Early versus delayed postpartum etonogestrel implant insertion: Similar impacts on 12-month bleeding patterns
Vieira CS, de Nadai MN, de Melo Pereira do Carmo LS, et al. Timing of postpartum etonogestrel-releasing implant insertion and bleeding patterns, weight change, 12-month continuation and satisfaction rates: a randomized controlled trial. Contraception. 2019. doi:10.1016/j.contraception.2019.05.007.
Initiation of a desired LARC method shortly after delivery is associated with significant reductions in short interpregnancy intervals.14 With that goal in mind, Vieira and colleagues compared bleeding patterns in women who received an etonogestrel implant within 48 hours of delivery with those who received an implant at 6 weeks postdelivery.
The study was a secondary analysis of data from a randomized controlled trial of early versus delayed postpartum insertion of the etonogestrel implant conducted in Sao Paulo, Brazil. That primary trial's goal was to examine the impact of early versus delayed implant insertion on infant growth (100 women were randomly assigned to the 2 implant groups); no difference in infant growth at 12 months was seen in the 2 groups.15 In the secondary analysis, bleeding patterns and BMI were evaluated every 90 days for 12 months. The mean BMI at enrollment postpartum was 29.4 kg/m2 in the early-insertion group and 30.2 kg/m2 for the delayed-insertion group.
Bleeding patterns with early or delayed implant insertion were similar
Vieira and colleagues found similar bleeding patterns between the groups over 12 months of follow-up. Amenorrhea was reported by 56% of the early-insertion group in the first 90 days and by 62% in the delayed-insertion group. During the last 90 days of the year, 52% of the early-insertion and 46% of the delayed-insertion group reported amenorrhea. Amenorrhea rates did not differ between women who were exclusively breastfeeding and those nonexclusively breastfeeding.
Continuation rates were high at 1 year
Prolonged bleeding episodes were uncommon in both groups, with only 2% of women reporting prolonged bleeding in any given reference period. Twelve-month implant continuation rates were high in both groups: 98% in the early- and 100% in the delayed-insertion group. Additionally, the investigators found that both groups experienced a BMI decrease, with no difference between groups (10.3% and 11% in the early- and delayed-insertion groups, respectively).
Study limitations and strengths
This study included a larger number of participants than prior randomized, controlled trials that evaluated bleeding patterns with postpartum etonogestrel implant insertion, and it had very low rates of loss to follow-up. The study's low rate of 12-month implant discontinuation (2%) is lower than that of other studies that reported rates of 6% to 14%.16,17 Although the authors stated that this low rate may be due to thorough anticipatory counseling prior to placement, it is also possible that this study population does not reflect all populations. Regardless, the data clearly show that placing an etonogestrel implant prior to hospital discharge, compared with waiting for later placement, does not impact bleeding patterns over the ensuing year.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
For patients who desire an etonogestrel implant for contraception postpartum, we now have additional information to counsel about the impact of implant placement on postpartum bleeding patterns. Overall, bleeding patterns are highly favorable and do not vary whether the implant is placed in the hospital or later. Additionally, the timing of placement does not impact implant continuation rates or BMI changes over 1 year. Further, the primary study assessed infant growth in the early- versus delayed-placement groups and found no differences in infant growth. Although the data are limited, immediate postpartum etonogestrel implant placement does not seem to affect the rate of breastfeeding or the volume of breast milk.18,19 Timing of implant placement, assuming adequate resources, should be based primarily on patient preference. And, given the correlation of immediate postpartum LARC placement to increased interpregnancy interval, particular efforts should be made to provide the implant in the immediate postpartum period, if the patient desires.20
For patients who desire an etonogestrel implant for contraception postpartum, we now have additional information to counsel about the impact of implant placement on postpartum bleeding patterns. Overall, bleeding patterns are highly favorable and do not vary whether the implant is placed in the hospital or later. Additionally, the timing of placement does not impact implant continuation rates or BMI changes over 1 year. Further, the primary study assessed infant growth in the early- versus delayed-placement groups and found no differences in infant growth. Although the data are limited, immediate postpartum etonogestrel implant placement does not seem to affect the rate of breastfeeding or the volume of breast milk.18,19 Timing of implant placement, assuming adequate resources, should be based primarily on patient preference. And, given the correlation of immediate postpartum LARC placement to increased interpregnancy interval, particular efforts should be made to provide the implant in the immediate postpartum period, if the patient desires.20