Postpartum LARC safety
ACOG states that immediate postpartum IUD insertion (within 10 minutes after placental delivery in vaginal and cesarean births), should be offered routinely as a safe and effective option for postpartum contraception.9 The Centers for Disease Control and Prevention US Medical Eligibility Criteria (US CDC MEC) classifies immediate postpartum copper IUD insertion as Category 1 (Table 2). Immediate postpartum insertion of LNG-IUS and the contraceptive implant is MEC Category 1 or 2, depending on breastfeeding status (Table 2). Immediate postpartum IUD insertion is contraindicated for women in whom uterine infection, puerperal sepsis, or ongoing postpartum hemorrhage are diagnosed. Immediate postpartum initiation of the contraceptive implant either before hospital discharge or after a hospital stay for birth should be offered routinely as a safe and effective options regardless of breastfeeding status. The US CDC MEC classifies placement of an implant in non-breastfeeding women less than 21 days postpartum as Category 1 and classifies placement for breastfeeding women as Category 2, given theoretical concerns regarding milk production; after 30 days postpartum, it is classified as US MEC Category 1 in breastfeeding women.20
Postplacental IUD perforation and expulsion
Uterine perforation at time of postplacental IUD placement is rare. In a prospective study of 8343 women receiving the Copper T380A at different postpartum timings, only one perforation occurred out of 460 postplacental insertions (0.2%).21 This risk is not greater than with interval IUD insertion.
The rate of postplacental IUD expulsion, on the other hand, is higher than after interval insertion. Reported expulsion rates range from 2% to 27% after vaginal delivery and 0% to 20% after cesarean delivery.22,23 In a large randomized controlled trial (RCT) of postplacental IUD insertion, Chen et al. randomized 102 women to postplacental insertion of the 52-mg LNG-IUS or interval insertion 6 to 8 weeks later. Expulsion was higher with postplacental insertion than with interval insertion. However, 10 of 12 women who experienced expulsion after immediate postpartum placement had a new LNG-IUS inserted and both groups had similar rates of IUS use at 6 months (84% vs. 77%, P = 0.32).24
Another study randomized women to immediate IUD placement at cesarean delivery versus interval placement at
6 weeks postpartum and found that significantly more women in the immediate placement group continued the IUD at 6 months (83% vs. 64%, RR 1.3, CI 1.02-1.66).25 In the interval group, 39% did not obtain the IUD, 25% did not return for the postpartum visit, and 14% either declined the IUD or had an unsuccessful insertion.25 When looking at expulsion rates after postplacental IUD insertion versus after insertions at other postpartum intervals (> 10 min to 48 or 72 hours), data are conflicting. Despite the higher expulsion rate for immediate postpartum IUD placement, evidence from clinical trials and cost-benefit analyses strongly suggest superiority of immediate placement, especially for women at greatest risk of not having recommended postpartum follow-up. Patients should be counseled about the increased expulsion risk, as well as signs and symptoms of expulsion. Given that many women experience barriers to interval LARC placement, advantages of immediate postpartum placement may outweigh disadvantages.
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- Jackson E, Glasier A. Return of ovulation and menses in postpartum nonlactating women: a systematic review. Obstet Gynecol. 2011; 117:657-662.
- McKinney J, Keyser L, Clinton S, Pagliano C. ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstet Gynecol. 2018 Sep;132(3):784-785.
- Danilack VA, Brousseau EC, Paulo BA, Matteson KA, Clark MA. Characteristics of women without a postpartum checkup among PRAMS participants, 2009-2011. Matern Child Health J. 2019 Jan 10. doi: 10.1007/s10995-018-02716-x. [Epub ahead of print]
- White K, Teal SB, Potter JE. Contraception after delivery and short interpregnancy intervals among women in the United States. Obstet Gynecol. 2015;125;1471-1477.
- Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA 2006; 295 (15): 1809-23
- U.S. Office of Disease Prevention and Health Promotion. Available at https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health
- Committee on Gynecologic Practice Long-Acting Reversible Contraception Working Group. Committee Opinion No. 642: Increasing Access to Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy. Obstet Gynecol. 2015 Oct;126(4):e44-e48.
- American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. Committee Opinion No. 670: Immediate Postpartum Long-Acting Reversible Contraception. Obstet Gynecol. 2016 Aug;128(2):e32-e37.
- Wu JP, Pickle S. Extended use of the intrauterine device: a literature review and recommendations for clinical practice. Contraception 2014; 89: 495-503
- Rivera R, Yacobson I, Grimes D. The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices. Am J Obstet Gynecol. 1999;181:1263-1269.
- Ortiz ME, Coxatta HB. Copper T intrauterine device and levonorgestrel intrauterine syste; biological bases of their mechanism of action. Contraception. 2007;75:S16-S30.
- Godfrey EM, Folger SG, Jeng G, Jamieson DJ, Curtis KM. Treatment of bleeding irregularities in women with copper-containing IUDs: a systematic review. Contraception. 2013;87:549-566.
- Natavio MF, Taylor D, Lewis RA, Blumenthal P, Felix JC, Melamed A, et al. Temporal changes in cervical mucus after insertion of the levonorgestrel-releasing intrauterine system. Contraception. 2013;87:426-431.
- Lewis RA, Taylor D, Natavio MF, Melamed A, Feliz J, Mishell D Jr. Effects of the levonorgestrel-releasing intrauterine system on cervical mucus quality and sperm penetrability. Contraception. 2010;82:491-496.
- Gemzell-Danielsson K, Schellschmidt I, Apter D. A randomized phase II study describing the efficacy, bleeding profile and safety of two low-dose levonorgestrel releasing intrauterine contraceptive systems and Mirena. Fertil Steril. 2012;97:616-622. E1-E3
- Graesslin O, Korver T. The contraceptive efficacy of Implanon: A review of clinical trials and marketing experience. Eur J Contracept Reprod Health Care. 2008;13 Suppl 1 4-12.
- Davies GC, Feng LX, Newton JR, Van Beek A, Coeling-Bennink HJ. Release characteristic, ovarian activity and menstrual bleeding pattern with a single contraceptive implant releasing 3-ketodesestril. Contraception. 1993;47:251-261.
- Croxatto HB. Mechanisms that explain the contraceptive action of progestin implants for women. Contraception. 2002;65:21-27.
- Update to CDCs U.S. Medical Eligibility Criteria for Contraceptive Use 2010: revised recommendations for the use of contraceptive methods during the postpartum period. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2011;60:878-883.
- Caliskan E. Ozurk N, Dilbaz S. Analysis of risk factors associated with uterine perforation by intrauterine devices. Eur J Contracept Reprod Health Care. 2003;8(3):150-155.
- Dahlke JD, Terpstra ER, Ramseyer AM, Busch JM, Rieg T, Magann EF. Postpartum insertion of levonorgestrel-intratuerine system at three time periods: a prospective randomized pilot study. Contraception. 2011;84;244-248.
- Celen S, Sucak A, Yildiz Y, Danisman N. Immediate postplacental insertion of intrauterine contraceptive device during cesarean section. Contraception. 2011;84:240-243.
- Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK, Creinin MD. Postplacetnal or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2010;116:1079-1087.
- 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.
- Sothornwit J, Werawatakul Y, Kaewrudee S, Lumbiganon P, Laopaiboon M. Immediate versus delayed postpartum insertion of contraptive implant for contraption. Cochrane Database Sys Rev. 2017 Apr 22;4.
- Chen BA, Reeves MF, Creinin MD, Schwarz EB. Postplacental or delayed levonorgestrel intrauterine devices insertion and breastfeeding duration. Contraception. 2011;84(5):499-504.
- Whitaker A, Chen BA. Society of Family Planning Guidelines: Postplacental insertion of intrauterine devices. Contraception. 2018;97:2-13.
- American College of Obstetrics and Gynecology. Video on Immediate Postplacental LARC Insertion. Available at https://cfweb.acog.org/district_ii/larc/section4.html
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- Lester F, Kakaire O, Byanugish J, Averbach S, Fortin J, Maurer R, et al. Intracesarean insertion of the copper T380A versus 6 weeks postcesarean: a randomized clinical trial. Contraception. 2015;91(3):198-203.
- Washington CI, Jamshidi R, Thung SF, Naveri UA, Caughey AB, Werner EF. Timing of postpartum intrauterine device placement: a cost-effectiveness analysis. Fertil Steril. 2015;103(1):131-137.
- Gariepy AM, Duffy JY, Xu X. Cost-Effectiveness of Immediate Compared With Delayed Postpartum Etonogestrel Implant Insertion. Obstet Gynecol. 2015 Jul;126(1):47–55.
- Rodriguez MI, Caugher AB, Edelman A, Darney PD, Foster DG. Cost-benefit analysis of state and hospital funded postpartum intrauterine contraception at a university hospital for recent immigrants to the United States. Contraception. 2010; 81(4):304-308.
- Ongoing barriers to immediate postpartum long-acting reversible contraception: a physician survey. Holden EC, Lai E, Morelli SS, Alderson D, Schulkin J, Castleberry NM, McGovern PG. Contracept Reprod Med. 2018 Nov 8;3:23.
- Moniz MH, Dalton VK, Davis MM, et al. Characterization of Medicaid policy for immediate postpartum contraception. Contraception. 2015 Dec;92(6):523-531.
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- ACOG Postpartum Contraceptive Access Initiative. Available at https://pcainitiative.acog.org