Postpartum IUD Insertion: Continued Usage at Six Months Based on Expulsion and Removal

Rates at Greenville Memorial Hospital in the First Year After Adoption of the Practice

Lindsey Tingen, MD

Department of Obstetrics and Gynecology,

Greenville Health System Greenville, SC

Disclosure

I have no meaningful

conflicts of interest to

declare for this educational

activity.

Background

• Facts about LARCs

– Long Acting Reversible

Contraception

– Gaining popularity in the

US

• Use is increasing

– 2.4% in 2002

– 8.5% in 2009

– 11.6% in 20121

Background

• The Contraceptive CHOICE

study

– Majority of women would

choose LARC for

contraception if provided

without cost

– 75% of the women chose

LARC

– 58% chose some form of

IUD2

• ACOG now recognizes immediate postpartum IUD insertion as

best practice3,4

• Cost-benefit analyses

– Preventing unintended pregnancies

– Decreasing short interconception interval

• More women continued IUD usage at six months postpartum when

the IUD was inserted immediately after delivery compared to at

postpartum visit10

• Postpartum IUD expulsion rates

– 10-27% depending on study5-8

Background

Objective

• Evaluate rates of expulsion and removal of IUDs

inserted immediately after delivery of the placenta,

both at vaginal delivery and cesarean

• Determine the percentage of continued usage at six

months after delivery

• Secondary objective

– Evaluate risk factors for expulsion or removal

Hypothesis

Postpartum IUD expulsion rate at Greenville

Memorial Hospital is similar to national

averages

Methods

Methods

• Retrospective chart review

• Patients who received IUDs

– September 2015 – May 2017

– Patients were identified through coding data

• CPT code 58300, Insertion of IUD, was used

to identify patients

• A RedCap Data collection tool was created

Methods

• Demographic Data

– Age, Ethnicity, Gravidity, Parity, Gestational Age, BMI

• Pregnancy Risk Factors

• Duration of Labor

– Spontaneous, Induced, Augmented

• Induction Method

– Misoprostol, Foley Balloon, Oxytocin, AROM

Methods

• Mode of Delivery

– Scheduled cesarean, cesarean after labor, spontaneous

vaginal delivery, forceps, vacuum

• Cervical Dilation at time of Cesarean

• Mode of Insertion at Vaginal Delivery

– IUD insertion device, Manual, Ring Forceps

• Inserter

– PGY 1-4, Attending

Outcomes

• IUD expulsions, removals, and retention

at 6 months

• Date of Insertion

• Date of Expulsion/Removal

• Reason for Removal

Statistical Analysis

• Proportions of expulsions, removals, and retention at 6

months

• Z-test was used to compare differences between vaginal

delivery and cesarean delivery

• Generalized linear model using Bernoulli likelihood ratio

was used to assess possible risk factors

• Statistical analyses performed using R software

Results

Results

• 357 patients were eligible for the study

• Majority of patients delivered vaginally (n=205,

57.4%)

• Mirena was the most common IUD inserted

(n=302, 84.5%)

• Majority of the patients were full term between

37.0-40.6 weeks (n=275, 77%)

Results Table 1 - Demographics

Ethnicity (N, %) African-American (120, 33.61%) Asian (4, 1.12%) Caucasian (159, 44.54%) Hispanic (62, 17.37%) Multiracial (8, 2.24%) Unknown (4, 1.12%)

BMI – Kg/m2 (mean) 17-77 (31.45)

Delivery Method Scheduled cesarean (106) Cesarean after labor (46) Spontaneous vaginal delivery (196) Forceps assisted vaginal delivery (6) Vacuum assisted vaginal delivery (3)

Labor Type Induction (110) Augmentation (74) Spontaneous (122)

Induction Methods Oxytocin (153) Foley Balloon (54) Misoprostol (57) AROM (110)

Pregnancy Complications Hypertensive Disease (105) Gestational Diabetes (31) Pregestational Diabetes (20) Magnesium Use (45) PPROM (8) Polyhydramnios (8) Connective Tissue Disorder (2)

Results

Table 1 – Demographics (continued)

Fetal Number Singleton (349) Twins (8)

Gestational Age at Delivery < 34 weeks (28) 34.0 – 36.6 weeks (36) 37.0 – 40.6 weeks (275) > 41.0 weeks (18)

Duration of Labor < 24 hours (218) 24-48 hours (30) > 48 hours (2)

IUD Placement Method Ring Forceps (6) IUD Insertion Device (159) Manually (40)

History of STD Gonorrhea (22) Chlamydia (71)

IUD type Mirena (302) ParaGard (26) Liletta (29)

Inserting Physician PGY-1 (171) PGY-2 (112) PGY-3 (59) PGY-4 (12) Attending (3)

Results

• 33 IUD expulsions (9.24%)

• 23 IUD removals (6.44%)

• 15 (45.45%) of the expulsions had their

IUD replaced prior to 6 months

• 319 patients had continued IUD usage at

6 months (89.35%)

Results

IUD In IUD Out

IUD Expulsion Rate IUD removal Rate

Figure 1

Table 2 Expulsion, Removal, Retention Proportions

Estimated Proportion (95% confidence interval)

Proportion of Expulsions out of all Deliveries 0.0924 (0.0920, 0.0929)

Proportions of Removals out of all Deliveries 0.0644 (0.0644, 0.0648)

Proportions of 6 month Usage out of all Deliveries 0.8936 (0.8930, 0.8941)

Proportions of Expulsions out of all Vaginal Deliveries

0.1415 (0.1403, 0.1426)

Proportions of Removals out of all Vaginal Deliveries 0.0732 (0.0725, 0.0738)

Proportions of 6 Month Usage out of all Vaginal Deliveries

0.8585 (0.8574, 0.8597)

Proportions of Expulsions out of all Cesareans 0.0263 (0.0260, 0.0266)

Proportions of Removals out of all Cesareans 0.0526 (0.0520, 0.0533)

Proportions of 6 Month Usage out of all Cesareans 0.9408 (0.9401, 0.9425)

Results

Results

• Proportion of IUD expulsions after vaginal delivery

was significantly higher than after cesarean

(p=0.0004)

• Retention rate at 6 months after vaginal delivery was

significantly lower than after cesarean (p=0.0204)

• Difference in removal proportions was not

statistically significant between vaginal and cesarean

delivery (p=0.573)

Results

• 19 of the 33 expulsions

(57.57%) were within

the first month after

placement

• Most commonly cited

cause for removal was

abnormal bleeding

Table 3 – Most Common Indications for Removal

Indication for Removal (N, %)

Heavy Bleeding (7, 30.43%) Irregular Bleeding (2, 8.70%) Pelvic Pain (6, 26.09%) Malposition (4, 17.39%) Unknown (3, 13.04%) Accidental (1, 4.35%)

Results – Risk Factors

• Vaginal delivery was a significant risk factor

for IUD expulsion compared to cesarean

(p=0.001)

• Among vaginal deliveries, duration of labor

24-48 hours was identified as a risk factor

when compared to duration of labor < 24

hours (p=0.019)

Results – Risk Factors

• Statistically insignificant risk factors

– Method of augmentation

– Gestational age at delivery

– Magnesium use

– Cervical dilation at the time of cesarean

– Diabetes (gestational and pregestational)

– BMI

• If a model fitting mode of delivery and duration of labor were

performed, only mode of delivery remained significant

This information is protected under the auspices of the SC Peer Statue (South

Carolina Annotated Code, 40-71-10 and 40-71-20)

Discussion

Discussion

• IUD expulsion rate

– 10-27% nationally

– GMH

• 9.24% overall

• 14.15% for vaginal deliveries

• 2.63% for cesarean deliveries

• Removal rate was 6.44%

• Retention rate of IUD at 6 months was 89.36%

Discussion

• Patients who did not re-present after hospital

discharge or after postpartum visit were

considered to have their IUD retained

• Did not re-present to Ob/Gyn Center for

prenatal care

– Unintended pregnancy prevented

– Short interconception interval prevented

Discussion

• Small number of expulsions (n=33)

– Only vaginal delivery and duration of labor were identified

as risk factors

• No statistically significant association could be made

regarding BMI, augmentation method, gestational age

at delivery, magnesium use, cervical dilation at the

time of cesarean, diabetes, IUD placement method

and spontaneous versus induced labor

Discussion

• Continue to offer post-placental placement of

IUDs to our qualifying patients

• Counsel our patients

– Institution specific data

– 45.45% of women whose IUD expelled continued

to desire LARC and had their preferred IUD

replaced without difficulty

Discussion

• Further research opportunities

– Cost-benefit analyses

– Quality of life studies

– Longitudinal research to evaluate for any long term

difficulties with removals

Conclusion

Post-placental IUD expulsion rates at

Greenville Memorial Hospital are consistent

with national data when citing vaginal

delivery (14.15%) and lower when

discussing overall rate (9.24%)

This information is protected under the auspices of the SC Peer Statue (South

Carolina Annotated Code, 40-71-10 and 40-71-20)

Strengths

• Duration of study data

• Single data importer

• Large overall sample size

Weaknesses

• Small number of actual expulsions

• Medical record review

– Actual expulsion rate may be higher

Acknowledgement

• Dr. Sharon Keiser

• Dr. Adam Tyson

• Stella Self, PhD candidate

• New Morning Foundation and ChooseWell

Initiative

• Easley Committee

This information is protected under the auspices of the SC Peer Statue (South

Carolina Annotated Code, 40-71-10 and 40-71-20)

References

1. Kavanaugh ML, Jerman J, Finer LB. Changes in use of long-acting reversible

contraceptive methods among U.S. women, 2009–2012. Obstet Gynecol 2015;126:917–27

2. Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by

providing no-cost contraception. Obstet Gynecol 2012;120:1291–7. (Level II-3)

3. Increasing access to contraceptive implants and intrauterine devices to reduce unintended

pregnancy. Committee Opinion No. 642. American College of Obstetricians and

Gynecologists. Obstet Gynecol 2015;126:e44–8

4. Immediate postpartum long-acting reversible contraception. Committee Opinion No. 670. American

College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e32–7

5. Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK, Creinin MD. Postplacental or delayed

insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol 2010;116:1079–87. (Level I)

6. Dahlke JD, Terpstra ER, Ramseyer AM, Busch JM, Rieg T, Magann EF. Postpartum insertion of

levonorgestrel--intrauterine system at three time periods: a prospective randomized pilot study.

Contraception 2011;84:244–8. (Level I)

7. Hayes JL, Cwiak C, Goedken P, Zieman M. A pilot clinical trial of ultrasound-guided postplacental

insertion of a levonorgestrel intrauterine device. Contraception 2007;76:292–6. (Level III) ⇦

8. Celen S, Sucak A, Yildiz Y, Danisman N. Immediate postplacental insertion of an intrauterine

contraceptive device during cesarean section. Contraception 2011;84:240–3.

9. Levi EE, Stuart GS, Zerden ML, Garrett JM, Bryant AG. Intrauterine device placement during cesarean

delivery and continued use 6 months postpartum: a randomized controlled trial.

Obstet Gynecol 2015;126:5–11

This information is protected under the auspices of the SC Peer Statute (South Carolina Annotated Code, 40-71-10 and 40-71-20)