Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section

Background

An intrauterine device (IUD) is an effective reversible form of contraception. We determined the efficacy and safety of immediate postplacental IUD insertion during cesarean section.

Study Design

Two hundred forty-five women with term pregnancies delivering by cesarean section between September 2006 and December 2007 were included in the study. A copper IUD (TCu 380A) was inserted using a ring forceps within 10 min of removing the placenta. The participants were examined before hospital discharge and at 6 weeks, 6 months and 12 months postpartum.

Results

None of the patients were lost to follow-up. There was one case of an unplanned pregnancy (0.4%). There were no serious complications associated with immediate IUD insertion during cesarean section. The cumulative rates of expulsion, removal for bleeding/pain and other medical reasons were 17.6, 8.2 and 2.4 per 100 women per year, respectively. The continuation rates were 81.6% and 62% at 6 and 12 months, respectively.

Conclusion

Immediate postplacental IUD insertion during cesarean section provides adequate protection against pregnancy. However, greater than one fourth of the participants discontinued IUD use due to spontaneous expulsion or other medical reasons.     

A pilot clinical trial of ultrasound-guided postplacental insertion of a levonorgestrel intrauterine device

BACKGROUND: Postplacental intrauterine device (IUD) insertion is a safe, convenient and effective option for postpartum contraception. Few studies involve ultrasound-guided insertion, and none involve the levonorgestrel IUD or take place in the United States. STUDY DESIGN: The study was conducted to assess the safety and feasibility of ultrasound-guided postplacental insertion of the levonorgestrel IUD following vaginal delivery in a U.S. residency program. Levonorgestrel IUDs were inserted under ultrasound guidance within 10 min of placental delivery by hand or using ring forceps. Subjects were examined at 4 and 10 weeks postpartum for evidence of expulsion or infection. RESULTS: Thirty-four subjects were enrolled and 20 received an IUD. Follow-up data are available for 19 subjects over the 10-week follow-up period; 16 subjects returned for the 4-week follow-up, and 14 returned at 10 weeks. Two additional subjects could be contacted by telephone only. At 4 and 10 weeks postpartum, no subjects had evidence of infection. There were two expulsions (2/19, 10.5%) by 10 weeks postpartum. None of the subjects examined had a partial expulsion (intracervical location of the IUD). CONCLUSIONS: In this pilot study, ultrasound-guided postplacental insertion of the levonorgestrel IUD was feasible and not associated with infection. The risk of expulsion was acceptable. Ultrasound-guided postplacental insertion of the levonorgestrel IUD may be an alternative to delayed insertion but warrants further study.     

Immediate postpartum intrauterine device insertion — a report on the Chinese experience

Immediate postplacental insertion (IPPI) of the intrauterine device (IUD) has been practiced in China for at least 17 years. This presentation reviews and integrates the clinical experiences of IPPIs at five Chinese centers. The stainless-steel ring IUD was the most commonly used device for this procedure.Our review indicates that: (a) IPPIs-both after vaginal delivery and at cesarean section-are medically safe and effective in preventing accidental pregnancies (given careful patient selection), and (b) the one-year life-table expulsion rates of IUDs inserted at cesarean section are lower than the rates for vaginal insertions after normal delivery. This review also discusses other issues, such as factors influencing expulsion rates.Generally, IPPIs, whether performed via vagina or cesarean section, seem to be a method of choice for postpartum contraception. Some findings are, however, tentative; thus, further studies are needed.

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Resumen La inserción del dispositivo intrauterino (DIU) inmediatamente después de la expulsión de la placenta (método denominado IPPI) se realiza en China desde hace al menos 17 años. Se examina aquí la experiencia clínica con el IPPI en cinco centro chinos. El DIU de tipo anillo de acero inoxidable es el que más se utiliza en este procedimiento.Nuestro estudio indica que (a) este procedimiento-tanto después del parto por vía vaginal o cesárea-no presenta peligros desde el punto de vista médico y es eficaz en la prevención de embarazos accidentales (con selección cuidadosa de pacientes) y que (b) las tablas de supervivencia al cabo de un año indican que los DIU insertados después de cesáreas son menos frecuentemente expulsados que los insertados por vía vaginal después de un parto normal. En este estudio se examinan asimismo otros problemas, tales como los factores que influyen sobre las proporciones de expulsión. El IPPI-por vía vaginal o después de una cesárea-parece ser en general en método de elección para la anticoncepción posparto. Sin embargo, algunos resultados son preliminares y se necesitan estudios más profundos.

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Résumé Il y a au moins 17 ans que se pratique en Chine l'insertion du dispositif intra-utérin (DIU) immédiatement après l'expulsion du placenta (méthode dite IPPI). Nous passons ici en revue l'expérience clinique de l'IPPI dans cinq centres de Planning familial en Chine. On utilise le plus souvent pour cette opération le stérilet en anneau d'acier inoxydable.Notre étude met en évidence que (a) cette procédure-qu'elle fasse suite à un accouchement par voie vaginale ou par césarienne-ne présente aucun danger sur le plan médical et prévient véritablement les grossesses accidentelles (les patientes étant soigneusement sélectionnées) et que (b) les tables de survie sur un an indiquent que les stérilets mis en place lors de césariennes sont moins souvent expulsés que ceux qui ont été insérés par voie vaginale après accouchement normal. Cette étude examine également d'autres problèmes, comme par exemple les facteurs ayant une incidence sur les taux d'expulsion.L'IPPI-par voie vaginale ou faisant suite à une césarienne-semble généralement être une méthode de choix pour la contrception post-partum. Certains résultats manquent cependant encore de précision, ce qui rend nécessaire une étude plus poussée.

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(this paper was prepared while the principal author was a visiting research fellow at Family Health International, Research Triangle Park, NC, USA)     

Immediate postplacental IUD insertion at cesarean delivery: a prospective cohort study

BackgroundImmediate postplacental insertion of intrauterine devices (IUDs) during cesarean delivery could reduce a substantial barrier to access to long-term effective contraception. Initiating IUD use prior to discharge from the hospital postpartum eliminates a 6-week postpartum waiting period and an additional office visit.Study DesignThis was a prospective cohort study of 90 patients undergoing cesarean delivery. After delivery of the placenta, a copper T380A IUD was inserted into the endometrial cavity through the incision. The study participants were followed up at 6 weeks and 6 months postpartum. This study was conducted at the Weiler Division of the Montefiore Medical Center and at the Jacobi Medical Center in the Bronx, NY.ResultsForty-three (48%) women returned for their 6-week follow-up visits, and among those, no expulsions were recorded. Forty-two (47%) women were reached for phone follow-up at 6 months postpartum, and 80% reported being “happy” or “very happy” with their IUD.ConclusionsImmediate postplacental IUD insertion at the time of cesarean delivery is safe and acceptable.     

Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices

OBJECTIVES: To assess the efficacy, safety and, thus, advantages and disadvantages, of early postplacental intrauterine device (IUD) insertion. METHODS: IUDs were inserted within 10 min after postplacental expulsion in term pregnancy both in vaginal and cesarean deliveries via a ring forceps. Of the 276 patients enrolled, 235 were included in the study. Recipients were scheduled for examination before hospital discharge and at 6 weeks, 6 months and 12 months after postplacental insertion. RESULTS: The percentages of women returning for a follow-up visit were 221 (94%), 210 (89%) and 183 (78%) at 6 weeks, 6 months and 12 months, respectively. Among IUD acceptors, 74% of the cases had vaginal deliveries and 26% had cesarean deliveries. Continuation rates were relatively high, 87.6% and 76.3%, at 6 and 12 months, respectively, after postplacental insertion of IUD. In this study, the 1-year cumulative expulsion rate with TCu 380A device was 12.3%, which may be regarded as a standard expulsion rate for immediate postplacental insertion of similar models of IUDs. CONCLUSION: The evidence from this study suggests that immediate postplacental insertion of CuT 380 models is an effective, useful, safe, convenient and low-cost procedure for early postpartum contraception.     

Medications to ease intrauterine device insertion: a systematic review

BackgroundPotential barriers to intrauterine device (IUD) use include provider concern about difficult insertion, particularly for nulliparous women.ObjectiveThis study aims to evaluate the evidence on the effectiveness of medications to ease IUD insertion on provider outcomes (i.e., ease of insertion, need for adjunctive insertion measures, insertion success).Search strategyWe searched the PubMed database for peer-reviewed articles published in any language from database inception through February 2016.Selection criteriaWe included randomized controlled trials (RCTs) that examined medications to ease interval insertion of levonorgestrel-releasing IUDs and copper T IUDs.ResultsFrom 1855 articles, we identified 15 RCTs that met our inclusion criteria. Most evidence suggested that misoprostol did not improve provider ease of insertion, reduce the need for adjunctive insertion measures or improve insertion success among general samples of women seeking an IUD (evidence Level I, good to fair). However, one RCT found significantly higher insertion success among women receiving misoprostol prior to a second IUD insertion attempt after failed attempt versus placebo (evidence Level I, good). Two RCTs on 2% intracervical lidocaine as a topical gel or injection suggested no positive effect on provider ease of insertion (evidence Level I, good to poor), and one RCT on diclofenac plus 2% intracervical lidocaine as a topical gel suggested no positive effect on provider ease of insertion (evidence Level I, good). Limited evidence from two RCTs on nitric oxide donors, specifically nitroprusside or nitroglycerin gel, suggested no positive effect on provider ease of insertion or need for adjunctive insertion measures (evidence Level I, fair).ConclusionsOverall, most studies found no significant differences between women receiving interventions to ease IUD insertion versus controls. Among women with a recent failed insertion who underwent a second insertion attempt, one RCT found improved insertion success among women using misoprostol versus placebo.     

多次或短期内重复人工流产后即时放置吉妮致美宫内节育器的临床效果观察

目的:探讨多次或短期内重复人工流产术后即时放置吉妮致美宫内节育器(IUD)避孕及其预防并发症的应用价值.方法:将要求终止早孕的多次(≥3次)或短期(半年)内重复人工流产者500例随机分成两组,观察组人工流产术后即时放置吉妮致美IUD,对照组人工流产术后采取口服短效避孕药或避孕套避孕.结果:术后出血量、出血时间两组比较差异无统计学意义(P＞0.05);术后月经恢复时间两组差异有统计学意义(P ＜0.05);12个月内再次妊娠观察组0例,对照组28例,差异有统计学意义(P＜0.05).结论:多次或短期内重复人工流产术后即时放置吉妮致美IUD是安全、可靠、有效的避孕方法,同时有助于正常转经,预防宫腔粘连.     

Immediate versus delayed insertion of the levonorgestrel-releasing intrauterine device following dilation and evacuation: a randomized controlled trial

BackgroundThe study was conducted to compare 6-month usage of the levonorgestrel-releasing intrauterine device (LNG-IUD) when placed immediately or 3 to 6 weeks after dilation and evacuation (D&;E) procedure.Study DesignWe enrolled women undergoing D&;E at 15 to 23 weeks of gestation. After completion of the D&;E, subjects without contraindications to immediate IUD insertion were randomized to immediate or delayed (3 to 6 weeks later) LNG-IUD insertion. Subjects in the immediate group had the LNG-IUD placed using ultrasound guidance. All subjects returned at 3 to 6 weeks and 8 to 10 weeks after D&;E and were contacted by phone at 6 months.ResultsOf the 93 subjects enrolled, 88 were randomized. All 44 subjects (100%) randomized to immediate insertion had successful IUD placement, while only 20 (45.5%) of the 44 subjects randomized to delayed insertion returned for IUD placement, all of which were successful [difference 54.5%, 95% confidence interval (CI) 39.8%–69.3%]. Seventeen (38.6%) participants in each group were lost to follow-up. Of subjects contacted at the 6-month follow-up phone call, 23 of 27 women (85.2%) and 17 of 27 women (62.9%) were utilizing the LNG-IUD in the immediate and delayed groups, respectively (difference 22.2%, 95% CI ?0.4% to 44.8%). Intrauterine device expulsion occurred in three subjects (6.8%) and one subject (5.0%) in whom the IUD was placed in the immediate and delayed groups, respectively (p=1.0). No significant adverse events occurred.ConclusionSignificantly more participants had the LNG-IUD placed in the immediate insertion group compared with the delayed insertion group. Given the low risk of complications, immediate post-D&;E insertion of the LNG-IUD should be offered, especially for populations that may have difficulty returning for follow-up.     

妇科清热利湿化瘀制剂在放置宫内节育器后的应用价值研究

目的:探讨妇科清热利湿化瘀制剂在放置宫内节育器术后的应用价值。方法:研究对象随机分为观察组和对照组,观察组675例,于置器术后即服用清热利湿化瘀类中药复方制剂,连服7d,以后每月于月经来潮第1天开始重复以上治疗,共3个周期;对照组696例,于术后口服头孢呋辛酯片剂3d及维生素E胶丸7d,后两个月经周期口服维生素E胶丸7d,共3个周期。观察两组放置IUD后6个月内月经期、月经量异常、经间期出血、腰腹部疼痛、白带异常的发生情况以及12个月内的因症取出率和续用率。结果:观察组月经期、月经量异常、经间期出血、腰腹部疼痛、白带异常的发生率均低于对照组;观察组12个月内因症取出率显著低于对照组,续用率显著高于对照组。结论:妇科清热利湿化瘀复方制剂有助于宫内节育器放置后的早期适应,对置器后的不良反应能起有效的预防作用。     

A clinical trial of the Delta-T intrauterine device: immediate postpartum insertion

The Copper T-220C intrauterine device was modified for use in early postpartum insertions. Biodegradable extensions consisting of No. 2 chromic suture were added to the horizontal arms of the device to enhance retention. This new device, Delta-T IUD, was inserted in 100 patients within 55 hours of the delivery of the placenta. No uterine perforations or cervical lacerations occurred in this study. There was one accidental pregnancy 4 months following the IUD insertion. Seven IUDs were removed for bleeding and pain. There was one case of postpartum endometritis. Seventeen IUD expulsions occurred. Expulsions were more frequent at the beginning of the study and when the IUD was inserted more than 30 minutes after delivery of the placenta. The immediate postpartum insertion of IUDs with the event rates observed in this study is acceptable in situations where alternatives for other family planning modalities or interval insertion of intrauterine devices are not feasible.     

Impact of training level on postplacental levonorgestrel 52 mg intrauterine device expulsion

Objective

To determine the association between provider training level and postplacental intrauterine device (IUD) outcomes following insertion instruction by email only.

Post-coital intrauterine device insertion — A further evaluation

A total of 191 patients have undergone post-coital insertion of an intrauterine contraceptive device up to ten days postcoitus. The majority of patients were nulliparous and underwent insertion of a standard Gravigard [Copper 7] device. The subsequent expulsion and medical removal rates were normal for this group of patients but the non-medical removal rates were higher. There was one possible post-coital contraceptive failure (0.6%) and one pregnancy at six months due to the device exhibiting a failure of conventional contraceptive action.     

Barriers to intrauterine device insertion in postpartum women

OBJECTIVE: The objective of this study was to determine the proportion of postpartum women at the University of New Mexico who choose an IUD for contraception, the number who actually obtain one and the barriers to postpartum IUD insertion. METHOD: We conducted a retrospective chart review of 1627 postpartum women who delivered at the University of New Mexico. Those women who indicated at hospital discharge that they desired an IUD comprised the study group of 193 women. Medical records were reviewed to identify the timing of IUD placement. If an IUD was not inserted, we attempted to determine the reason by reviewing clinic records. RESULTS: Twelve percent of postpartum women requested an IUD. Records were available for 114 women. Of these, only 69 (60%) actually obtained an IUD. Barriers to postpartum IUD insertion included provider advice against the IUD, patient failure to return for a postpartum visit and early repeat pregnancy. CONCLUSION: We conclude that postpartum women desiring an IUD may have difficulty obtaining one.     

种类、放置时期和技术影响宫内节育器失败的系统评价

目的:评价宫内节育器(IUD)种类、放置时期和放置技术对其失败率的影响。方法:用循证医学方法,检索7个数据库和9种相关杂志,纳入相关临床研究并予以质量评价,提取原始研究的数据和进行合并分析。对无异质性可合并的文献使用Meta分析,对不可合并的资料作定性系统评价。结果:纳入16项(共计23295例)研究,因文献间异质性大,仅进行定性系统评价。结果显示活性带铜IUD较惰性IUD的失败率低;在放置时期比较中,剖宫产后即时放置IUD的脱落率低于阴道分娩后放置者;人流后即时和哺乳期放置IUD的脱落率可能较高,但哺乳期放置因症取出率低;服务提供人员置器技术与脱落率相关。结论:活性IUD值得推广使用。对阴道分娩后放器者应该加强随访,哺乳期放置IUD的脱落率可能较高,但因症取出率低,为知情选择提供了依据。放置IUD应该由技术娴熟和有经验的服务提供者完成。因纳入分析的文献以回顾性病例分析和病例-对照研究为主,结论需要进一步论证。     

Safety of intrauterine device insertion by trained nurse-midwives in the Sudan

Insertion of intrauterine devices (IUDs) by trained health workers other than physicians is increasing, particularly in developing countries. Twenty nurse-midwives in government service in the Sudan, called health visitors (HVs), were trained to provide intrauterine contraceptives in a research project designed to evaluate the safety of insertion of IUDs by medical personnel who are not physicians. After training, they inserted 763 IUDs. Independent evaluation of 520 clients was conducted by gynecologists who found that only six devices (1.2%) had been incorrectly inserted. Outcomes for clients of the health visitors, with respect to perforations, infections, expulsions, and pregnancies, compared well with those of eight physicians who participated in the study. The research strongly supports the concept of nurse-midwife training for IUD insertion. This would greatly expand the availability of family planning services and would conserve physician time and skills for problem cases.     

Postplacental or delayed levonorgestrel intrauterine device insertion and breast-feeding duration

Background

The objective of this study was to assess the effect of timing of postpartum levonorgestrel-releasing intrauterine device (IUD) insertion on breast-feeding continuation.

Study Design

Women interested in using a levonorgestrel IUD postpartum were randomized to immediate postplacental insertion (postplacental group) or insertion 6–8 weeks after vaginal delivery (delayed group). Duration and exclusivity of breast-feeding were assessed at 6–8 weeks, 3 months, and 6 months postpartum. Only women who received an IUD were included in this analysis.

Results

Breast-feeding was initiated by 32 (64%) of 50 of women receiving a postplacental IUD and 27 (58.7%) of 46 of women receiving a delayed IUD (p=.59). More women in the delayed group compared with the postplacental group continued to breast-feed at 6–8 weeks (16/46 vs. 15/50, p=.62), 3 months (13/46 vs. 7/50, p=.13), and 6 months postpartum (11/46 vs. 3/50, p=.02). The results did not differ when only women who initiated breast-feeding or only primiparous women with no prior breast-feeding experience were analyzed.

Conclusions

Immediate postplacental insertion of the levonorgestrel IUD is associated with shorter duration of breast-feeding and less exclusive breast-feeding. Further studies on the effects of early initiation of progestin-only methods on women's lactation experience are needed.