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

Longitudinal impact of a residency-based postplacental levonorgestrel intrauterine device insertion program: Expulsion rates in years 1, 2, and 3

OBJECTIVE

To evaluate expulsion rates in the first 3 years of an academic postplacental levonorgestrel intrauterine device (LNG-IUD) insertion program.

STUDY DESIGN

Retrospective case series, January 2016 to December 2018. We measured LNG-IUD expulsion rates by 12 weeks postpartum.

RESULTS

Of 235 LNG-IUD insertions, in years 1, 2, and 3, expulsion rates were 11/39 (28%), 9/94 (10%), and 15/102 (15%) (p = 0.03). After vaginal delivery, manual insertion was associated with a higher expulsion rate than ring-forceps (10/28 [36%] vs 17/105 [16%], p = 0.04).

CONCLUSIONS

LNG-IUD expulsion rates decreased after program year 1, suggesting program maturity may be associated with a lower expulsion risk.

Utilisation, effectiveness, and safety of immediate postpartum intrauterine device insertion: a systematic literature review

BACKGROUND

Intrauterine devices (IUDs) are highly effective contraception. IUDs inserted directly following delivery provide immediate birth control and may decrease unintended pregnancies, including short-interval pregnancies, thereby mitigating health risks and associated economic burden.

METHODS

This systematic literature review included published global data on the utilisation, effectiveness, and safety of postpartum intrauterine devices (PPIUDs) of any type. English language articles indexed in MEDLINE, Embase, and Cochrane from January 2010-October 2021 were included.

RESULTS

133 articles met the inclusion criteria (46% interventional studies; 54% observational; n=87 from lower-income countries; n=46 from higher-income countries). PPIUD use was low in higher-income countries (6/10 000 US deliveries in 2013-2016) and varied widely in lower-income countries (2%-46%). Across both higher- and lower-income countries, in most studies (79%), >80% of women with PPIUDs had an IUD in place by 3 months; at 6 and 12 months, 76% and 54% of included studies reported that >80% of women had an IUD in place; reason for discontinuation was infrequently reported. Pregnancies were rare (96 pregnancies across 12 191 women from 37 studies reporting data) and were generally unrelated to device failure, but rather occurred in women no longer using a PPIUD. Expulsions occurred mainly in the early outpatient period and ranged widely (within 3 months: 0-41%). Abnormal bleeding, infections, or perforations were rare.

CONCLUSIONS

PPIUDs are safe and effective. Long-term follow-up data are limited. Future research elucidating reasons underlying lack of PPIUD use is warranted.

Decision-making regarding immediate vs. interval postpartum levonorgestrel intrauterine device insertion timing

BACKGROUND

Understanding decision-making for contraception initiation timing postpartum may help guide patients in selecting a contraceptive method most aligned with their reproductive goals. The objective of this study was to explore the decision-making process in patients who chose immediate postplacental (IPP) levonorgestrel intrauterine device (LNG IUD) insertion versus interval insertion at the postpartum follow-up visit.

METHODS

We recruited English-speaking, reproductive-aged adult postpartum participants who received either an IPP or interval postpartum LNG IUD from September to December 2017 at MetroHealth Medical Center. We conducted interviews over the phone utilizing a pilot-tested, semi-structured interview guide. Interview topics included past experiences with contraception, provider counseling, intrapartum factors, and current experiences after IUD insertion.

RESULTS

We interviewed 20 participants (12 IPP and eight interval IUD recipients). Participants receiving an IPP IUD described convenience, desire for immediate contraception, pain control and availability of alternative contraception options as influential for their decision. Patients who received an interval IUD performed outside research, focused on the events surrounding delivery, and generally favored additional recovery time before obtaining an IUD. Patients who received interval IUDs were often not aware that IPP IUDs were available. Early, frequent, and comprehensive counseling was viewed favorably when compared to counseling upon arrival to the laboring unit. While overall there was congruence of participant expectations and experiences, unexpected expulsion affected desire for future IUD use in some participants.

CONCLUSION

Providers should be mindful that prior experience and knowledge as well as delivery room considerations affect insertion timing decision-making.

TRIAL REGISTRATION

N/A.

Perforation of levonorgestrel-releasing intrauterine system found at one month after insertion: A case report

BACKGROUND

The levonorgestrel-releasing intrauterine system (LNG-IUS) is widely used in contraception, menorrhagia, dysmenorrhea and to prevent endometrial hyperplasia during estrogen supplementation. Perforation is more often seen after early postpartum placement. Perforation of the LNG-IUS occurring one month after placement is rare.

CASE SUMMARY

A 42-year-old female complained of progressive dysmenorrhea and increased menstrual volume. She was diagnosed with adenomyosis and the LNG-IUS was inserted in her uterine cavity. Routine ultrasound examination one month later revealed that the intra-uterine device (IUD) was not found in the uterine cavity, and further X-ray and pelvic magnetic resonance imaging showed an abnormal signal area in the left posterior region of the uterus. Laparoscopic exploratory surgery was performed and the LNG-IUS was found in the left uterosacral ligament.

CONCLUSION

Perforation of a LNG-IUS occurring one month after placement is rare, and is more common in inexperienced operators and after early postpartum placement. When the operation is difficult, ultrasound monitoring is recommended to reduce the risk of IUD perforation. For patients with inadequate surgery, postoperative imaging is recommended to detect potential risks as soon as possible.

Changes in Rates of Inpatient Postpartum Long-Acting Reversible Contraception and Sterilization in the USA, 2012-2016

OBJECTIVES

To examine recent rates of long-acting and permanent methods (LAPM) of contraception use during delivery hospitalization and correlates of their use.

METHODS

A retrospective cohort study utilizing the 2012-2016 National Inpatient Sample of hospitalizations in the United States of America. The International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes were used to identify deliveries, inpatient long-acting reversible contraception (IPP LARC), and postpartum tubal ligation (PPTL). We conducted univariable and multivariable logistic regression to examine associations between demographic, clinical, hospital and geographical characteristics with likelihood of LAPM including IPP LARC and PPTL.

RESULTS

Our sample included 3,642,328 unweighted deliveries. The rate of IPP LARC increased from 34.6 to 54.9 per 10,000 deliveries (58.7%), while the rate of PPTL utilization decreased from 719.5 to 671.8 per 10,000 deliveries (6.6%) over the study period. In multivariable analysis of LAPM utilization versus neither, cesarean delivery (aOR 7.25, 95% CI 7.08-7.43) was associated with greater utilization. Native American (aOR 4.01, 95% CI 2.91-5.53) race was associated with increased use of IPP LARC compared to a non-long-acting method of contraception. Age between 18 and 29 years (aOR 6.21, 95% CI 5.42-7.11) was associated with greater use of IPP LARC versus PPTL. Delivering in a rural hospital ((aOR 0.09, 95% CI 0.06-0.12) and cesarean delivery (aOR 0.09, 95% CI 0.06-0.12) were associated with greater use PPTL versus IPP LARC.

CONCLUSIONS

The IPP LARC rate remains at less than 10% the PPTL rates in our study timeframe. The demonstrated variation in uptake of highly effective methods of contraception inpatient after delivery offer possible opportunities for better understanding and improvement in access.

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.