Sarita Sonalkar

Intrauterine device insertion in the postpartum period: A systematic review

Abstract Objectives Given new research on postpartum placement of levonorgestrel and copper intrauterine devices (IUDs), our objective was to update a prior systematic review of the safety and expulsion rates of postpartum IUDs. Methods We searched MEDLINE, CENTRAL, LILACS, POPLINE, Web of Science, and ClinicalTrials.gov databases for articles between the database inception until July 2013. We included studies that compared IUD insertion time intervals and routes during the postpartum period. We used standard abstract forms and the United States Preventive Services Task Force grading system to summarise and assess the quality of the evidence. Results We included 18 articles. New evidence suggests that a levonorgestrel releasing-intrauterine system (LNG-IUS) insertion within 48 hours of delivery is safe. Postplacental insertion and insertion between 10 minutes and 48 hours after delivery result in higher expulsion rates than insertion 4 to 6 weeks postpartum, or non-postpartum insertion. Insertion at the time of caesarean section is associated with lower expulsion rates than postplacental insertion at the time of vaginal delivery. Conclusions This review supports the evidence that insertion of an intrauterine contraceptive within the first 48 hours of vaginal or caesarean delivery is safe. Expulsion rates should be further studied in larger randomised controlled trials. Chinese Abstract 摘要： 目的：鉴于有关产后放置左炔诺孕酮和铜制的宫内节育器（IUDs）的新研究，我们的目的是更新前一个关于产后宫内节育器的安全性和脱落率的系统综述。 方法：我们检索了MEDLINE，CENTRAL，LILACS，POPLINE，Web of Science和ClinicalTrials.gov 数据库自建库到2013年7月的文章。我们收录的研究比较了产后放置宫内节育器时间间隔和途径。我们采用标准的抽象形式和美国预防服务工作组的分级系统来总结和评估证据的质量。 结果：我们收录了18篇文章。新的证据表明，分娩后48小时内放置左炔诺孕酮宫内缓释系统（LNG-IUS）是安全的。分娩后10分钟到48小时内放置宫内节育器比产后4-6周或非产后放置宫内节育器具有更高的脱落率。剖宫产手术时放置宫内节育器的脱落率比阴道分娩产后放置的脱落率低。 结论：本文支持的证据表明，阴道分娩或剖宫产分娩后48小时内放置宫内节育器是安全的。脱落率应需要更大的随机对照试验进一步研究。

Effect of Immediate Compared With Delayed Insertion of Etonogestrel Implants on Medical Abortion Efficacy and Repeat Pregnancy: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effect of insertion of etonogestrel implants with mifepristone compared with after the abortion on the risks of medical abortion failure and repeat pregnancy over the subsequent 6 months. METHODS: In a randomized trial, we assigned patients undergoing medical abortion to receive etonogestrel implants either with the mifepristone (Quickstart group) or after the abortion (Afterstart group). We followed them for 7 months to ascertain abortion outcome, pregnancies, and contraception use. RESULTS: Between September 2013 and August 2014, we enrolled 236 participants in the Quickstart group and 240 in the Afterstart group. To examine abortion failure, we conducted a noninferiority analysis from which we excluded nine participants who had missing outcome data and four with specified protocol violations. Of the rest, 9 of 229 (3.9%) and 9 of 234 (3.8%) in the Quickstart and Afterstart groups, respectively, had surgery to complete the abortion; the difference of 0.08% (90% confidence interval −3.1% to 3.3%) excluded our prestipulated noninferiority margin of 5 percentage points. Among participants with pregnancy follow-up through 6 months, 1 of 213 (0.5%) and 3 of 208 (1.4%) in the Quickstart and Afterstart groups, respectively, became pregnant within that time; 6-month pregnancy rates did not differ significantly by group (exact log-rank test, P=.28). At enrollment, significantly more participants in the Quickstart group than in the Afterstart group were satisfied with their group assignments (187/236 [79%] compared with 129/240 [54%], respectively; P<.001). CONCLUSION: Insertion of etonogestrel implants with mifepristone did not appreciably increase medical abortion failure risk and it enhanced patient satisfaction, but we found no evidence that it decreased repeat pregnancy rates. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01902485.

Barriers to Immediate Post-placental Intrauterine Devices among Attending Level Educators.

OBJECTIVE To determine whether barriers to immediate post-placental intrauterine device (PPIUD) placement exist at the provider level. STUDY DESIGN Obstetrics providers at seven academic teaching hospitals in Massachusetts were asked to complete an electronic survey regarding their knowledge, experience, and opinions about immediate PPIUDs. RESULTS Eighty-two providers, including obstetricians, family medicine physicians, and midwives, completed the survey. Thirty-five (42.7%) reported experience placing an immediate PPIUD with the majority of them having placed three to five PPIUDs. Of participants who had never placed a PPIUD, the reason cited most frequently was inadequate training. Fewer than one-half (43.4%) correctly identified the PPIUD expulsion rate, whereas 75.9% knew the correct expulsion rate for interval IUD placement. The majority of providers responded that PPIUDs are acceptable in certain clinical scenarios. CONCLUSIONS Overall, knowledge and experience with PPIUD placement is relatively low. As increasing numbers of states amend Medicaid policy to include reimbursement for immediate postpartum IUDs, additional education and training opportunities are needed.

Mifepristone and Misoprostol Compared With Osmotic Dilator Insertion Before Surgical Abortion at 15–18 Weeks

BACKGROUND: Cervical preparation is recommended before surgical evacuation of second-trimester pregnancies. Both mechanical (osmotic dilator) and pharmacologic (misoprostol) methods are used in the United States. Mifepristone facilitates medical abortion in the second trimester. The combination of mifepristone and misoprostol may effectively permit evacuation without the need for osmotic dilators. METHODS: A randomized controlled trial of 50 women was performed to compare pharmacologic cervical preparation with mifepristone and misoprostol with mechanical preparation with osmotic dilators. Group 1 was administered mifepristone 200 mg orally 24 hours before uterine evacuation plus misoprostol 400 mcg buccally 2 hours before the procedure. Group 2 underwent osmotic dilator insertion 24 hours before the procedure. The primary outcome was total procedure time from insertion of the speculum to removal of the speculum. RESULTS: For total procedure time, mifepristone (median 13.0 minutes) was noninferior to osmotic dilators (median 14.5 minutes, P=.99). Operative time (from intrauterine instrumentation to speculum removal) was also noninferior (mifepristone median 7.0 minutes, osmotic dilator median 8.5 minutes, P=.51). Initial dilation was less with mifepristone (41 French compared with 56 French), but procedure dilation was similar (58 French compared with 60 French). Physicians rated the ease of procedure similarly for both techniques. Women had more cramping and bleeding overnight with osmotic dilators. Women in both groups said they would prefer mifepristone if they ever needed another procedure. CONCLUSION: Use of a pharmacologic method of cervical preparation did not result in longer procedure times and was acceptable to both operators and patients.

Introducing the World Health Organization Postpartum Family Planning Compendium

The postpartum period offers multiple opportunities for healthcare providers to assist with family planning decision making. However, there are also many changing factors during the first year after delivery that can affect family planning choices. Given that several different documents have addressed WHO guidance on postpartum family planning, the electronic WHO Postpartum Family Planning Compendium (http://srhr.org/postpartumfp) has been introduced. This resource integrates essential guidance on postpartum family planning for clinicians, program managers, and policy makers. The development of the Compendium included consultations with family planning experts, key international stakeholders, and web developers. Once the website had been created, user testing by family planning experts allowed for improvements to be made before the official launch. Future directions are adaptation of the website into a mobile application that can be more easily integrated to low‐resource settings, and translation of the content into French and Spanish.

Six-week retention after postplacental copper intrauterine device placement

OBJECTIVES We sought to evaluate the 6-week clinical outcomes (intrauterine device [IUD] retention, recognized expulsions, ability to visualize or palpate strings, and need for ultrasound evaluation) in women who received a TCu380A postplacental IUD (PPIUD) after vaginal (VD) or cesarean delivery (CD). STUDY DESIGN We conducted a retrospective cohort study to examine the 6-week retention of TCu380A IUDs placed within 10 min of placental delivery in VD (n=137) and CD (n=73). We used Students t test and Wilcoxon rank sum tests for continuous data and Pearson χ2 test and Fishers Exact Test for categorical data. RESULTS Of the 169 women who had follow-up, 151 (89.3%) retained their IUD at 6 weeks (95% CI 84.7%-93.9%). All women who underwent CD retained their IUD at 6 weeks postpartum (56/56), whereas 95/113 (84% [95% CI 76.0%-90.3%]) who underwent VD retained their original IUD (p<.01). Strings were detected more frequently in women who had a VD (93.1% [95% CI 85.6-97.4]) compared to those who delivered by CD (44.2% [95% CI 30.5-58.7]; p<.01). Women who underwent CD had an ultrasound to evaluate IUD location more frequently (42.9% [95% CI 29.7-56.8]) compared to women who underwent VD (13.7% [95% CI 7.5-22.3]; p<.01). CONCLUSION Women are more likely to retain a PPIUD after CD compared to a VD (p<.01); however, women who have a PPIUD placed after CD are more likely to have nonvisible strings with a pelvic exam (p<.01) and undergo pelvic ultrasound evaluation (p<.01) compared to a PPIUD placed at the time of a VD.

Mifepristone pretreatment for the medical management of early pregnancy loss

Background Medical management of early pregnancy loss is an alternative to uterine aspiration, but standard medical treatment with misoprostol commonly results in treatment failure. We compared the efficacy and safety of pretreatment with mifepristone followed by treatment with misoprostol with the efficacy and safety of misoprostol use alone for the management of early pregnancy loss. Methods We randomly assigned 300 women who had an anembryonic gestation or in whom embryonic or fetal death was confirmed to receive pretreatment with 200 mg of mifepristone, administered orally, followed by 800 μg of misoprostol, administered vaginally (mifepristone‐pretreatment group), or 800 μg of misoprostol alone, administered vaginally (misoprostol‐alone group). Participants returned 1 to 4 days after misoprostol use for evaluation, including ultrasound examination, by an investigator who was unaware of the treatment‐group assignments. Women in whom the gestational sac was not expelled were offered expectant management, a second dose of misoprostol, or uterine aspiration. We followed all participants for 30 days after randomization. Our primary outcome was gestational sac expulsion with one dose of misoprostol by the first follow‐up visit and no additional intervention within 30 days after treatment. Results Complete expulsion after one dose of misoprostol occurred in 124 of 148 women (83.8%; 95% confidence interval [CI], 76.8 to 89.3) in the mifepristone‐pretreatment group and in 100 of 149 women (67.1%; 95% CI, 59.0 to 74.6) in the misoprostol‐alone group (relative risk, 1.25; 95% CI, 1.09 to 1.43). Uterine aspiration was performed less frequently in the mifepristone‐pretreatment group than in the misoprostol‐alone group (8.8% vs. 23.5%; relative risk, 0.37; 95% CI, 0.21 to 0.68). Bleeding that resulted in blood transfusion occurred in 2.0% of the women in the mifepristone‐pretreatment group and in 0.7% of the women in the misoprostol‐alone group (P=0.31); pelvic infection was diagnosed in 1.3% of the women in each group. Conclusions Pretreatment with mifepristone followed by treatment with misoprostol resulted in a higher likelihood of successful management of first‐trimester pregnancy loss than treatment with misoprostol alone. (Funded by the National Institute of Child Health and Human Development; PreFaiR ClinicalTrials.gov number, NCT02012491.)

Six-month expulsion of postplacental copper intrauterine devices placed after vaginal delivery

BACKGROUND: Immediate placement of an intrauterine device after vaginal delivery is safe and convenient, but longitudinal data describing clinical outcomes have been limited. OBJECTIVE: We sought to determine the proportion of TCu380A (copper) intrauterine devices expelled, partially expelled, malpositioned, and retained, as well as contraceptive use by 6 months postpartum, and determine risk factors for expulsion and partial expulsion. STUDY DESIGN: In this prospective, observational study, women who received a postplacental TCu380A intrauterine device at vaginal delivery were enrolled postpartum. Participants returned for clinical follow‐up at 6 weeks, and for a research visit with a pelvic exam and ultrasound at 6 months. We recorded intrauterine device outcomes and 6‐month contraceptive use. Partial expulsion was defined as an intrauterine device protruding from the external cervical os, or a transvaginal ultrasound showing the distal end of the intrauterine device below the internal os of the cervix. Multinomial logistic regression models identified risk factors associated with expulsion and partial expulsion by 6 months. The area under the receiver operating characteristics curve was used to assess the ability of a string check to predict the correct placement of a postplacental intrauterine device. The primary outcome was the proportion of intrauterine devices expelled at 6 months. RESULTS: We enrolled 200 women. Of 162 participants with follow‐up data at 6 months, 13 (8.0%; 95% confidence interval, 4.7–13.4%) experienced complete expulsion and 26 (16.0%; 95% confidence interval, 11.1–22.6%) partial expulsion. Of 25 malpositioned intrauterine devices (15.4%; 95% confidence interval, 10.2–21.9%), 14 were not at the fundus (8.6%; 95% confidence interval, 5.2–14.1%) and 11 were rotated within the uterus (6.8%; 95% confidence interval, 3.8–11.9%). Multinomial logistic regression modeling indicated that higher parity (odds ratio, 2.05; 95% confidence interval, 1.21–3.50; P = .008) was associated with expulsion. Provider specialty (obstetrics vs family medicine; odds ratio, 5.31; 95% confidence interval, 1.20–23.59; P = .03) and gestational weight gain (normal vs excess; odds ratio, 9.12; 95% confidence interval, 1.90–43.82; P = .004) were associated with partial expulsion. Long‐acting reversible contraceptive method use at 6 months was 80.9% (95% confidence interval, 74.0–86.6%). At 6 weeks postpartum, 35 of 149 (23.5%; 95% confidence interval, 16.9–31.1%) participants had no intrauterine device strings visible. Sensitivity of a string check to detect an incorrectly positioned intrauterine device was 36.2%, and specificity of the string check to predict a correctly positioned intrauterine device was 84.5%. This corresponds to an area under the receiver operating characteristics curve of 0.5. CONCLUSION: This prospective assessment of postplacental TCu380A intrauterine device placement, with ultrasound to confirm device position, finds a complete intrauterine device expulsion proportion of 8.0% at 6 months. The association of increasing parity with expulsion is consistent with prior research. The clinical significance of covariates associated with partial expulsion (provider specialty and gestational weight gain) is unclear. Due to the observational study design, any associations cannot imply causality. The proportion of partially expelled and malpositioned intrauterine devices was high, and the area under the receiver operating characteristics curve of 0.5 indicates that a string check is a poor test for assessing device position. Women considering a postplacental intrauterine device should be counseled about the risk of position abnormalities, as well as the possibility of nonvisible strings, which may complicate clinical follow‐up. The clinical significance of intrauterine device position abnormalities is unknown; future research should evaluate the influence of malposition and partial expulsion on contraceptive effectiveness and side effects.

Comparison of complications associated with induction by misoprostol versus dilation and evacuation for second‐trimester abortion

To compare the frequency of complications between medical induction with misoprostol and dilation and evacuation (D&E) for second‐trimester uterine evacuation.

Does the Use of Bedsider.org Increase Long-Acting Reversible Contraception Uptake in Patients Presenting for Induced First-Trimester Abortion? [21].

INTRODUCTION: The objective of this randomized controlled trial was to assess if contraceptive counseling aided by the web site Bedsider.org, as compared with routine counseling, improves uptake of long-acting reversible contraception (LARC) in women ages 18–29 years seeking first-trimester induced abortion. METHODS: Between September 2012 and November 2013, we randomized preoperative abortion clinic days to incorporate either contraceptive counseling with the aid of Bedsider.org or the health care providers routine counseling. All participants completed a precounseling questionnaire and a questionnaire at their surgical abortion appointment or at their medical abortion follow-up appointment. We assessed desired contraceptive method and usefulness of the contraceptive counseling received. RESULTS: We enrolled 345 women. Although baseline desire for a LARC method was high, 24.1% overall, there was a baseline difference in LARC desire before counseling among the Bedsider and routine groups (Bedsider, 16.7%; routine 28.3%; P=.01). For women who were counseled with Bedsider.org, 15.5% who did not initially desire LARC chose a LARC method after contraceptive counseling (P<.001). In the routine counseling group, 7.9% of women who initially did not desire LARC chose a LARC method after their abortion (P=.85). CONCLUSION AND IMPLICATION: This research supports the use of Bedsider.org, as an adjunct to counseling by an experienced health care provider, to promote postabortion LARC.