Postplacental Insertion of Levonorgestrel-releasing IUS
Abstract & Commentary
By Jeffrey T. Jensen, MD, MPH, Editor, Leon Speroff, Professor and Vice Chair for Research, Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, is Editor for OB/GYN Clinical Alert.
Synopsis: Immediate postplacental insertion of a levonorgestrel intrauterine system results in a significantly higher rate of expulsion and does not increase the number of women using an IUD at 6 months of follow-up.
Source: Chen BA, et al. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: A randomized controlled trial. Obstet Gynecol 2010;116:1079-1087.
The authors enrolled women desiring postpartum use of a levonorgestrel-releasing intrauterine system in a randomized trial to determine whether use of the device would be higher when insertion occurred immediately postpartum rather than delaying placement to the standard postpartum visit. Subjects were randomly assigned to postplacental or delayed intrauterine device (IUD) insertion when admitted in labor. Post-enrollment exclusion events included intrapartum infection, hemorrhage, and cesarean delivery. Eligible subjects randomized to immediate insertion received the device within 10 minutes after delivery of the placenta, while those in the delayed group had the IUD insertion performed at the scheduled postpartum visit 6-8 weeks later. All of the women were asked to follow up in person at 6-8 weeks and at 6 months, and were contacted by telephone at 3 months. Expelled IUDs were replaced per patient preference.
IUD placement occurred in 98% (50/51) of subjects randomized to postplacental insertion and 90% (46/51) of those in the delayed groups (P = 0.2). Expulsion within 6 months occurred in 24% (12/50) of those in the immediate group, but in only 4.4% (P = 0.008) of those women receiving the device at the postpartum visit. There was no difference in overall usage of an IUD at 6 months (84% immediate, 77% delayed; P = 0.32). However, for ineligible patients, only 11 of 41 (26.8%) were using IUDs at 6 months and two (4.9%) had become pregnant.
Commentary
The best way to prevent unintended pregnancy is effective contraception. Highly effective long-acting reversible contraception (LARC) methods provide the best protection because they are free from user failure. LARC methods include both IUDs (LNG and copper) and contraceptive implants. After decades of misunderstanding, the IUD has returned to a position of prominence as a first-line method appropriate for most women. The link between IUDs and pelvic inflammatory disease and infertility has been debunked by solid evidence demonstrating that common infections like chlamydia, and not the IUD, cause tubal disease.1 Use of IUDs has also increased due to the added health benefits of reduced menstrual bleeding seen with the levonorgestrel system. Compared to the typical use failure of almost 8% seen with combined oral contraceptives, the failure rate with the IUD is < 1%.
Postpartum women are at high risk for unintended pregnancy during the first year, and this is particularly true among high-risk women such as adolescents.2 This occurs even with almost universal counseling regarding contraception prior to discharge from the hospital. Since women who do not breastfeed may ovulate within 4 weeks after delivery, contraception should be initiated within 3 weeks in non-breastfeeding women.3 Given that the postpartum visit is often delayed beyond this time, Chen and colleagues hypothesized that immediate postplacental insertion would reduce the risk of pregnancy and provide long-lasting contraception.
To be an effective method of contraception, the IUD must move beyond its position as a theoretical concept and occupy a more effective position within the uterus. To address this, the authors of this study assessed how many subjects were using the IUD at the 6-month follow-up. Although there was a trend toward greater IUD use at 6 months in the group receiving the device immediately postpartum, this was not statistically significant. Moreover, the incidence of device expulsion was almost 6-fold higher in the immediate group. Therefore, the high continuation rate at 6 months in the immediate group was influenced in part by a policy of free replacement of the device upon request after expulsion. Whether a liberal replacement policy like this is possible outside the research setting is unknown. So for simple matters of economy, immediate postplacental insertion of a levonorgestrel IUS may not work out. For my money, I would rather reduce the potential barriers to obtaining the device at the postpartum or interval visit.
On the other hand, women in the delayed group received confirmation of the postpartum IUD appointment by research staff prior to hospital discharge and a reminder call prior to the appointment. These steps exceed the standard of care at many institutions (but are still less expensive than an IUS or an unintended pregnancy). Moreover, research populations may differ from the general population in terms of compliance. The investigators addressed this point by following women who consented to participate, but were found to be ineligible. These individuals were not provided with special instructions or with a free IUD. Not surprisingly, only 27% received an IUD by 6 months and there were two repeat pregnancies among 41 participants. This might reflect the extreme of the other end, but is also one view of the real world.
Taking all this together, it is important to look at how likely your obstetric patient is to return for a postpartum check, and to consider the timing of this visit. Although expulsion is higher with immediate postplacental insertion, it is otherwise safe and well-tolerated and might be worth it for some patients. However, since most women are compliment with a postpartum visit, routine insertion should be delayed. While the package insert states that the IUD should not be placed until full involution, this term is poorly defined and the risk of pregnancy is present after 4 weeks in nonbreastfeeding women. Drs. Dan Mishell and Leon Speroff wrote an excellent review in 2008, advocating moving the postpartum visit to 4 weeks and including IUD insertion at this time.3
Consider offering immediate postplacental insertion to women at high risk for loss to follow-up, but recognize that it is far more cost-efficient to insert the device at a postpartum visit for everyone else. Liberal use of post-insertion verification of IUD position with a vaginal ultrasound should help provide reassurance if insertion at 4 weeks makes you nervous.
References
- Hubacher D, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345:561-567.
- Kershaw TS, et al. Short and long-term impact of adolescent pregnancy on postpartum contraceptive use: Implications for prevention of repeat pregnancy. J Adolesc Health 2003;33:359-368.
- Speroff L, Mishell DR, Jr. The postpartum visit: It's time for a change in order to optimally initiate contraception. Contraception 2008;78:90-98.
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