post-abortion iuc insertion eleanor drey, md, edm assistant clinical professor obstetrics,...
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Post-Abortion IUC InsertionEleanor Drey, MD, EdM
Assistant Clinical ProfessorObstetrics, Gynecology and Reproductive Sciences
University of California, San Francisco
Sarah Prager, MD, MAS
Assistant Clinical ProfessorObstetrics and GynecologyUniversity of Washington
Disclosures
Eleanor Drey, MD, EdM
Consultant and Speaker, Organon
Research Grant, Ortho
Copper vs. Levonorgestrel IUC: Summary
Cu T380A (ParaGard)
regular menses
heavier bleeding
10 years use
no follicular cysts
no PID protection
no therapeutic role
effective EC
Levonorgestrel (Mirena)
irregular bleeding
reduced or no menses
5 years use
cysts may form
some PID protection
DUB and HRT role
not for EC
Why insert IUC immediately following abortion?
• Patients motivated
• Increased patient comfort– Cervix open enough for abortion to be done– Pre-medicated for pain control for abortion
• No longer pregnant at time of placement
• May not return for interval placement
Is it safe to insert IUC immediately following abortion?
• Does it increase risk of infection/PID?
• Does it increase risk of bleeding after the abortion?
• Does it increase risk of perforation or expulsion?
“Immediate Postabortion Intrauterine Contraception in Nulliparous Adolescents.”
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
Expulsion Bleeding
Pain
InflammationPregnancy
Cumulative Events at 12 months (%)
Lippes A
Cu7
CuT
Goldman, Israel J Med Sci, 1979
1983 WHO Study: PIDpost abortion insertion
0
0.2
0.4
0.6
0.8
1
1.2
1.4
TCu220c Lippes Copper7
Discontinuation for PID (%)
390 days
750 days
1983 WHO Study: Expulsion of TCu220c post abortion
0
5
10
15
20
25
30
390 750
Days after insertion
Expulsion of TCu220c(%)
<9 weeks
9-12 weeks
13-20 weeks
*p<0.01 *p<0.01
*p<0.05*p<0.05
Immediate Post abortion IUC Insertion versus 2-week Delay of Insertion
0
2
4
6
8
10
12
2 weeks 6 weeks 10 weeks
Weeks after insertion
Cumulative Expulsion Rate (%)
Immediate
2-weekDelay
Moussa, Contraception, 2001
*all p=NS
Rates of complications after interval IUC insertion
Complication % occurrence interval
% occurrence post-abortion
Bleeding 4-15 5-27
Infection 0.1 0.2-1.3
Perforation 0.1 0.1
Expulsion 5 4-8 (1st trimester)
Continuation 80 75-86
Johns Hopkins School of Public Health/Population Information Project; Managing Contraception
Conclusions: Immediate Post-abortion IUC Insertion
• IUD placement after abortion is safe– PID rate not increased
• Expulsion rate after first-trimester abortion is less than or equal to interval insertion
• IUDs inserted after abortion provide effective contraception– Pregnancy rate same as interval insertion
• Limited data about post-second-trimester• No data about antibiotics or uterotonics
How do LNG and Copper IUC compare?
RCT of Mirena vs. NovaT after First-Trimester Abortion
• 305 patients received Mirena®
• 133 patients received NovaT (200 mm2 copper on same frame as Mirena®)
• Multi-center in Denmark, Finland, Hungary, Norway, & Sweden.
• Not blinded• Inserted after abortion at less than 12
weeks
• Pakarinen, 2003, Contraception
Results of Mirena vs. NovaT:Expulsion after Post abortion Insertion
Cumulative Expulsion Rates (%)
02468
1012141618
1 yr 3 yrs 5yrs
Nova T
Mirena
Pakarinen, 2003.
*p<0.01
Cumulative Termination Rates Per 100 women: LNG vs. Cu T
0
5
10
15
20
1 3 5
Andersson et al. Contraception 1994;49:56
0
5
10
15
20
1 3 5
LNG IUS N=1821
HormonalBleeding ProblemsExpulsion
Nova T N=937
Post-Abortion Mirena Compared with Norplant and “Traditional Methods”
• 2 expulsions at 12 months (4%)
• No pregnancies in Mirena or Norplant groups
• 4 pregnancies in group using traditional methods 0
20
40
60
80
100
12 months
Continuation Rate (%)
Norplant
Mirena
Traditional
Ortayli, Contraception, 2001
*p<0.01
How do you do post-abortion IUC insertion?
SFGH IUC Placement Protocol: Operative Technique
• All D&E procedures done under ultrasound guidance• Methergine for bleeding/atony
– Methergine is not routinely given
• IUC placement under ultrasound guidance after D&E (second trimester)
• Ring forceps used for T380a if >14 weeks• Ring forceps used to guide Mirena inserter if difficult
to place
When not to insert IUC immediately post-abortion:
• If the patient’s bleeding post-procedure is not well controlled
• If the patient appears to be infected
• If you are concerned about perforation
54%
13%
33%
1st Trimester13-19 Weeks20-23 Weeks
The Women’s Option Centerat San Francisco General Hospital
• Abortions up to 23 weeks
• >2000 terminations per year
• Contraceptive failure common
• Diverse patients
WOC Post-Abortion IUC Insertion:Patient Satisfaction• 90% of patients are very or
somewhat satisfied (65% “very”)
• Patient quotes:– “I am not going to forget to
take a pill, and I’m not going to get poked every 3 months.”
– “I’m thrilled. It’s so easy. I don’t have to think about it.”
– “My husband is a sex maniac, so I am more comfortable knowing it’s there”
0
1020
30
40
50
60
70
Very Satisfied
Somewhat SatisfiedSomewhat Unsatisfied
Very Unsatisfied
Patient Satisfaction
What are the benefits to immediate post-abortion insertion?
• Patients leave with long-term, highly efficacious contraception
• Don’t have to depend on patient follow-up
• More comfortable insertion
Thanks to :
• Gillian Dean, MD, Assistant Professor, Einstein Univ.• Philip Darney, MD, MSc, Professor, UCSF/SFGH• Mathew Reeves, MD, Assistant Professor, Pittsburgh
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