CASE 1 Multiparous female with short-interval pregnancies desires contraception
A 24-year-old woman (G4P3) presents for a routine prenatal visit in the third trimester. Her last 2 pregnancies have occurred within 3 months of her prior birth. She endorses feeling overwhelmed with having 4 children under the age of 5 years, and she specifies that she would like to avoid another pregnancy for several years. She plans to breast and bottle feed, and she notes that she tends to forget to take pills. When you look back at her prior charts, you note that she did not return for her last 2 postpartum visits. What can you offer her? What would be a safe contraceptive option for her?
Intrauterine devices (IUDs) are safe, effective, and reported by patients to be satisfactory methods of contraception precisely because they are prone to less user error. The Contraceptive Choice Project demonstrated that patients are more apt to choose them when barriers such as cost and access are removed and nondirective counseling is provided.1 Given that unintended pregnancy rates hover around 48%, the American College of Obstetricians and Gynecologists (ACOG) recommends them as first-line methods for pregnancy prevention.2,3
For repeat pregnancies, the postpartum period is an especially vulnerable time—non-breastfeeding women will ovulate as soon as 25 days after birth, and by 8 weeks 30% will have ovulated.4 Approximately 40% to 57% of women report having unprotected intercourse before 6 weeks postpartum, and nearly 70% of all pregnancies in the first year postpartum are unintended.3,5 Furthermore, patients at highest risk for short-interval pregnancy, such as adolescents, are less likely to return for a postpartum visit.3
Short-interval pregnancies confer greater fetal risk, including risks of low-birth weight, preterm birth, small for gestational age and increased risk of neonatal intensive care unit admission.6 Additionally, maternal health may be compromised during a short-interval pregnancy, particularly in medically complex patients due to increased risks of adverse pregnancy outcomes, such as postpartum bleeding or uterine rupture and disease progression.7 A 2006 meta-analysis by Conde-Agudelo and colleagues found that waiting at least 18 months between pregnancies was optimal for reducing these risks.6
Thus, the immediate postpartum period is an optimal time for addressing contraceptive needs and for preventing short-interval and unintended pregnancy. This article aims to provide evidence supporting the use of immediate postpartum IUDs, as well as their associated risks and barriers to use.
IUD types and routes for immediate postpartum insertion
There are several randomized controlled trials (RCTs) that examine the immediate postpartum use of copper IUDs and levonorgestrel-releasing (LNG) IUDs.8-11 In 2010, Chen and colleagues compared placement of the immediate postpartum IUD following vaginal delivery with interval placement at 6–8 weeks postpartum. Of 51 patients enrolled in each arm, 98% received an IUD immediately postpartum, and 90% received one during their postpartum visit. There were 12 expulsions (24%) in the immediate postpartum IUD group, compared with 2 (4.4%) in the interval group. Expelled IUDs were replaced, and at 6 months both groups had similar rates of IUD use.8
Whitaker and colleagues demonstrated similar findings after randomizing a small group of women who had a cesarean delivery (CD) to interval or immediate placement. There were significantly more expulsions in the post-placental group (20%) than the interval group (0%), but there were more users of the IUD in the post-placental group than in the interval group at 12 months.9
Two RCTs, by Lester and colleagues and Levi et al, demonstrated successful placement of the copper IUD or LNG-IUD following CD, with few expulsions (0% and 8%, respectively). Patients who were randomized to immediate postpartum IUD placement were more likely to receive an IUD than those who were randomized to interval insertion, mostly due to lack of postpartum follow up. Both studies followed patients out to 6 months, and rates of IUD continuation and satisfaction were higher at this time in the immediate postpartum IUD groups.10,11
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