EXPERT ANALYSIS FROM THE ACOG ANNUAL CLINICAL MEETING

SAN FRANCISCO (FRONTLINE MEDICAL NEWS) – Immediate postpartum intrauterine device placement offers multiple advantages, and is generally safe and effective for preventing rapid repeat pregnancy, according to Dr. Eve Espey.

“I personally think that the postpartum IUD is the next big thing,” she said during a clinical seminar on contraception at the annual meeting of the American College of Obstetricians and Gynecologists.

The biggest barrier to immediate postpartum IUD insertion is payment. In most states, IUD placement can’t be split out from the global fee for delivery, but that is steadily changing, said Dr. Espey, chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque.

There are now 11 states where Medicaid has agreed to split out postpartum placement of IUDs or contraceptive implants from the global fee for delivery, she said. The 11 states are Alabama, Colorado, Georgia, Iowa, Louisiana, Maryland, Montana, New Mexico, New York, Oklahoma, and South Carolina.

“We are fortunate in New Mexico to be one of those states, so we now have IUDs and implants available for postpartum women,” she said.

If placing an IUD at the time of delivery, Dr. Espey said insertion should occur as soon as possible since data suggest that insertion within 10 minutes of expulsion of the placenta or at the time of cesarean delivery is associated with a lower rate of IUD expulsion, compared with insertion that occurs after 10 minutes.

“We actually have not had difficulty getting them in within 10 minutes, but we give a 30-minute window,” she said, noting that the definitive study on the expulsion rate of IUDs has not yet been done, but that estimates range from 10% to 40%.

“But I think that the public health impact is such that, even if there is a high expulsion rate, it will still be worthwhile to place IUDs immediately, because of the multiple advantages,” she said.

In addition to knowing that the woman is not pregnant at the time of placement, advantages include the fact that postpartum women are “quite motivated to utilize a contraceptive method right after having a baby,” the patient and physician are already in the same place at the same time, and the procedure is relatively simple.

The prevention of rapid repeat pregnancy – within 18 months of delivery – is another major advantage to immediate postpartum insertions. About a third of pregnancies are rapid repeat pregnancies, Dr. Espey said.

“So again, a postpartum IUD or a postpartum implant may really have the power to reduce those rapid repeat pregnancies,” Dr Espey said.

The disadvantages are few, she said, as are the contraindications, which include infection and postpartum hemorrhage.

As for safety, Dr. Espey said reasonable evidence suggests that IUDs – in contrast with hormonal contraceptives, and despite the fact that there is hormone in the levonorgestrel IUD – have no impact on cardiovascular risk or venous thromboembolism risk, and likely no impact on breastfeeding.

Postpartum IUD insertion isn’t difficult, but the postpartum uterus does pose some unique challenges, most notably the angle.

Insertion can be performed manually, or by using ring forceps or an inserter. However, an inserter is not recommended because of the difficulty with the angle in postpartum cases.

Dr. Espey recommended using ring forceps to grasp the IUD on the bias to allow the string to remain free. Long ring forceps are particularly helpful for postpartum cases, but standard ring forceps also work, she said.

“We typically will place the posterior blade of a [Graves] speculum in the posterior vagina, exert downward traction, identify the anterior cervix, and grasp the anterior cervix with the ring forceps,” she said.

The only setup needed involves the Graves speculum and two ring forceps, she added.

The speculum spreads the walls of the vagina to allow insertion without the IUD touching the vaginal walls. The IUD can be held in the down direction upon insertion to help prevent its touching the vaginal walls, then turned to provide the correct orientation all the way up to the fundus, she explained.

Ultrasound guidance may be useful and reassuring for those learning the procedure, but generally won’t be required once the physician gains experience in postpartum IUD placement, she added.

Interest in postpartum IUD placement is currently low and will likely remain that way until payment is more widespread, Dr. Espey said. But she recommended that physicians seek out training opportunities because payment is coming.

“We’ve been doing this for a year and a half. I think it is a really patient centered way to approach IUD insertion, so I would highly recommend being abreast of what’s going on in your state relative to reimbursement for postpartum IUD insertion,” she said.

Dr. Espey reported having no financial disclosures. She is a member of the Ob.Gyn. News editorial advisory board.

sworcester@frontlinemedcom.com

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