative incidence of alopecia was 0.33% (95% CI 0.07-0.95) in the responder population. The WHO database contained a further 68 reports.

CONCLUSIONS

Counselling prior to insertion of the levonorgestrel IUD should include information on systemic effects, including the possibility of alopecia.

Alopecia associated with quetiapine

Alopecia has previously been reported with the atypical antipsychotic medicines olanzapine and risperidone, but has not been described with quetiapine. Case reports of alopecia associated with quetiapine reported to the New Zealand Intensive Medicines Monitoring Programme were reviewed. The World Health Organization international spontaneous reporting database was also searched for additional case reports. Literature searches were conducted for previous reports of alopecia associated with quetiapine. The Intensive Medicines Monitoring Programme database included two case reports of alopecia associated with quetiapine. Assessment of these cases suggested a causal relationship with the medicine. The World Health Organization international database included a further 15 case reports, providing evidence supporting this association. No previously published reports of alopecia associated with quetiapine were identified. In conclusion, these are the first published case reports of alopecia associated with quetiapine.

Safety and Usage of Atypical Antipsychotic Medicines in Children

OBJECTIVE

To study the safety and usage of atypical antipsychotic medicines in post-marketing use in a nationwide paediatric population.

DESIGN

Prospective observational cohort study using prescription event monitoring and record linkage.

POPULATION

New Zealand children aged < or =15 years, who were prescribed atypical antipsychotic medicines between April and July 2003.

OUTCOMES

Usage measures included prescription data for each medication, the diagnosis for which the patient was being treated and main target symptom. Safety outcome measures were all new clinical adverse events between the start of treatment (which could be before April 2003) and 30 November 2004.

RESULTS

The cohort included 420 children aged 2-15 years. Total exposure to atypical antipsychotic medicines was 641.2 patient-years of treatment with most (94%) of the exposure being to risperidone. The most common diagnoses were disruptive disorders. The symptoms most frequently targeted by the atypical antipsychotic were aggression and difficult behaviour. The treatment of sleep disorders as a target symptom was reported in 3% of children. A total of 131 (31%) children experienced an adverse event. The most frequent adverse events reported were weight gain, severe dental caries and somnolence. The incidence of diabetes mellitus was 4 (95% CI 0.5, 15) cases per 1000 patient-years of treatment in this study. Four children prescribed risperidone developed symptoms of depression, giving an incidence of 8 (95% CI 2.0, 21) cases per 1000 patient-years of treatment.

CONCLUSIONS

This study provides a picture of 'real-life' use of atypical antipsychotics in a nationwide cohort of children. Most prescriptions were for risperidone and the most common diagnoses were disruptive disorders. Investigation of the symptoms targeted by these medicines identified unexpected use for the treatment of sleep disorders. Regarding safety, symptoms of depression were identified as a potential new signal for risperidone in the paediatric population. Further research is now required to investigate this.

QT interval prolongation associated with sibutramine treatment

AIMS

To investigate a possible association of sibutramine with QT interval prolongation.

METHODS

Post-marketing surveillance using prescription event monitoring in the New Zealand Intensive Medicines Monitoring Programme (IMMP) identified a case of QT prolongation and associated cardiac arrest in a patient taking sibutramine for 25 days. This patient was further investigated, including genotyping for long QT syndrome. Other IMMP case reports suggesting arrhythmias associated with sibutramine were assessed and further reports were obtained from the World Health Organisation (WHO) adverse drug reactions database.

RESULTS

The index case displayed a novel mutation in a cardiac potassium channel subunit gene, KCNQ1, which is likely to prolong cardiac membrane depolarization and increase susceptibility to long QT intervals. Assessment of further IMMP reports identified five additional patients who experienced palpitations associated with syncope or presyncopal symptoms, one of whom had a QT(c) at the upper limit of normal. Assessment of reports from the WHO database identified three reports of QT prolongation and one fatal case of torsade de pointes in a patient also taking cisapride.

CONCLUSIONS

This case series suggests that sibutramine may be associated with QT prolongation and related dysrhythmias. Further studies are required, but in the meantime we would recommend that sibutramine should be avoided in patients with long QT syndrome and in patients taking other medicines that may prolong the QT interval.

Bruising associated with sibutramine: results from postmarketing surveillance in New Zealand

OBJECTIVE

To determine whether postmarketing data provide evidence of an association of sibutramine with bruising.

DESIGN AND PATIENTS

During a postmarketing surveillance study of sibutramine in New Zealand by the Intensive Medicines Monitoring Programme (IMMP), a series of reports of bruising was identified. Further case reports were also obtained from the World Health Organisation (WHO) adverse drug reactions database.

OUTCOME MEASURES

All platelet, bleeding and clotting events associated with sibutramine were identified and causality assessments were performed.

RESULTS

From the IMMP and WHO databases a total of 16 cases of bruising that improved on withdrawal of sibutramine were identified. Of these, two had a recurrence of bruising on reintroduction of sibutramine.

CONCLUSIONS

Evidence from postmarketing surveillance suggests that there is a causal association between sibutramine and bruising/ecchymosis. This represents a newly recognized adverse reaction for this medicine.

Unintended pregnancies with the etonogestrel implant (Implanon): a case series from postmarketing experience in Australia

This paper describes a case series of over 200 unintended pregnancies associated with the etonogestrel implant, Implanon. These cases have been reported to the Australian Adverse Drug Reactions Advisory Committee during the first 3 years of marketing in this country. Of 218 cases included, 45 had insufficient data to assess the reason for contraceptive failure and 46 women were determined to have been already pregnant prior to Implanon insertion. Of the remaining 127 cases, the most common reason for unintended pregnancy was failure to insert the implant in 84 women. Other reasons included incorrect timing of insertion (19 cases), expulsion of Implanon (3 cases) and interaction with hepatic enzyme-inducing medicines (8 cases). The remaining 13 cases were classified as product/method failures once other reasons had been excluded. Using the 204,486 Implanon devices subsidized in this period to estimate the population exposed and the 218 pregnancies reported, the approximate failure rate in postmarketing use was 1 in 1000 insertions. These findings (and reports to medical indemnity insurers) have resulted in the development of guidelines and training for doctors inserting Implanon in Australia.

Incidence of Thrombotic Cardiovascular Events in Patients Taking Celecoxib Compared with Those Taking Rofecoxib

BACKGROUND

Rofecoxib was withdrawn from the market worldwide because of concerns relating to cardiovascular safety. There is conflicting evidence as to whether celecoxib, the most popular alternative to rofecoxib, carries the same cardiovascular risks. This study's aim was to compare the incidence of thrombotic cardiovascular events in patients taking celecoxib with patients taking rofecoxib.

METHODS

Prescription event monitoring methodology was used in this prospective, longitudinal, observational cohort study, in which cohorts of patients were established from prescription data and thrombotic cardiovascular events were identified from follow-up questionnaires to patients' doctors and other sources.

SUBJECTS

New Zealand patients with at least one prescription for either rofecoxib or celecoxib between 1 December 2000 and 30 November 2001.

ANALYSIS

For this interim analysis the total cohorts were separated into three groups at different stages of follow-up: complete, incomplete and no follow-up. Cox's proportional hazards models were applied to calculate hazard ratios for celecoxib compared with rofecoxib.

RESULTS

The total cohorts included 26,403 patients receiving rofecoxib and 32,446 patients receiving celecoxib. 4882 (18%) rofecoxib and 6267 (19%) celecoxib patients had been completely followed up. In this group the unadjusted hazard ratio for celecoxib compared with rofecoxib was 1.07 (95% CI 0.59, 1.93). After adjustment for age this hazard ratio was 0.94 (95% CI 0.51, 1.70). Further adjustment for sex, 'as required' use, indication for use, concomitant NSAID use and pre-existing cardiovascular disease resulted in only minor changes to the hazard ratio.

CONCLUSION

This interim analysis of the Intensive Medicines Monitoring Programme data suggests that in 'real-life' postmarketing use in New Zealand there is no significant difference in the risk of cardiovascular thrombotic events in patients taking celecoxib compared with those taking rofecoxib.

Insertion of intrauterine devices: a comparison of experience with Mirena and Multiload Cu 375 during post-marketing monitoring in New Zealand

AIM

To compare the incidence of reported insertion problems with the levonorgestrel-releasing intrauterine device (Mirena) with that of the copper device Multiload Cu 375.

METHODS

Prescription Event Monitoring (PEM) methodology, as used in the Intensive Medicines Monitoring Programme, was used to identify cohorts of women and record events associated with insertion.

RESULTS

Data were analysed from 16 159 women receiving Multiload Cu 375 between 1991 and 2001, and 3452 women receiving Mirena between 1998 and 2001. Difficult insertion was reported more often with Mirena (RR= 2.7, 95% CI = 2.2--3.3, p <0.0001). Stratified analyses suggested this was not explained by the presence of more nulliparous women in the Mirena cohort or the non-contraceptive indications for use of Mirena. Mechanical problems with the device were reported in about 1% of Mirena insertions compared with 0.01% of Multiload Cu 375 insertions and this difference was significant (p <0.001). About 2% of Mirena insertions were performed under general anaesthetic compared with 0.1% of Multiload Cu 375 insertions. Adverse reactions to insertion, including pain and vaso-vagal reaction, were more frequent with Mirena than with Multiload Cu 375 (p <0.001).

CONCLUSIONS

During the period of study, insertion of Mirena was more difficult and was associated with more device problems and adverse reactions than insertion of Multiload Cu 375.

Use of the New Zealand Intensive Medicines Monitoring Programme to study the levonorgestrel-releasing intrauterine device (Mirena)

PURPOSE

To demonstrate how the Intensive Medicines Monitoring Programme (IMMP) can be used to monitor adverse events associated with an intrauterine device, using the levonorgestrel-releasing intrauterine device (Mirena) as an example.

METHODS

A long-term prospective observational cohort study using Prescription Event Monitoring (PEM) is currently being undertaken in women using Mirena in New Zealand. This report describes the method used and reports the early results for those women who used the device between March 1998 and March 2001. Adverse events were recorded by inserting doctors and general practitioners on registration forms and systematic follow-up questionnaires.

RESULTS

Between March 1998 and March 2001, the IMMP received 3519 registration forms for insertions in 3452 women. 'Difficult insertion' was the most frequently reported event (3.6% of all insertions). Approximately, 2% of the Mirena insertions were carried out under GA and there were three uterine perforations (0.9 per 1000 insertions) in the total cohort. To date, follow-up questionnaires have been processed for 495 patients. The response rate for these was 83%.

CONCLUSION

As adapted in the IMMP, PEM is an effective tool for the early post-marketing surveillance of an intrauterine device in real life clinical practice.

Uterine perforation on intrauterine device insertion: is the incidence higher than previously reported?

The objective of the study was to determine the rate of uterine perforation associated with insertion of Multiload Cu375 in 'real-life' clinical use. It was a prospective observational cohort study using Prescription Event Monitoring methodology. There were 17,469 Multiload Cu375 insertions in 16,159 women between 1991 and 2001. The insertions were performed by 1,699 different doctors (mostly general practitioners) in surgeries, clinics, and hospitals throughout New Zealand. The results found 28 reports suggesting complete or partial uterine perforation, giving an incidence of 1.6 per 1000 insertions. Most perforations (86%) were not diagnosed at the time of insertion, with some remaining undiagnosed for several years. Doctors who reported inserting fewer than 10 Multiload Cu375 devices in the study period reported significantly more perforations than doctors who reported inserting between 10 and 100 devices did. In conclusion, we found the perforation rate in this study is higher than in clinical trials of Multiload Cu375. This might be because of inclusion of partial perforations in this study, a longer follow-up period, the large number of insertions studied, or because the majority of inserting doctors were less experienced than inserters in other studies.

Insertion of the Multiload Cu375 intrauterine device; experience in over 16,000 New Zealand women

Insertion of Multiload Cu375 was studied in 16,159 women in a 10-year prospective observational cohort study in New Zealand. Of 17,468 insertions, about 9% were performed in nulliparous women. Problems fitting Multiload Cu375 (e.g., failed or difficult insertion) were experienced during approximately 2% of all insertions. The incidence of these was significantly higher in nulliparous women compared to parous women. Adverse reactions to insertion (e.g., pain, bleeding) occurred in 1.2% of all insertions, with nulliparous women experiencing significantly more adverse reactions than parous women. The insertions were performed by 1,700 different doctors in New Zealand with general practitioners performing 92% of these. Doctors who reported inserting over 100 devices in the study period experienced significantly less insertion problems than doctors who reported inserting less than 10 devices. This study suggests that insertion of Multiload Cu375 in a mixed community setting is associated with few inserting problems and adverse reactions to insertion. Risk factors identified for inserting problems included nulliparity and experience of the doctor inserting the intrauterine device.