Eve Espey

Immediate versus Delayed IUD Insertion after Uterine Aspiration

BACKGROUND Intrauterine devices (IUDs) provide highly effective, reversible, long-term contraception that is appropriate for many women after first-trimester uterine aspiration. However, the effects of immediate versus delayed IUD insertion after uterine aspiration on rates of complications and IUD use are uncertain. METHODS We performed a randomized noninferiority trial involving women undergoing uterine aspiration for induced or spontaneous abortion at 5 to 12 weeks of gestation who desired an IUD. Subjects were randomly assigned (in a 5:6 ratio) to IUD insertion immediately after the procedure or 2 to 6 weeks afterward (delayed insertion). The primary outcome was the rate of IUD expulsion 6 months after IUD insertion; an expulsion rate 8 percentage points higher in the immediate-insertion group was defined as inferior. RESULTS Among 575 women who underwent randomization, an IUD was inserted in 100% (258 of 258) of the women in the immediate-insertion group and in 71.3% (226 of 317) of those in the delayed-insertion group (difference, 28.7 percentage points; 95% confidence interval [CI], 23.7 to 33.7). The 6-month expulsion risk was 5.0% (13 of 258 women) after immediate insertion and 2.7% (6 of 226) after delayed insertion (difference, 2.3 percentage points; 95% CI, -1.0 to 5.8), which was consistent with the predefined criterion for noninferiority. Six-month rates of IUD use were higher in the immediate-insertion group (92.3%, vs. 76.6% after delayed insertion; P<0.001). Adverse events were rare and did not differ significantly between groups. No pregnancies occurred in the immediate-insertion group; five occurred in the delayed-insertion group (P=0.07), all in women who never received an IUD. CONCLUSIONS The 6-month rate of expulsion of an IUD after immediate insertion was higher than but not inferior to that after delayed insertion. Immediate insertion resulted in higher rates of IUD use at 6 months, without an increased risk of complications. (Funded by the Susan Thompson Buffett Foundation; ClinicalTrials.gov number, NCT00562276.).

To the point: medical education review of the role of simulators in surgical training

Simulation-based training (SBT) is becoming widely used in medical education to help residents and medical students develop good technical skills before they practice on real patients. SBT seems ideal because it provides a nonthreatening controlled environment for practice with immediate feedback and can include objective performance assessment. However, various forms of SBT and assessment often are being used with limited evidence-based data to support their validity and reliability. In addition, although SBT with high-tech simulators is more sophisticated and attractive, this is not necessarily superior to SBT with low-tech (and lower cost) simulators. Therefore, understanding the types of surgical simulators and appropriate applications can help to ensure that this teaching and assessment modality is applied most effectively. This article summarizes the key concepts that are needed to use surgical simulators effectively for teaching and assessment.

Long-acting reversible contraceptives: intrauterine devices and the contraceptive implant.

The provision of effective contraception is fundamental to the practice of womens health care. The most effective methods of reversible contraception are the so-called long-acting reversible contraceptives, intrauterine devices and implants. These methods have multiple advantages over other reversible methods. Most importantly, once in place, they do not require maintenance and their duration of action is long, ranging from 3 to 10 years. Despite the advantages of long-acting reversible contraceptive methods, they are infrequently used in the United States. Short-acting methods, specifically oral contraceptives and condoms, are by far the most commonly used reversible methods. A shift from the use of short-acting methods to long-acting reversible contraceptive methods could help reduce the high rate of unintended pregnancy in the United States. In this review of long-acting reversible contraceptive methods, we discuss the intrauterine devices and the contraceptive implant available in the United States, and we describe candidates for each method, noncontraceptive benefits, and management of complications.

Renewed Interest in Intrauterine Contraception in the United States: Evidence and Explanation

This commentary discusses the increasing prevalence of intrauterine contraception in the United States since reaching a low point in 1995. It describes the different product-related factors provider-related factors and patient-related factors that have contributed to the rise in use of intrauterine devices (IUDs) in the United States. It also explains how the IUD practice guidelines published by the American College of Obstetricians and Gynecologists (ACOG) in 2005 were written during a time of resurgence of positive attitudes about IUDs and increasing recognition of their safety and efficacy rather than the more negative attitudes of previous years. Copyright

Depo-provera associated with weight gain in Navajo women.

Depo-medroxyprogesterone acetate (DMPA) is an increasingly popular contraceptive choice among Navajo women. Weight gain is cited as a common side effect and major reason for discontinuation of DMPA. No controlled trials have evaluated the association between weight gain and DMPA in Navajo women. We aimed to clarify whether DMPA is associated with weight gain in Navajo women and to quantify the magnitude of weight gain. A cohort of 172 Navajo women who had used DMPA continuously for one or 2 years comprised the study group. A cohort of 134 Navajo women who used a non-progestin method or no method over 1 or 2 years comprised the comparison group. Initial weight, one-year weight and 2-year weights were recorded for all patients. Study subjects gained a mean of 6 pounds over one year and 11 pounds over 2 years relative to the comparison group (p < 0.001) after controlling for possible confounding variables including age, parity and initial weight. Use of DMPA is associated with significant weight gain in Navajo women. This weight gain is greater than that reported in previous uncontrolled studies in non-Navajo populations. This information should be utilized in counseling Navajo women about the side effects of DMPA.

Effect of Progestin Compared With Combined Oral Contraceptive Pills on Lactation: A Randomized Controlled Trial.

OBJECTIVE: To estimate the effect of progestin-only compared with combined hormonal contraceptive pills on rates of breastfeeding continuation in postpartum women. Secondary outcomes include infant growth parameters, contraceptive method continuation, and patient satisfaction with breastfeeding and contraceptive method. METHODS: Postpartum breastfeeding women who desired oral contraceptives were randomly assigned to progestin-only and combined hormonal contraceptive pills. At 2 and 8 weeks postpartum, participants completed in-person questionnaires that assessed breastfeeding continuation and contraceptive use. Infant growth parameters including weight, length, and head circumference were assessed at 8 weeks postpartum. Telephone questionnaires assessing breastfeeding, contraceptive continuation, and satisfaction were completed at 3–7 weeks and 4 and 6 months. Breastfeeding continuation was compared between groups using Cox proportional hazards regression. Differences in baseline demographic characteristics and in variables between the two intervention groups were compared using &khgr;2 tests, Fisher exact test, or two-sample t tests as appropriate. RESULTS: Breastfeeding continuation rates at 8 weeks (progestin-only 63.5%; combined hormonal 64.1%), contraceptive continuation, and infant growth parameters did not differ between users of progestin-only and combined hormonal contraceptive pills. Infant formula supplementation and maternal perception of inadequate milk supply were associated with decreased rates of breastfeeding in both groups. CONCLUSION: Choice of combined hormonal or progestin-only contraceptive pills administered 2 weeks postpartum did not adversely affect breastfeeding continuation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01465022. LEVEL OF EVIDENCE: I

Advocating for immediate postpartum LARC: increasing access, improving outcomes, and decreasing cost☆☆☆★

Unintended pregnancy, endemic in the United States Expulsion rates appear to be lower with postplacental (within (US), carries significant health and economic consequences and disproportionately affects poor women and women of color [1,2]. Rapid repeat pregnancy—defined as a pregnancy within 12 to 18 months after delivery—can occur if women are unsuccessful at initiating contraception [3]. Improving postpartum initiation of effective contraception including long-acting reversible contraception (LARC), the intrauterine device (IUD) and contraceptive implant, is a key strategy to reduce unintended pregnancy and health inequities. However, nonreimbursement by insurers for both LARC devices and the immediate insertion procedure, is a critical barrier to the provision of postpartum LARC during the hospital admission for a birth. Recently, coalitions in three states have successfully advocated for modification of Medicaid policy to allow reimbursement for immediate postpartum placement, both for the devices and the insertion procedure, separate from the global fee for delivery. By removing a key financial barrier, these policy changes signal an important advance in provision of the most effective forms of immediate postpartum contraception. Immediate postpartum LARC insertion is safe and supported by recent clinical guidelines [4,10]. According to the US Medical Eligibility Criteria for Contraceptive Use, both the levonorgestrel (LNG) IUD and copper IUD may be inserted prior to hospital discharge after vaginal or cesarean delivery in both breastfeeding and nonbreastfeeding women.

Misoprostol for intrauterine device insertion in nulliparous women: a randomized controlled trial

OBJECTIVE To examine the effects of preprocedure misoprostol on intrauterine device (IUD) placement in nulliparous women. STUDY DESIGN In this randomized controlled double-blind trial at the University of New Mexico reproductive health clinic, nulliparous women requesting an IUD were randomized to 400 mcg of buccal misoprostol or placebo 2-8 hours before insertion. Primary outcomes included pain on a 10-cm visual analog scale and womens perception of the value of delaying insertion for an effective medication. Provider ease of insertion and need for adjunctive insertion measures were also assessed, on a visual analog scale. Participants indicated maximum pain after IUD insertion, pain level they would tolerate to avoid delay in IUD insertion, and preference for IUD insertion without delay if an effective medication was available. RESULTS Of 85 women enrolled, 3 were ineligible; 42 were randomized to misoprostol and 40 to placebo. There were no differences between groups in worst insertion pain, (5.8 ± 2.0 vs 5.9 ± 2.0, P = .94), provider ease of insertion (2.2 ± 2.2 vs 2.5 ± 2.2; P = .54) or adjunctive measures (14% vs 25%; P = .27). The groups were willing to tolerate the same mean pain (4.9 ± 2.5 vs 5.7 ± 2.4, P = .18) to avoid waiting for medication. The majority of women (85%) preferred to wait for an effective medication. CONCLUSION Misoprostol for nulliparous women did not decrease pain or improve the ease of insertion of an IUD. Most women were willing to wait for a medication that decreases pain, indicating a need to pursue alternatives for pain control with IUD insertion.

Prophylactic ibuprofen does not improve pain with IUD insertion: a randomized trial

OBJECTIVE To evaluate if ibuprofen 800mg reduces pain with intrauterine device (IUD) insertion among U.S. women. STUDY DESIGN We conducted a randomized, double-blind, placebo-controlled trial of women undergoing IUD insertion approximately 2-6weeks following first-trimester uterine aspiration. Subjects were randomized to receive ibuprofen 800mg or placebo 30-45min prior to IUD insertion. A 100-mm visual analog scale (VAS) was administered to measure pain after speculum insertion (baseline) and immediately following IUD insertion. RESULTS A total of 202 women were enrolled, with 101 randomized to each group (ibuprofen or placebo). Sociodemographic characteristics and baseline VAS scores were similar between groups. The median pain score with IUD insertion was 41.5mm in the placebo group and 38.0mm in the ibuprofen group (p=.50). Mean and median pain scores did not differ between placebo and ibuprofen when nulliparous and parous women were analyzed independently. Overall, median pain scores were 17.5mm higher in nulliparous women than parous women (p=.004). Median pain scores did not differ by age, IUD-type, history of dysmenorrhea or time since aspiration. CONCLUSIONS Administration of ibuprofen 800mg prior to IUD insertion does not reduce pain associated with the procedure for U.S. women. Overall, nulliparous women report more pain with IUD insertion than multiparous women.

Student attitudes about a clinical experience in abortion care during the obstetrics and gynecology clerkship.

Purpose An optional half-day clinical experience in abortion care was offered to third-year medical students rotating through the core obstetrics and gynecology (Ob/Gyn) clerkship at the University of New Mexico to improve education about women’s reproductive health. This study using survey methods was conducted to rate the acceptability of the clinical experience and to document any changes in students’ attitudes toward women’s access to abortion. Method All 145 students who rotated through the Ob/Gyn clerkship between March 2000 and March 2002 were provided an 11-item, confidential questionnaire to complete. Students who did not participate in the abortion care experience were asked questions about their reasons for declining participation; students who did participate were asked questions about the value of the experience. Results Of the 145 students who rotated through the clerkship during the study period, 126 (87%) completed the questionnaire. Of these students, 86 (68%) participated in the clinical experience and 40 (32%) did not. The majority of students who participated in the clinical experience rated it very highly. Of the 86 students who participated in the clinical experience, 33 (38%) reported a change in their attitudes about abortion; 31 (94%) of these became more supportive of women’s access to abortion services. Conclusion Clinical experiences in abortion care are acceptable to and valued by a diverse group of medical students and should be offered at medical schools throughout the United States.