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23/05/18
1
LENGTH OF ENDOMETRIAL CAVITY AND OTHER RISK FACTORS FOR IUD DISPLACEMENT, EXPULSIONS AND
REEXPULSIONS
ESC, Budapest, May 2018
Luis BahamondesProfessor of Gynaecology
Department of Obst & GynaecolUniversity of Campinas, Medical School
Campinas, SP, Brazil
COMMON IUCs WORLDWIDE
32 x 32 mm
52-mg LNG-IUS
28 x 30 mm
19.5-mg and 13.5-mg LNG-IUS
TCu380A IUD
32 x 32 mm
Multi Load 375IUD Nova T
36 x 38 mm31 x 33 mm24 x 30 mm35 x 19 mm
Gyne Fix
IUB
• For Cu-IUD and LNG-IUS: Bleeding disturbances
• For Cu-IUD and LNG-IUS: Pain at placement
• For Cu-IUD and LNG-IUS: Greater difficulty at placement among nulligravidas (?)
• For Cu-IUD and LNG-IUS: High expulsion rates among nulligravidas (?)
• Only for LNG-IUS Fear of hormonal effects
These concerns induced the:
Development of new Copper-IUD and new LNG-IUS with small size and low LNG dose
COMMON REASONS REPORTED BY HCPs AND WOMEN ABOUT IUC PLACEMENT DIFFICULTIES AND WHY THEY WANT
NEW SMALL IUC.
EVIDENCE IN IUC EXPULSIONS
• Between 2-10% of all insertions• More than 50% occurred in the first 6 months after placement
REPORTED ASSOCIATED FACTORS TO EXPULSION OF IUC• Young age
• Insertions performed by less skilled professionals• Post abortion and post partum insertion
• Heavy menstrual bleeding at time of insertion• Distorted cavity by uterine fibromas
HOWEVER• The length of endometrial cavity is not related to expulsions;
• The size of IUC is not related to expulsion.
Canadian Contraception Consensus (Part 3 of 4): Chapter 7 –Intrauterine Contraception. J Obstet Gynaecol Can 2016;38:182-222.
IT IS IMPORTANT THE ENDOMETRIAL LENGTH TO PREDICT EXPULSION?
Dragoman et al, Contraception 2016;94:195–201.J Minim Invasive Gynecol. 2018 Mar - Apr;25(3):411-417
TRUE UTERINE CAVITY LENGTH IS UNDERESTIMATED BY BLIND SOUNDING
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DISTRIBUTION OF ENDOMETRIAL LENGTH (only cavity) (IN Cm) ASSESSED BY UTERINE SOUND (A) AND ULTRASOUND (B) (N=570).
Canteiro R et al. Contraception, 2010
Length of uterine cavity UTERINE SOUND (cm) ULTRASOUND (cm)
Minimum 2.5 2.2
Median 4.0 3.7
Maximum 6.0 6.5
Mean 4.06 3.78
S.D. 0.67 0.62
S.E.M. 0.02 0.02
DESCRIPTIVE VALUES OF THE ENDOMETRIAL LENGHT ASSESSED BY UTERINE SOUND AND ULTRASOUND (n=570)
Canteiro R et al. Contraception, 2010
ENDOMETRIAL CAVITY LENGTH OF THE 10 WOMEN WHOSE IUC WERE EXPELLED (n=395)
Participantnumber
Type ofIUC
Number ofpregnancies
Endometrial lengthby uterine sound, cm
Endometrial lengthby ultrasonography, cm
1 LNG-IUS 1 4.0 3.7
2 LNG-IUS 2 5.0 4.0
3 TCu380A 0 3.4 3.6
4 TCu380A 0 3.5 3.5
5 TCu380A 0 5.0 5.3
6 TCu380A 1 4.0 3.7
7 TCu380A 1 4.7 5.4
8 TCu380A 2 3.0 3.99 TCu380A 2 4.0 3.010 TCu380A 4 3.0 3.3
Int J Gynaecol Obstet. 2011 Apr;113(1):50-3
DISTRIBUTION OF CHANGE IN UTERINE LENGTH BEFORE AND AFTER TERM DELIVERY AMONG 495 INFERTILE WOMEN
J Matern Fetal Neonatal Med. 2014 Jul;27(10):989-93
GROSS CUMULATIVE RATES MLCu375 – 2 YEARS USE
Adv Contracept. 1993 Dec;9(4):285-90
0
1
2
3
4
5
6
7
8
9
Pregnancy Expulsion P < 0.01 Bleeding/Pain
ECL < 45mmECL > 45mm
%
WHO’s QUESTION: DOES CHECKING FOR THE PRESENCE OF AN
IUD STRING(s) INCREASE THE METHOD’S EFFECTIVENESS BY ALERTING THE USER
WHEN/IF AN EXPULSION HAS OCCURRED?
Dragoman et al, Contraception 2016;94:195–201.
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TIME BETWEEN IUC PLACEMENT AND EXPULSION. CAMPINAS, BRAZIL
Month(s) between IUC placement and expulsion TCu380A (n=1532) SIU-LNG (n=254)
Between placement and month 6 49.1 % 54.3 %
7 to 12 11.8 % 14.6 %
13 to 24 12.3 % 15.0 %
Simonatto et al. J Obstet Gynaecol Res 2016;42(5):554-9.
TCu380A IUD and 52-mg LNG-IUS.NUMBER OF EXPULSIONS ACCORDING TO MONTHS OF USE
N=2,235 EXPULSIONS, CAMPINAS, BRAZIL
Number of expulsions according to months of use
Months
WOMEN AGE AND EXPULSION RATE
MYTH: ADOLESCENTS ARE PRONE TO EXPULSIONS IN COMPARISON TO ADULTS
WOMEN
EXPULSION RATE IN 52-mg LNG-IUS USERS OVER 3 YEARS
[N (%)].
16–35 years old
(n= 1600)
36–45 years old
(n= 151)
Total
(n= 1751)
56 (3.5) 6 (4.0) 62 (3.4)
Contraception. 2015 Jul;92(1):10-6.
ADJUSTED HAZARD RATIOS OF RISKS OF EXPULSION
VariableExpulsion
HR (95% CI) P-value
Age (y)
13–19Reference
20–24 0.79 (0.47–1.35) .39
25–35 0.68 (0.40–1.13) .14
IUD type
LNG-IUS Reference
Copper-IUD 1.62 (1.06–2.50) .03
Obstet Gynecol. 2014 Mar;123(3):585-92
CUMULATIVE PROBABILITY OF NOT HAVING AN INTRAUTERINE DEVICE EXPULSION STRATIFIED BY AGE.
Madden. IUD Expulsion. Obstet Gynecol 2014.
Higher expulsions at girls aged 14-19 years old
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EXPULSION RATES OF IUDs AMONG ADOLESCENTS
Am J Obstet Gynecol 2017
Overall8%
PARITY AND EXPULSION RATE
MYTH: NULLIGRAVIDAS ARE PRONE TO EXPULSIONS IN COMPARISON TO PAROUS
WOMEN
CUMULATIVE PROBABILITY OF NOT HAVING AN IUC EXPULSION STRATIFIED BY PARITY
Madden. IUD Expulsion. Obstet Gynecol 2014.
TIME OF INSERTION:POSTPARTUM IUC PLACEMENT AND
EXPULSION RATE
CLINICAL OUTCOMES OF PPIUD BY MODE OF DELIVERY
Vaginal Delivery CaesareanDelivery P-value
Total women 137 73
Strings present on examd 93.1% (81/87) 44.2% (23/52) <.01
IUD present by ultrasounde 13.7% (13/95) 42.9% (24/56) <.01
IUD in place at 6 ws PP 84% (95/113) 100% (56/56) <.01
Insertions at CD are more likely to less expulsion (p<.01);IUC placed after CD are more likely to have nonvisible strings with a pelvicexam (p<.01) and undergo pelvic ultrasound evaluation (p<.01) compared to aPPIUD placed at the time of a VD.
Contraception 97 (2018) 215–218
Rate per 100 women/years p-value
Timing of insertion 0.4
Postpartum/postabortion 5.1
Interval 6.5
CUMULATIVE RATES OF EXPULSION OF COPPER-IUD AND LNG-IUS ACCORDING TO TIMING OF INSERTION. USA. N=1,164 WOMEN
Backman et al. EJCRHCare 2001;6:23-6.
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LNG-IUS PLACEMENT AT THE TIME OF ACCUTE HMB EPISODE AND EXPULSION
All womenRegular
menstrual cycles
HMB
Expulsion 4.1 2.9 8.9
Number of placements 256 206 50
SMALL LNG-IUS AND EXPULSION RATE
PHASE III: THREE-YEAR OUTCOMES (JAYDESS)
Outcome Jaydess®
(N=1,432)
Partial and total expulsion, K-M analysis % 4.6
PROBALITY OF PARTIAL OR TOTAL EXPULSION AT MONTH 36, BY PARITY AND AGE (K-M ANALYSIS)
Probability of at leastpartial expulsion
Probability of total expulsion
LCS 12 and LCS 16
0 births 2.63% 0.84%
1 birth or more 4.92% 2.72%
Age ≤ 25 years 4.78% 2.42%
Age >25 <35 years 3.61% 1.77%
Total 4.05% 2.01%
PROBALITY OF PARTIAL OR TOTAL EXPULSION BY GROUP –ALL SUBJECTS TREATED WITH LCS16
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LEVEL OF TRAINING OF THE HCP AND EXPULSION RATE Rate per 100
women/yearsp-value
HCP 0.37
Faculty member 5.7
Resident 7.0
CUMULATIVE RATES OF EXPULSION OF COPPER-IUD AND
LNG-IUS ACCORDING TO LEVEL OF TRAINING OF THE HCP.
USA. N=1,164 WOMEN
Backman et al. EJCRHCare 2001;6:23-6.
ULTRASOUND EXAMINATION REDUCE THE RISK OF EXPULSION?
DIAGRAM SHOWING A CORRECTLY PLACED IUD AS DETECTED BY ULTRASOUND
Contraception. 1996 Nov;54(5):287-9.
SCATTERGRAM OF THE IUD-MYOMETRIUM DISTANCE ACCORDING TO ENDOMETRIAL THICKNESS, EXCLUDING
SUBJECTS BELOW THE 90 PERCENTILE
Contraception. 1998 Jun;57(6):413-5.
WE CONCLUDE THAT THE T-SHAPED IUD ACCOMMODATES ITS
POSITION IN THE UTERINE CAVITY DURING THE FIRST 3 MONTHS
FOLLOWING INSERTION, AND THAT ULTRASOUND EVALUATION OF ITS
POSITION IS NOT A GOOD PREDICTOR OF FUTURE EVOLUTION.
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IN CONCLUSIONVARIABLES ASSOCIATED TO HIGHER EXPULSION RATES
• Adolescents• LNG-IUS placement at the time of acute HMB episode
• First 6 months after IUC placement• Insertions performed by less skilled professionals
• Distorted cavity by uterine fibromas
CONFLICTED VARIABLES ASSOCIATED TO HIGHER EXPULSION RATES
Nulligravidas• Post partum insertion in comparison to CD placement
HOWEVER• The length of endometrial cavity is not related to expulsions;
• The size of IUC is not related to expulsion.