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UW MEDICINE │ POSTPARTUM IUD INSERTION
SARAH PRAGER, MD, MAS
ASSOCIATE PROFESSOR, UNIVERSITY OF WASHINGTON
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
Everything You'd Ever Want to
Know about Immediate Postpartum
LARC Insertion
I am a Nexplanon insertion trainer
I participate in PPIUD trainings
for Population Services International (PSI)
DISCLOSURES
OBJECTIVES
• Impact of immediate postpartum LARC
insertion on Washington State population
health outcomes
• How to promote LARC use among your
patients and set up the infrastructure to
provide it in the immediate postpartum period
• How to receive appropriate reimbursement
IUD and Implant Epidemiology
Attitude Regarding IUDs
Favorable
Satisfaction at One Year
Satisfied
Forrest JD. Obstet Gynecol Surv. 1996; 51(12)
US Public Opinions - IUDs
• Perfect use
• Typical use
• Efficacy
• Effectiveness
Efficacy x compliance x continuation
Fecundability x coital frequency
Contraceptive Effectiveness
2 0.3 0.2 0.6 0.2 0.05
18
9
6
0.8 0.2 0.05
Condoms Pill/ Patch/ Ring
DMPA Copper IUD LNG-IUS Implanon
Percent of women with unintended pregnancy in the first year of use
Perfect Typical
Adapted from Trussell J. Contracept. 2011; 83(5)
Comparative Effectiveness
Contraceptive Failure Rates
Winner et al. NEJM 2012, prospective cohort
12%
10%
8%
6%
4%
2%
0%
Co
ntr
acep
tive
Failu
re
LARC DMPA PPR
Year 1 Year 2 Year 3
pill, patch, ring injectable
0 1 2 3 4 5
LNG-IUS
Copper IUD
Injection
Pill
Sterilization
Diaphragm
Spermicide
Cervical cap
Thousands in dollars
Cost of female contraceptive methods at 5 years
Chiou CF, et al. Contracept. 2003; 68(1)
Cost Effectiveness
Epidemiology of Postpartum LARC
Significant clinical
differences
between interval and
immediate
postpartum insertion
for IUDs
Technical aspects of
insertion and clinical
indications remain
the same for
implants regardless
of the time of
insertion
IUD Implant
Immediate Postpartum LARC Insertion:
IUD v. Implant
Provider and patient both present without anyone making a special trip
Negligible time investment for insertion
Cervix is open
Fewer “Accessories” than for interval insertion
Many side effects in the early post-insertion period masked by postpartum status
Public health value of provision far outweighs cost of expulsion
ADVANTAGES OF PPIUD
Washington. Postpartum IUD cost-effectiveness. Fertil Steril 2015.
COST BENEFIT ANALYSIS IN THE U.S.
Decision Tree
COST BENEFIT ANALYSIS IN THE US: RESULTS
Immediate PP Insertion
DEFINITIONS
Immediate Postplacental
Insertion
Transcesarean Insertion
Delayed PP Insertion
Interval Placement
Within 48 hours of delivery
Within 10 minutes of placental extraction
Through uterine incision at time of cesarean delivery
Typically placed 4–6 weeks postpartum
Placement not related to timing of childbirth
• Immediate post placental (within 10 minutes of placental extraction)
– No Chorioamnionitis (during labor)
– No more than 18 (24) hours from rupture of membranes to
delivery of baby
– No unresolved postpartum hemorrhage
Candidates for PPIUD
• Immediate postpartum (10 minutes after placental extraction to 48 hours after
delivery)
– No puerperal sepsis
– No postpartum endometritis/myometritis
– No continued excessive postpartum bleeding
– No extensive genital trauma where the repair would be disrupted
by immediate postpartum placement of an IUD
Candidates for PPIUD
Chi Contraception 1985
9.5%
31.5% 28.8%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Ad
juste
d C
um
ula
tive
Exp
uls
ion
Ra
tes
*p<0.001 (≤10 minutes compared to all other groups)
PPIUD Insertion: WHY 10 MINUTES?
37.3%
Chi et al. Contraception 1985
6.9%
12.0%
p<0.001
POSTPLACENTAL IUD & PROVIDER EXPERIENCE
Objectives (CASE): Continuation Rate
Acceptability
Safety
Expulsion Rate
~1600 PPIUDs inserted
305 women interviewed/examined at 6–12 months after PPIUD insertion
PPIUD ZAMBIA
Jan 2009 – Jul 2010:
October 2010:
PPIUD ZAMBIA
Counseling How did you hear about it?
Timing When was it inserted?
Postplacental 24.3%
Postpartum (or “MADIUD”— Morning After Delivery) 71.1%
Couldn’t remember timing 4.6%
During antenatal care 65.9%
During early labor 17%
Post-delivery 8.9% (before discharge)
Blumenthal, European Journal of Contraception & Reproductive Health Care, 2016
PPIUD ZAMBIA
Expulsion & Continuation
Acceptability/Satisfaction
5.6% expulsion!
10.8% postplacental
4.1% MADIUD
3% requested removal (~ interval client removal rate)
90% IUDs in situ
94.1 VERY SATISFIED (57.7%) or SATISFIED (36.4%)
Safety NO Adverse Events
Blumenthal, European Journal of Contraception & Reproductive Health Care, 2016
Prospective cohort of 235 women
who received postplacental IUD
74% had vaginal deliveries
26% had cesarean sections
Follow-up at 6 weeks, 6 months, 12 months
Celen et al. Contraception, 2004.
DOES IT STAY IN?
Celen et al. Contraception, 2004.
Did not separate out c/s vs. vaginal delivery
DOES IT STAY IN?
Review of 5 clinics over 17 years
3,172 cesarean deliveries
5.5% expulsion at one year
84.5% continuation
No perforations
“No benefit to addition of suture”
Matched with 905 cesareans with no IUD
No difference in vaginal bleeding, infection,
duration of lochia
Xu Adv Contracep 1992.
CESAREAN DELIVERY
Women enrolled to have LNG-IUS placed immediately after vaginal delivery vs. at the 6-8 week postpartum visit
50/51 women received immediate PPIUD
46/51 women received delayed IUD
Expulsion occurred within 6 months:
12/50 (immediate)
2/46 (delayed)
IUDs replaced as desired
Continuation at 6 months:
43/51 (immediate)
39/51 (delayed)
Chen B. Postplacental or Delayed Insertion of the Levonorgestrel
Intrauterine Device After Vaginal Delivery. Obstet Gynecol, Nov 2010
PPIUD WITH LNG-IUS
AK Whitaker et al. Contraception 89 (2014);534–539
PPIUD WITH LNG-IUS AFTER CESAREAN
AK Whitaker et al. Contraception 89 (2014);534–539
PPIUD WITH LNG-IUS AFTER CESAREAN
1 No restriction for the use of the contraceptive method
for a woman with that medical condition
2 Advantages of using the method generally outweigh
the theoretical or proven risks
3
Theoretical or proven risks of the method usually
outweigh the advantages – or that there are no other
methods that are available or acceptable to the
women with that medical condition
4 Unacceptable health risk if the contraceptive method
is used by a woman with that medical condition
CDC. Morb Mortal Wkly Rep. 2010; 59(RR-4)
US Medical Eligibility Criteria: Categories
Condition Sub-
condition
Implant LNG-IUD Copper IUD
Postpartum
(BF or not BF,
including post
C/S)
< 10 minutes
after delivery
of the placenta
1 1/2 1
10 minutes
after delivery
of the placenta
to 4 weeks
1 2 2
After 4 weeks
postpartum
1 1 1
Puerperal
Sepsis
1 4 4
CDC. Morb Mortal Wkly Rep. 2010; 59(RR-4)
CDC Medical Eligibility Criteria for
Contraception Use: Postpartum Timing
CLINICAL GUIDANCE AND HELPFUL HINTS
2
1
HOW DO YOU DO IT?
Postplacental IUD Insertion
Drawing by Tracy Angulo
FORCEPS PPIUD INSERTION
Hand on fundus
High fundal placement
Reduced/eliminated chance of perforation
Know where to aim
Direct forceps straight up toward abdomen
NOT toward the head
DROP YOUR WRIST!!!
Cut strings at external os
Different depths of postpartum uterus
Different length strings
KEY POINTS WITH PPIUD INSERTION
COMMON IUDS
Mirena
Copper T
Know where sterile insertion packs and gloves are kept
Know where devices are kept
Forceps: Ring/Vulsellum or Kelly
KNOW THE ORIENTATION OF THE TIP
OF THE FORCEPS WITH RESPECT TO
THE ORIENTATION OF THE HANDLES!!!!!
EQUIPMENT FOR PPIUD
Complication
• Expulsion
Management
• Verify expulsion (ultrasound and/or x-ray)
• Replace if patient desires
Complications and Management
Complication
• “Missing” strings
Management
• Verify IUD in uterus (ultrasound and/or x-ray)
• Reassure patient
Complications and Management
Complication
• Elongating strings
Management
• Trim strings
Complications and Management
Complication
• Infection (rare)
Management
• Treat with antibiotics
• Removed IUD if no improvement
Complications and Management
Complication
• Perforation (no reported cases)
Management
• Remove IUD immediately
• Laparoscopy may be required for removal if
perforation not immediately recognized
Complications and Management
Easy to do
Take an on-line training module and practice with a low-
cost pelvic module
Use resources from ACOG for billing/coding assistance
Ask for help from someone who already has implemented
this practice
How Can I Implement This in MY Hospital?
Inserting Long Acting
Reversible Contraception (LARC)
Immediately After Childbirth Expiration Date: This activity was originally released on September 30, 2014 and is available for continuing
education credit until September 30, 2016.
CNE
Upon successful completion of this educational activity 1.6 contact hours (including 1.5 hours of
pharmacology) will be awarded.
Cardea Services is an approved provider of continuing nursing education by the Washington State Nurses Association
Continuing Education Approval & Recognition Program (CEARP), an accredited approver by the American Nurses
Credentialing Center’s Commission on Accreditation.
CME
Cardea designates this enduring material for a maximum of 1.6 AMA PRA Category 1 Credit(s)™.
Physicians should claim credit commensurate with the extent of their participation in the activity.
This credit may also be applied to the CMA Certification in Continuing Medical Education.
Cardea is accredited by the Institute for Medical Quality/California Medical Association for issuing AMA PRA Category 1
Credit(s)™ for physicians.
Activity
Description
Target
Audience
Learning
Objectives Faculty Fees
Please turn on your computer
speakers to hear audio on this
and subsequent pages.
http://www.cardeaservices.org/resourcecenter/inserting-long-acting-reversible-contraception-larc-immediately-after-childbirth
Medicaid Reimbursement for Postpartum LARC By State Medicaid Reimbursement for Postpartum (In-Hospital) LARC
Alabama: Click here for more information
California: Click here for more information
Colorado: Click here for more information *See page 9
Connecticut: Click here for more information
District of Columbia: Click here for more information
Georgia: Click here for more information
Illinois: Click here for more information
Indiana: Click here for more information
Iowa: Click here for more information
Louisiana: Click here for the Health Plan Advisory and see page 18 here for the Hospital Services Provider Manual
Maryland: Click here for more information
Missouri: Click here for more information
Montana: Click here for more information
New Mexico: Click here for more information
New York: Physicians, Inpatient, Midwives, Nurse Practitioners
Ohio: Click here for more information *See page 34
Oklahoma: Click here for more information
South Carolina: January 2012 Bulletin, August 2013 Update
Texas: Click here for more information.
Washington: Click here for more information *See page 74
Please forward any corrections, updates, or newly published guidance to Mica Bumpus at [email protected]
Last Updated: June 2, 2016
Medicaid Reimbursement for Postpartum LARC By State Medicaid Reimbursement for Postpartum (In-Hospital) LARC
PPIUD is safe
PPIUD results in reasonable continuation rates
at 6 and 12 months
Especially for patients unlikely to return for postpartum care
Expulsion rate may be lower after cesarean
vs. vaginal delivery
LNG-IUS may have a higher expulsion rate
than copper IUDs
We have no data on expulsion rates for Skyla or Liletta
LNG-IUDs
CONCLUSIONS
THANK YOU! QUESTIONS?