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