Lisa M. Goldthwaite

Insertion characteristics of intrauterine devices in adolescents and young women: success, ancillary measures, and complications.

OBJECTIVE The objective of the study was to evaluate success and safety of intrauterine device (IUD) placement in a large cohort of adolescents. STUDY DESIGN We examined the medical records of patients aged 13-24 years at the Childrens Hospital Colorado Adolescent Family Planning Clinic with at least 1 attempt at IUD placement. We abstracted demographic, reproductive, and procedural variables. The primary outcome was successful placement at first IUD insertion visit. We compared nulliparous with parous adolescents and patients younger than 18 years with those 18 years of age and older. RESULTS Between April 2009 and December 2011, 1177 adolescent women aged 13-24 years (mean age 20.8 ± 2.5 years) had an attempted IUD placement, 1012 (86%) of which were with an advanced practice clinician. The first attempt was successful for 1132 women (96.2%). The first-attempt success rate was 95.8% for nulliparous women and 96.7% for parous women (P = .45). The first-attempt success rate was 95.5% (n = 169) for women aged 13-17 years compared with 96.3% (n = 963) for women aged 18-24 years (P = .6). Only 1.8% (n = 21) of all first-attempt successful insertions required ancillary measures. Of the 45 patients with a failed first insertion attempt, 40% (n = 18) had a second attempt with a physician, of which 78% (n = 14) were successful. Within the first 6 months of IUD placement, no perforations were identified and 24 patients (3.0%) expelled the IUD. Insertion failures and IUD expulsions were not related to IUD type, age, or parity. CONCLUSION Intrauterine devices can be inserted in nulliparous adolescents of any age with similar success to parous adolescents, by both physicians and advanced practice clinicians. Inability to provide ancillary measures such as paracervical block or cervical dilation should not limit access to this first-line contraceptive method.

Comparison of interventions for pain control with tenaculum placement: a randomized clinical trial.

OBJECTIVE Although previous studies have demonstrated that a variety of local anesthetics are effective to decrease pain associated with tenaculum placement, no studies directly compare an injection with a topical anesthetic. The objective of this study was therefore to compare mean pain scores with tenaculum placement after an intracervical lidocaine injection or topical lidocaine gel. STUDY DESIGN A randomized, single-blinded trial of women presenting for office gynecologic procedures that required a tenaculum. Women aged 18 years or older were randomized to receive either a 1% lidocaine intracervical injection or topical application of 2% lidocaine gel to the cervix immediately prior to tenaculum placement. The primary outcome was pain at the time of tenaculum placement, measured on a 100 mm Visual Analog Scale. Secondary outcomes included pain with the intervention and satisfaction with tenaculum placement. RESULTS Seventy-four women were enrolled and randomized; 35 subjects in each group met criteria for analysis. The two groups had similar socio-demographic characteristics. Women who received the injection had lower mean pain levels at tenaculum placement [12.3 mm (S.D. 17.4 mm) versus 36.6 mm (S.D. 23.0 mm), p<.001] but higher mean pain levels with study drug application [20.4 mm (S.D. 19.4 mm) versus 5.9 mm (S.D. 8.6 mm), p<.001]. Satisfaction with tenaculum placement was similar for the two groups. CONCLUSION Mean pain with tenaculum placement is lower after receiving a lidocaine injection than after receiving a topical lidocaine gel. Satisfaction with tenaculum placement is similar with both interventions.

Intrauterine Device Insertion During Cesarean Delivery: The Rising Tide of the Postdelivery Intrauterine Device.

The late Allan Rosenfield once commented that family planning is one of the most important public health achievements of the 20th century. Yet, worldwide, unmet need for family planning remains high, particularly in the postpartum period, with estimates for this indicator as high as 70% in some countries. For many women and couples, the failure to achieve effective contraception during this period is as much about access and timely decisionmaking as it is about issues relating to contraceptive efficacy, contraindications, and eligibility criteria. The article in this month’s journal by Dr. Levi and colleagues (see page 5) provides Level 1 evidence that widening the window of intrauterine device (IUD) access to include immediate post–cesarean delivery insertion can increase overall IUD continuation when compared with a group who planned for an interval insertion after hospital discharge. There has been a dramatic increase in IUD use among American women in the past decade and a parallel global trend toward increased IUD use in developing countries. As a further indication of an IUD renaissance, the volume of IUD-related research has increased in both clinical and programmatic domains. In particular, immediate postpartum IUD insertion is gaining both currency and popularity, reflected by Medicaid policy changes to include reimbursement for postpartum IUD use in 11 states in the past 2 years. Similar trends are present internationally, as evidenced by resources such as the immediate postpartum IUD toolkit available through the United States Agency for International Development and the development of a dedicated inserter for postpartum IUD use. Indeed, programmatically, the postpartum IUD represents an increasingly recognized opportunity to reduce the high unmet need documented for postpartum women. Although much postpartum IUD research focuses on IUD placement after vaginal delivery, this month’s highlighted article brings the focus to insertion at the time of cesarean delivery. Considering the fact that cesarean delivery represents approximately one third of deliveries in the United States and that developing countries are also rapidly realizing increased cesarean delivery rates, IUD placement at the time of cesarean delivery is an important intervention that could further reduce the unmet need for family planning. The serendipity of postpartum IUD use is compelling and applies to the post–cesarean delivery scenario as it does after vaginal delivery: 1) both the provider and the patient are in the same place at the same time, avoiding the need for a separate visit for contraception initiation; 2) access to the uterine cavity is facilitated by the hysterotomy, just as the open cervix facilitates access in the post–vaginal delivery setting; 3) the insertion process is highly expeditious, commonly requiring less than 30 seconds for actual deployment, and adding no appreciable cost or duration to the primary delivery procedure; and 4) fewer accessories (eg, speculum, sound, tenaculum, light source) are required. See related article on page 5.

Postplacental intrauterine device expulsion by 12 weeks: A prospective cohort study

Background An intrauterine device placed immediately following a delivery can serve as an effective and safe contraceptive strategy in the postpartum period. There is limited evidence that the levonorgestrel intrauterine system may have a higher rate of expulsion compared to the copper intrauterine device; however, rates of expulsion for these 2 intrauterine device types have not been compared directly. Objective We sought to compare expulsion rates by 12 weeks’ postpartum for the levonorgestrel intrauterine system and copper intrauterine device. Study Design We enrolled women who received postplacental intrauterine devices at 2 urban hospitals. Eligible women were ≥18 years old, English‐ or Spanish‐speaking, with singleton vaginal delivery at ≥35 weeks’ gestation. Intrauterine devices were inserted within 10 minutes of placental delivery by trained providers using ring forceps or the operator’s hand. Intrauterine device location was evaluated via abdominal ultrasound at 24‐48 hours’ postpartum, and via transvaginal ultrasound 6 and 12 weeks later, categorizing position of the intrauterine device at the fundus, below the fundus but above the internal os, any part of the intrauterine device below the internal os (partial expulsion), or no intrauterine device visualized. Outcomes included intrauterine device expulsion and method continuation. We used multivariable logistic regression to identify factors associated with expulsion. Results We enrolled 123 women ages 18‐40 years. Of these, 68 (55%) initiated levonorgestrel intrauterine system and 55 (45%) initiated copper intrauterine device. Groups were similar except more copper intrauterine device users were Hispanic (66% vs 38%) and fewer were primiparous (16% vs 31%). Among the 96 (78%) with 12‐week follow‐up, expulsion was higher for levonorgestrel intrauterine system users (21/55 or 38%) than for copper intrauterine device users (8/41 or 20%) (odds ratio, 2.55; 95% confidence interval, 0.99–6.55; P = .05). At 24 hours’ postpartum, there was no significant difference in median distance from the intrauterine device to the fundus between intrauterine device types or between those who did or did not experience expulsion. Of expulsions, 86% occurred ≤6 weeks’ postpartum. All complete expulsions were clinically identified, but of the partial expulsions, only 4/10 (40%) were clinically suspected prior to ultrasound. The only independent predictor of expulsion was intrauterine device type. Including reinsertions, intrauterine device use at 12 weeks was not significantly different for levonorgestrel intrauterine system and copper intrauterine device users (80% vs 93%; P = .14). Conclusion Women initiating postplacental levonorgestrel intrauterine system are more likely to experience complete expulsion than those initiating copper intrauterine device. Using sonographic criteria results in higher expulsion rates than previously reported. It is unclear if such high expulsion rates would be identified following standard clinical practice.

Immediate postpartum provision of long-acting reversible contraception.

Purpose of review The objective of this review is to describe current literature regarding the role and characteristics of long-acting reversible contraception (LARC) used immediately postpartum. Recent findings Copper and levonorgestrel intrauterine devices (IUDs) inserted immediately postpartum at the time of both vaginal and cesarean deliveries are associated with higher rates of continuation at 6–12 months when compared with IUDs placed at the postpartum visit (4–8 weeks after delivery), despite higher rates of expulsion. IUDs and contraceptive implants are cost-effective when used immediately postpartum, and they are associated with longer interpregnancy intervals. There is limited evidence regarding the effects of immediate postpartum LARC on breastfeeding. Summary Use of LARC methods in the immediate postpartum period is both effective and safe, and could reduce unmet need for contraception during this time. More research is needed to explore various immediate postpartum IUD insertion methods and the effects of immediate postpartum progestin-containing LARC on breastfeeding.

Adverse Birth Outcomes in Colorado: Assessing the Impact of a Statewide Initiative to Prevent Unintended Pregnancy.

OBJECTIVES We assessed whether living in counties with Title X clinics and increased use of long-acting reversible contraception (LARC) in Colorado are associated with decreased risk of adverse birth outcomes. METHODS We linked Title X clinic counties to the Colorado birth data set by using the mothers county of residence. We compared low birth weight (LBW) and preterm birth (PTB) in 2008 and 2012, in counties with and without Title X clinics. We compared the relationship between LARC use and the incidence of LBW or PTB in 2012 for women living in counties with Title X clinics. RESULTS For women living in counties with Title X clinics, the odds of PTB were significantly lower in 2012 compared with 2008 (odds ratio = 0.85; 95% confidence interval = 0.81, 0.89; interaction P = .02). For women living in Title X clinic counties in 2012, a higher proportion of LARC use (> 12.4%) was significantly associated with decreased risk of PTB (P = .02) compared with a low proportion of LARC use (≤ 4.96%). CONCLUSIONS Improved access to family planning services and increased use of LARC are associated with lower risk of PTB.

Comfort With Skills and Knowledge After Immediate Postpartum Intrauterine Device Training.

OBJECTIVE: To estimate whether a standardized immediate postpartum intrauterine device (IUD) simulation results in sustained improvement in perceived comfort with procedural skills. METHODS: From November 2013 to April 2015, obstetric health care providers at two teaching hospitals participated in a 30-minute immediate postpartum IUD simulation workshop and program evaluation. We assessed knowledge of indications, insertion technique, safety, and comfort with knowledge and skills preintervention immediately after and 6 months posttraining. RESULTS: Training participants (N=84) included 39 residents and 45 attendings (25 certified nurse–midwives and 20 obstetrician–gynecologists). Fifty-seven participants (68%) completed the 6-month assessments. Many participants had placed immediate postpartum IUDs before the training (54% of residents compared with 64% of attendings, P=.32); 60% were comfortable with their knowledge and 52% with their insertion skills defined by self-assessment of 7 or greater on a 10-point scale. On the pretest, 77% answered 80% or greater of the knowledge-based questions correctly; this proportion rose to 95% and 97% on the immediate and 6-month assessments, respectively, and were similar between residents and attendings. Immediately posttraining, 94% of participants rated their comfort with knowledge at 7 or greater out of 10; this fell to 86% by 6 months. Likewise, 87% and 74% scored their comfort with skills at 7 or greater out of 10 immediately and at 6 months, respectively. By 6 months, 81% reported placing one or more immediate postpartum IUDs(92% of residents and 71% of attendings, P=.05). CONCLUSION: Residents and attendings demonstrate sustained improvement in knowledge and comfort with immediate postpartum IUDs 6 months after a standardized simulation workshop.

Family planning and the Zika era.

Purpose of review To review the current evidence regarding the impact of the Zika virus epidemic on pregnancy and the implications for family planning and reproductive health services for women in affected countries. Recent findings In the past 2 years, over the course of the Zika epidemic, much has been learned about the virus. Specifically in regard to pregnancy, a causative relationship has been established between the Zika virus and adverse fetal outcomes, and sexual transmission of the virus has been documented. Broad recommendations by government agencies and public health officials regarding avoidance of pregnancy for women at risk of acquiring the Zika virus have theoretical and documented implications for abortion and contraception demand and access. Summary Additional research is needed to better understand the impact of Zika virus health recommendations and advisories on womens decision making around pregnancy, as well as their impact on demand, access and safety of family planning services.

Rectal perforation with an intrauterine device: a case report.

A 27-year-old woman presented for routine examination 1 year after intrauterine device (IUD) placement; strings were not visualized. The device was found to be penetrating through the rectal mucosa. It was removed easily through the rectum during an examination under anesthesia. Perforated IUDs with rectal involvement require thoughtful surgical planning to optimize outcomes.

Early hysteroscopic removal of intratubal microinserts with urologic stone retrieval forceps.

BACKGROUND: Nickel hypersensitivity reactions can be an indication for the removal of intratubal microinserts used for hysteroscopic sterilization. Although early removal can be attempted hysteroscopically, hysteroscopic grasping forceps may be inadequate to grasp deeply positioned inserts. CASE: Three days after hysteroscopic sterilization, the patient presented with a rash consistent with a nickel hypersensitivity reaction. Ten days after placement, we successfully performed hysteroscopic removal of an intratubal microinsert with tri-prong urologic stone retrieval forceps after standard hysteroscopic grasping forceps was unable to reach the deeply positioned device. Within 36 hours of bilateral microinsert removal, all symptoms resolved. CONCLUSION: In difficult cases, 1-mm tri-prong urologic stone retrieval forceps can be useful for early hysteroscopic removal of intratubal microinserts.