Women can be safely offered IUDs beyond 4 weeks postpartum with minimal risk of perforation: STUDY
Researchers have found in a new study that Uterine perforation after interval postpartum IUD insertion is greater at 4–8 weeks than at 9–36 weeks, although perforation rates remain low at <1%. The study has appeared in the American journal of Obstetrics and Gynaecology.
Unintended pregnancies are associated with increased risk of maternal depression and anxiety, and short interpregnancy intervals are associated with an increased risk of maternal and infant morbidity and mortality, including preterm birth, abruption, preterm premature rupture of membranes, and low birthweight. To optimize interpregnancy intervals and reduce unintended pregnancies, effective contraception should be addressed and provided in the postpartum period.
Long-acting reversible contraception (LARC), which includes intrauterine devices (IUDs) and the etonogestrel subdermal contraceptive implant, are the most effective forms of reversible contraception. Women who choose IUDs and implants tend to have the highest contraceptive continuation rates.
Timing of postpartum IUD placement varies among providers. Placement may be delayed because of concerns for uterine perforation at the postpartum visit. This results in additional clinic visits, which may reduce IUD uptake while increasing unintended pregnancies and overall costs.
The primary objective of this study by Ramos-Rivera M and team was to compare uterine perforation rates with postpartum IUD insertion at 4-8 weeks postpartum vs 9-36 weeks postpartum. The secondary objective was to compare uterine expulsion rates for IUDs inserted at these postpartum intervals.
Authors performed a retrospective cohort study using the Kaiser Permanente Southern California electronic medical record from 2010 to 2016. They calculated the proportion of perforations and expulsions with IUD insertion at 4-8 weeks vs 9-36 weeks postpartum. The primary outcome was the perforation rate. Secondarily, they evaluated the expulsion rate.
A total of 24,959 patients met inclusion criteria (n=13,180 in the 4-8 week group, n=11,777 in the 9-36 week group). Of 430 patients with a confirmed complication, 157 uterine perforations and 273 IUD expulsions were identified. Perforation rates were significantly higher with placement at 4-8 weeks than at 9-36 weeks (0.78% vs 0.46%; P=.001). After adjusting for race and ethnicity, breastfeeding, IUD type, provider type, parity, most recent delivery, and body mass index, the odds of perforation remained higher with placement at 4-8 weeks than at 9-36 weeks (adjusted odds ratio, 1.92; 95% confidence interval, 1.28-2.89). Our Kaplan-Meier survival curve showed that the risk of uterine perforation remained elevated until approximately 22-23 weeks postpartum. Expulsion rates were similar between the 2 groups (1.02 vs 1.17; P=.52).
Although the difference in perforation rates was statistically significant, the absolute difference was only 0.32%.
Authors found that the odds of perforation were 4.5 times higher among those breastfeeding in the 4-8 week group than the 9-36 week group, similar to what was previously reported. Based on this data, providers would need to defer IUD insertion until at least 22 weeks postpartum to minimize the risk of perforation to baseline risk. This is neither practical nor advisable because most will have resumed sexual activity. With proper counseling, data supports offering interval postpartum IUD insertion any time at or beyond 4 weeks postpartum, without delay owing to a concern for perforation.
Although study demonstrated higher perforation rates in the earlier interval postpartum placement group, the difference was not clinically significant and expulsion rates were not different. Given the significant positive public health impact of providing effective contraception soon after delivery with proper counseling, patients should be offered IUD insertion at their desired postpartum time interval.
Source: Ramos-Rivera M, Averbach S, Selvaduray P, et al. Complications after interval postpartum intrauterine device insertion. Am J Obstet Gynecol 2022;226:95.e1-8.
MBBS, MD Obstetrics and Gynecology
Dr Nirali Kapoor has completed her MBBS from GMC Jamnagar and MD Obstetrics and Gynecology from AIIMS Rishikesh. She underwent training in trauma/emergency medicine non academic residency in AIIMS Delhi for an year after her MBBS. Post her MD, she has joined in a Multispeciality hospital in Amritsar. She is actively involved in cases concerning fetal medicine, infertility and minimal invasive procedures as well as research activities involved around the fields of interest.