Nathalie Kapp

Intrauterine device insertion during the postpartum period: a systematic review.

BACKGROUND Insertion of an intrauterine device (IUD) at different times or by different routes during the postpartum period may increase the risk of complications. METHODS We searched Medline, Lilacs and Cochrane Collaboration databases for articles in any language, between database inception until December 2008, which compared outcomes of postpartum IUD insertion time intervals. Search terms included postpartum, puerperium, postcesarean delivery, cesarean section, IUD(s), IUCD(s), intrauterine device(s) and insertion. RESULTS From 297 articles, we identified 15 for inclusion in this review: all studies examined the outcomes from copper IUD insertions within the postpartum time period compared to other time intervals or compared routes (vaginal or via hysterotomy) of postpartum insertion. No studies of levonorgestrel IUDs were identified. Immediate IUD insertion (within 10 min of placental delivery) was safe when compared with later postpartum time periods and interval insertion. Immediate postpartum IUD insertion demonstrated lower expulsion rates when compared with delayed postpartum insertion but with higher rates than interval insertion. Immediate insertion following cesarean delivery demonstrated lower expulsion rates than immediate insertion following vaginal delivery. CONCLUSION Poor to fair quality evidence from 15 articles demonstrated no increase in risk of complications among women who had an IUD inserted during the postpartum period; however, some increase in expulsion rates occurred with delayed postpartum insertion when compared to immediate insertion and with immediate insertion when compared to interval insertion. Postplacental placements during cesarean delivery are associated with lower expulsion rates than postplacental vaginal insertions, without increasing rates of postoperative complications.

Progestogen-only contraceptive use among breastfeeding women: a systematic review

BACKGROUND Postpartum women need effective contraception. Concerns have been raised that use of progestogen-only contraceptives (POCs) may affect breastfeeding performance and infant health outcomes. OBJECTIVES We investigated the clinical outcomes of breastfeeding duration, initiation of supplemental feeding and weaning, as well as infant outcomes including infant growth, health and development among breastfeeding women using POCs compared with breastfeeding women not using POCs. SEARCH STRATEGY We searched the PubMed database for all articles published from database inception through December 2014. SELECTION CRITERIA We included primary research studies of breastfeeding women of any age or parity who received POCs, including progestogen-only pills, injectables, implants or hormonal intrauterine devices (IUDs). The main outcomes were breastfeeding performance (as measured by initiation, continuation, frequency and exclusivity of breastfeeding) and infant health (as measured by growth, development or adverse health effects). RESULTS Forty-nine articles reporting on 47 different studies were identified that investigated the use of POCs in breastfeeding women and reported clinically relevant outcomes of infant growth, health or breastfeeding performance. Studies ranged from poor to fair methodological quality and generally failed to show negative effects of the use of POCs on breastfeeding outcomes or on infant growth or development. One randomized controlled trial (RCT) raises concerns that immediate insertion of the levonorgestrel IUD postpartum may be associated with poorer breastfeeding performance when compared with delayed insertion, although two other RCTs evaluating early etonogestrel implants compared with delayed initiation of implants or depot medroxyprogesterone acetate failed to find such an association. CONCLUSION The preponderance of evidence fails to demonstrate adverse breastfeeding outcomes or negative health outcomes in infants such as restricted growth, health problems or impaired development. Evidence newly added to this review was largely consistent with previous evidence.

WHO recommendations for misoprostol use for obstetric and gynecologic indications

Misoprostol, a prostaglandin E1 analog, stimulates uterine contractility and cervical ripening. A number of randomized trials and systematic reviews have evaluated its use in obstetric and gynecologic conditions. Misoprostol is inexpensive, stable at room temperature, and available in more than 80 countries, making it particularly useful in resource‐poor settings. WHO recognizes the crucial role of misoprostol in reproductive health and has incorporated recommendations for its use into 4 reproductive health guidelines focused on induction of labor, prevention and treatment of postpartum hemorrhage, and management of spontaneous and induced abortion.

Safety of hormonal and intrauterine methods of contraception for women with HIV/AIDS: a systematic review.

Objective:To determine from the literature whether HIV-infected women who use hormonal or intrauterine contraception are at increased risk of HIV disease progression, other adverse health outcomes, or HIV transmission to uninfected sexual partners. Design:A systematic review. Methods:We searched PubMed for articles published in peer-reviewed journals through August 2009 for evidence relevant to all hormonal and intrauterine contraceptive methods and HIV/AIDS. Results:Eight observational studies reported no increased risk of HIV disease progression with hormonal or intrauterine contraceptive use, whereas one randomized controlled trial found increased risks of declining CD4 cell count and death for hormonal contraceptive users compared with intrauterine device users. Women with HIV who used hormonal contraception had increased risks of acquiring sexually transmitted infections compared with women not using hormonal contraception, similar to the risks reported among uninfected women. One study found no association between hormonal or intrauterine contraceptive use and increased risk of HIV transmission to uninfected partners, whereas findings from nine studies examining contraceptive use and viral shedding from the genital tract were inconsistent. Conclusion:Evidence regarding the safety of hormonal and intrauterine contraceptive use among women with HIV remains limited, but generally reassuring regarding adverse health effects, disease transmission to uninfected partners, and disease progression; however, one randomized trial raised concerns about enhanced disease progression among women using hormonal contraception. Preventing unintended pregnancy among women with HIV remains a high priority in public health, both for the health of the woman as well as for the prevention of mother-to-child transmission of HIV.

Effect on pregnancy rates of the delay in the administration of levonorgestrel for emergency contraception: a combined analysis of four WHO trials.

BACKGROUND Levonorgestrel is an effective method for emergency contraception (EC) and is used worldwide. Consistent with its mechanism of action in delaying ovulation, the earlier it is administered within 72 h of an unprotected act of intercourse, the more effective it is. There is uncertainty, however, about its effectiveness after 72 h. This analysis explores the effect of 24-h intervals of delay in levonorgestrel administration on pregnancy rates when used until 120 h of an unprotected act of intercourse. STUDY DESIGN Data were analyzed from 6794 women participating in four World Health Organization randomized trials and receiving 1.5 mg of levonorgestrel for EC in a single dose or split into two doses 12 h apart, within 48, 72 or 120 h of an act of unprotected intercourse. The pregnancy rates among women in successive days after an unprotected act of intercourse and odds ratios of pregnancy were calculated using logistic regression with the first day as the reference. RESULTS For the four trials combined, odds ratios for pregnancy in the second, third and fourth day with respect to the first day were not significantly different from 1 at the 5% level of significance. On the fifth day, the odds ratio of pregnancy compared to the first day was almost 6. CONCLUSIONS Levonorgestrel for EC should be administered as soon as possible after unprotected intercourse. Delaying levonorgestrel administration until the fifth day after unprotected intercourse increases the risk of pregnancy over five times compared with administration within 24 h. It is uncertain whether levonorgestrel administration on the fifth day still offers some protection against unwanted pregnancy.

Mifepristone in Second-Trimester Medical Abortion : A Randomized Controlled Trial

OBJECTIVE: To investigate the adjunctive use of mifepristone in second-trimester induction abortions using misoprostol 1 day after feticidal digoxin. METHODS: This is a randomized, placebo-controlled, double-blind trial of mifepristone in second-trimester induction termination using misoprostol after feticidal digoxin. Women seeking abortion between 18 and 23 weeks of gestation were offered enrollment. At the time of digoxin amnioinfusion, participants received a randomly allocated, identical-appearing capsule containing either mifepristone, 200 mg, or placebo. Patients returned the following day for induction with buccal misoprostol. The primary outcome was the time interval from the first misoprostol dose to abortion. Analysis utilized survival curves with log-rank testing. RESULTS: Of 64 women, 32 received mifepristone and 32 received placebo. The groups did not differ by ethnicity, age, parity, reason for termination, or gestational age. Median procedure time was significantly shorter for those who received mifepristone, 10 hours (95% confidence interval [CI] 8–12), than those who did not, 18 hours (95% CI 15–22), P<.01, and those parous, 10 hours (95% CI 9–14), compared with nulliparous, 16 hours (95% CI 12–22, P=.02). Other findings in the mifepristone compared with placebo group included rates of placental retention, 3.1% compared with 6.3% (P=.61), length of hospitalization, 0.66 days compared with 0.8 days (P=.23), and analgesic requirements, 27.2 mg compared with 39.3 mg morphine (P=.22). Side effects during induction were similar between groups. CONCLUSION: Addition of mifepristone in second-trimester termination inductions using misoprostol significantly reduces the abortion time interval. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, www.clinicaltrials.gov, NCT00382538 LEVEL OF EVIDENCE: I

Labor induction abortion in the second trimester

Labor induction abortion is effective throughout the second trimester. Patterns of use and gestational age limits vary by locality. Earlier gestations (typically 12 to 20 weeks) have shorter abortion times than later gestational ages, but differences in complication rates within the second trimester according to gestational age have not been demonstrated. The combination of mifepristone and misoprostol is the most effective and fastest regimen. Typically, mifepristone 200 mg is followed by use of misoprostol 24-48 h later. Ninety-five percent of abortions are complete within 24 h of misoprostol administration. Compared with misoprostol alone, the combined regimen results in a clinically significant reduction of 40% to 50% in time to abortion and can be used at all gestational ages. However, mifepristone is not widely available. Accordingly, prostaglandin analogues without mifepristone (most commonly misoprostol or gemeprost) or high-dose oxytocin are used. Misoprostol is more widely used because it is inexpensive and stable at room temperature. Misoprostol alone is best used vaginally or sublingually, and doses of 400 mcg are generally superior to 200 mcg or less. Dosing every 3 h is superior to less frequent dosing, although intervals of up to 12 h are effective when using higher doses (600 or 800 mcg) of misoprostol. Abortion rates at 24 h are approximately 80%-85%. Although gemeprost has similar outcomes as compared to misoprostol, it has higher cost, requires refrigeration, and can only be used vaginally. High-dose oxytocin can be used in circumstances when prostaglandins are not available or are contraindicated. Osmotic dilators do not shorten induction times when inserted at the same time as misoprostol; however, their use prior to induction using misoprostol has not been studied. Preprocedure-induced fetal demise has not been studied systematically for possible effects on time to abortion. While isolated case reports and retrospective reviews document uterine rupture during second-trimester induction with misoprostol, the magnitude of the risk is not known. The relationship of individual uterotonic agents to uterine rupture is not clear. Based on existing evidence, the Society of Family Planning recommends that, when labor induction abortion is performed in the second trimester, combined use of mifepristone and misoprostol is the ideal regimen to effect abortion quickly and completely. The Society of Family Planning further recommends that alternative regimens, primarily misoprostol alone, should only be used when mifepristone is not available.

Effect of body weight and BMI on the efficacy of levonorgestrel emergency contraception

OBJECTIVES To further evaluate the effect of weight and body mass index (BMI) on the efficacy of levonorgestrel emergency contraception. METHODS Data from two large, multicenter, randomized controlled trials designed to assess emergency contraceptive efficacy were pooled to evaluate the effect of weight and BMI on pregnancy rates among women who received levonorgestrel. Descriptive methods (comparison of means and distributions according to pregnancy status and pregnancy rates across weight and BMI categories) as well as cubic spline modeling were used to describe the relationship between pregnancy risk and weight/BMI. RESULTS The analysis population comprised 1731 women, among whom 38 pregnancies were reported. Women for whom levonorgestrel was not effective in preventing pregnancy had a significantly higher mean body weight and BMI than women who did not become pregnant (76.7 vs. 66.4 kg, p<.0001; 28.1 vs. 24.6 kg/m², p<.0001). The estimated pregnancy rate increased significantly from 1.4% [95% confidence interval (CI): 0.5%-3.0%] among the group of women weighing 65-75 kg to 6.4% (95% CI: 3.1%-11.5%) and 5.7% (95% CI: 2.9%-10.0%) in the 75-85 kg and >85 kg groups, respectively. Statistical modeling demonstrated a steep increase in pregnancy risk starting from a weight near 70-75 kg to reach a risk of pregnancy of 6% or greater around 80 kg. Similar results were obtained for statistical modeling of BMI as well as when the two studies were analyzed individually. CONCLUSIONS All analyses showed a significant drop in the efficacy of levonorgestrel emergency contraception with increasing body weight, with pregnancy risk in the higher weight categories similar to expected rates in the absence of contraception. Like body weight, increasing BMI was highly correlated with increased pregnancy risk.

Intrauterine contraceptive insertion postabortion: a systematic review☆

BACKGROUND This review was conducted to evaluate the evidence regarding the safety and effectiveness of intrauterine device (IUD) insertion immediately following spontaneous or induced abortion. STUDY DESIGN We searched MEDLINE databases for all articles (in all languages) published in peer-reviewed journals from January 1966 through March 2010 for evidence comparing immediate postabortion IUD insertion with either no IUD insertion, insertion at a different time, insertion following first-trimester compared with second-trimester abortion or copper IUD insertion compared with hormone-releasing IUD insertion postabortion. We used standard abstraction forms to summarize and assess the quality of the evidence. RESULTS The search strategy identified a total of 990 articles, of which 19 met our inclusion criteria for this review. Studies comparing immediate postabortion IUD insertion with no IUD insertion found that both groups experienced similar rates of pain and infection and a similar number of bleeding days, but one study reported that women with copper IUD insertion experienced a greater amount of bleeding than women without IUD insertion after abortion. Results from studies comparing immediate postabortion IUD insertion and insertion at a time not associated with pregnancy did not report differences between the two groups in the duration of bleeding, pain, expulsions or pelvic inflammatory disease (PID). One study however reported a greater amount of bleeding and another reported more removals for medical reasons among women with postabortion IUD insertion. Evidence from studies that examined immediate vs. delayed postabortion insertion reported minimal differences in bleeding, pain, expulsion and PID between groups. Studies comparing immediate IUD insertion after first- vs. second-trimester abortion reported no difference in removals for pain and bleeding, and an increased risk of expulsion among those women who had insertions after second-trimester abortion. In addition, women with insertions immediately after abortions occurring later in the first trimester had higher expulsion rates than those with insertions after early first-trimester abortions. Studies examining women using a copper IUD compared with a hormone-releasing IUD reported inconsistent results, with one paper reporting more bleeding days in the copper IUD group and another finding higher rates of removal for bleeding in the progesterone-releasing IUD group. CONCLUSION Intrauterine device insertion immediately after abortion is not associated with an increased risk of adverse outcomes compared with use of other contraceptive methods or with no IUD insertion after abortion and compared with IUD insertion at times other than immediately after abortion. Intrauterine device expulsion rates, while generally low, were higher with insertions that occurred after later first-trimester abortion compared with after early first-trimester abortion and higher with IUD insertion after second-trimester abortion compared with after first-trimester abortion.

Hormonal contraceptive use among women with liver tumors: a systematic review

BACKGROUND The review was conducted to evaluate from the literature the safety of hormonal methods of contraception in women with liver tumors, specifically in benign and malignant disease. STUDY DESIGN We searched PubMed and Cochrane databases to find all articles published from database inception through July 2008 that were relevant to hormonal contraception use and liver tumors. RESULTS Of 148 articles, three publications of two studies met the criteria for inclusion in this review; both investigated the use of hormonal contraception in women with the benign liver tumor focal nodular hyperplasia (FNH). In one small, retrospective case series, use of combined oral contraceptives (COCs) over a 4-year average follow-up was not associated with a change in either the number or size of hepatic lesions. In another case series, use of either COCs or progestogen-only contraceptives (POCs) after FNH diagnosis had no influence on disease progression or resolution. CONCLUSIONS The studies identified examined oral contraceptive use among women with FNH. We did not identify any studies of hormonal contraceptive use among women with hepatocellular adenoma or with malignant liver tumors. Limited, poor-quality evidence suggests that for women with FNH, use of low-dose COCs or POCs does not appear to influence either liver lesion resolution or progression.