SAN DIEGO – Women expelled 54% of intrauterine devices placed immediately after giving birth, compared with a 6% expulsion rate after conventional placement at 6 weeks post partum or later, a study of an indigent population found.
The expulsion rate in the immediate-placement group (12 of 22 women) was significantly higher than when the levonorgestrel-containing intrauterine device (the Mirena IUD) was placed 6 weeks postpartum or later (1 of 18 women). The finding suggests that the immediate-placement strategy is prohibitively expensive, Dr. Tiffany D. Justice and her associates reported in a poster presentation at the annual meeting of the American College of Obstetricians and Gynecologists.
Immediate placement after delivery might be acceptable for women who are nearly certain to not return for follow-up visits after delivery, but even in those cases, a different long-acting reversible contraceptive such as a progesterone-containing implant might make more sense, said Dr. Justice, an ob.gyn. specializing in reproductive endocrinology and infertility at the University of Louisville, Ky.
The study randomized women who desired contraception after delivery in a university-based prenatal obstetrics clinic that primarily serves the indigent. In the immediate-placement group, women received the IUD within 10 minutes after placental delivery.
Photo courtesy Mirena-US.com
Over half of women in the study institution who choose IUD for postpartum contraception never return for placement.
Among 32 women randomized to immediate IUD placement, 9 patients did not receive one due to cesarean section delivery (5 patients), infection in 2 patients, and a change of mind by 2 patients. One patient who got immediate placement was lost to follow-up and 22 returned at 6 weeks post partum for a repeat ultrasound to confirm placement.
Among 34 women randomized to standard-interval IUD placement, 5 were disqualified due to cesarean section (2), infection (1), or a change of mind (1). Eleven of the remaining 29 patients did not return as planned for IUD placement 6 weeks post partum or later (38%), a high rate of patients being lost to follow-up in this group, Dr. Justice said.
Dr. Tiffany D. Justice
Despite the poor follow-up rate in the standard-interval group, 59% had an IUD in place at 6 months post partum, significantly greater than the 46% of patients in the immediate placement group who were still using their original IUD at 6 months.
In general, 60% of women in the university-based system who choose an IUD for postpartum contraception never return for placement, she said. Ovulation resumes very quickly after delivery in all women and especially in those who do not breastfeed, creating a risk for repeat conception as soon as 4 weeks after delivery. Unintended pregnancies are a huge problem affecting nearly half of all pregnancies.
The comparison groups in the current study did not differ significantly in age, proportion of nulliparous women, gestational age, length of rupture of membranes, infant weight, breastfeeding rate, use of epidurals, race, or rates of infection, perforation, or unintended pregnancy.
Follow-up ultrasounds in the immediate placement group found that some women had the IUD oriented obliquely or upside down at the fundus, but it’s not clear if these abnormal orientations within the uterine cavity had any significance, Dr. Justice said.
A previous study reported a 24% expulsion rate after immediate postpartum placement of an IUD, compared with a 4% expulsion rate after standard interval placement (Obstet. Gynecol. 2010;116:1079-87).
The 54% expulsion rate after immediate placement in the current study "is a closer approximation to the expected experience in general practice and represents a ‘typical use’ in that multiple physicians placed the device over the length of the study," Dr. Justice said.
Studies are underway to assess placement of progesterone-containing implants immediately after delivery, she said.
Dr. Justice reported having no relevant financial disclosures.