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CME / ABIM MOC / CE

Does Timing Affect Intrauterine Device Injury Risk After Delivery?

  • Authors: News Author: Michelle Dendy Washmuth; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 7/29/2022
  • Valid for credit through: 7/29/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0.25 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
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Target Audience and Goal Statement

This activity is intended for obstetricians/gynecologists/women's health clinicians, internists, critical care clinicians, pharmacists, nurses, physician assistants, family medicine/primary care clinicians, and other members of the healthcare team considering intrauterine device use for women after delivery.

The goal of this activity is for learners to be better able to describe the comparative incidence and risks for intrauterine device-related uterine perforations by nonpostpartum and postpartum intervals at intrauterine device insertion and among postpartum individuals, and to describe the effect of breastfeeding on these outcomes, based on a large US multisite cohort study using electronic health records.

Upon completion of this activity, participants will:

  • Assess comparative incidence and risks for intrauterine device-related uterine perforations by nonpostpartum and postpartum intervals at intrauterine device insertion and among postpartum individuals and the effect of breastfeeding on these outcomes, based on the APEX-IUD study
  • Describe clinical implications of the comparative incidence and risks for intrauterine device-related uterine perforations by nonpostpartum and postpartum intervals at intrauterine device insertion and among postpartum individuals and the effect of breastfeeding on these outcomes, based on the APEX-IUD study
  • Outline implications for the healthcare team


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Michelle Dendy Washmuth

    Freelance writer, Medscape

    Disclosures

    Michelle Dendy Washmuth has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie

Editor/Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Nurse Planner

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

Peer Reviewer:

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 7/29/2023. PAs should only claim credit commensurate with the extent of their participation.

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CME / ABIM MOC / CE

Does Timing Affect Intrauterine Device Injury Risk After Delivery?

Authors: News Author: Michelle Dendy Washmuth; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/29/2022

Valid for credit through: 7/29/2023

processing....

Clinical Context

Intrauterine devices (IUDs) are highly effective contraceptives used by 14% of women worldwide. Adverse events associated with insertion are rare and include uterine perforation, with an estimated rate of 1.1 to 3.6 per 1000 insertions.

Uterine perforation may be recognized at the time of insertion or later with symptoms of abdominal pain and cramps, or on speculum examination in an asymptomatic individual. Women and clinicians need information about benefits and risks for IUD use to make informed choices, but large, population-based studies are limited.

Study Synopsis and Perspective

Women for whom an IUD is inserted from 4 days to 6 weeks or less after giving birth, as well as those who are breastfeeding, are at higher risk for the contraceptive device puncturing their uterus, new research shows.

The risk for perforation was nearly 7 times higher for patients who received an IUD within that window than for those with an IUD who had never given birth or who were more than a year out from delivery, the researchers found. Healthcare providers should make patients aware of the heightened risk and should monitor these patients more closely, according to Susan Reed, MD, an obstetrician-gynecologist at the University of Washington School of Medicine, Seattle, who is the lead author of the new study.

"I'm a surgeon, and I like to be able to give people good information and good data about risks and benefits for their choices," Dr Reed told Medscape Medical News. "Uterine perforations related to IUDs are exceedingly rare, and to get good data or known risk factors, you need huge studies. This was the largest study done that really provided accurate information for patients and providers." The new study, which appears in a recent issue of the Lancet, also found that the risk for uterine perforation was lower if an IUD had been inserted immediately after delivery.

Dr Reed and colleagues analyzed data from the health records of 326,658 women ages 50 years or younger for whom an IUD was inserted between 2001 and 2018 at 4 healthcare systems. Nearly 30% of these patients received an IUD after giving birth.

The researchers identified a total of 1008 uterine perforations, for a cumulative incidence at 5 years of 0.6%. The cumulative incidence of uterine perforations was lowest in the group of women who were considered nonpostpartum; these women either received an IUD a full year after giving birth or had not given birth during the study period (0.29%; 95% confidence interval [CI], 0.26%-0.34%).

Women who received an IUD during the 3 days after delivery had a nearly 3-fold increased risk for an IUD perforation over nonpostpartum women.

In addition, the cumulative incidence of perforation was almost double among breastfeeding women compared with among women who were not breastfeeding. However, Dr Reed and coauthors noted that breastfeeding is highly beneficial for babies and that the risk for IUD perforation is relatively small.

Among the women who received an IUD after birth, Dr Reed's group found that 673 uterine perforations, of which 62% were complete, occurred in breastfeeding individuals, which was 37% more than for those who did not breastfeed.

Dr Reed said that the study provided some clarity on previous notions that women who had never given birth were possibly at higher risk for uterine perforation because of smaller uteruses.

"We used to be concerned that women who had never had a pregnancy at all might be at higher risk because their uterus was smaller, the cervix was tighter, and therefore perhaps they might have greater risks," Dr Reed told Medscape Medical News. "As a clinician and as a provider, it's pretty exciting to me to be able to tell our younger women who have never had a pregnancy that indeed their risk is lower than anybody else's."

The findings help women to make informed decisions, but overall, the benefits of IUDs outweigh the risks, said Monica V. Dragoman, MD, assistant professor of obstetrics, gynecology, and reproductive science at the Icahn School of Medicine at Mount Sinai, New York City.

"The likelihood of anyone experiencing these types of complications of that population level remains really low," Dr Dragoman said.

The findings also provide guidance for members of the healthcare team as to which patients should come in for additional follow-up visits after insertion, Dr Reed said.

"These are small risks, but it does tell us where we need to consider if there's a challenging insertion," Dr Reed said. "You're going to look with the ultrasound and make sure the placement looks right. You're going to give instructions that if the woman has pain or a change in her bleeding pattern, you want to see her back."

Patients should be aware of the symptoms of uterine perforation: an abrupt change in bleeding pattern and pelvic pain. Perforation correction typically consists of a minimally invasive surgical procedure.

The study was conducted as a result of an order from the US Food and Drug Administration to evaluate risks for uterine perforation for women who had received IUD’s.

Study authors received research funding from Bayer. Multiple authors are employees of Bayer. One study author has in the past received funding from CooperSurgical, Bayer Healthcare Pharmaceutical, and Merck & Co.

Lancet. 2022;399:2103-12.[1]

Study Highlights

  • APEX-IUD used electronic health records from 3 health care systems and a site using data from a health care information exchange.
  • The study population included individuals aged 50 years or younger with IUD insertion between January 1, 2001, and April 30, 2018.
  • Primary outcome was any IUD-related uterine perforation for first insertion.
  • In the full cohort (n=326,658), 1008 uterine perforations occurred (51.2% complete; 1.57 perforations/1000 person-years of follow-up; 95% CI, 1.48-1.67).
  • Lowest 5-year cumulative incidence was in the nonpostpartum group (0.29%; 95% CI, 0.26%-0.34%).
  • Among nonpostpartum individuals, 55% of IUD-related uterine perforations were recognized more than 12 months from insertion, whereas among postpartum individuals, 63% were recognized 12 or fewer months from insertion.
  • Among postpartum women, insertions at 4 days to 6 or fewer weeks had the highest perforation rate (5.53 per 1000 person-years; 95% CI, 4.75-6.40) and the highest cumulative incidence at 1 year (0.78%; 95% CI, 0.65%-0.93%) and 5 years (1.98%; 95% CI, 1.61%-2.43%).
  • The postpartum subcohort (n=94,817) with breastfeeding information had 673 uterine perforations (62% complete), with 5-year cumulative incidence of 1.37% (95% CI, 1.24%-1.52%) overall, 1.61% (95% CI, 1.43%-1.81%) in breastfeeding women, and 0.88% (95% CI, 0.71%-1.08%) in nonbreastfeeding individuals (adjusted hazard ratio, 1.37; 95% CI, 1.12-1.66).
  • Researchers concluded that although risk for uterine perforation with IUD insertion 4 days to 6 or fewer weeks postpartum is nearly 7-fold that of insertion nonpostpartum, perforation is incredibly rare for all clinical times.
  • Among individuals 52 or fewer weeks postpartum, risk for uterine perforation with breastfeeding at IUD insertion was increased, but this added risk was smaller than previously reported and was most pronounced in later postpartum insertions.
  • Despite slightly increased perforation risk with breastfeeding at IUD insertion, benefits of breastfeeding and effective contraception generally outweigh risks and should have little clinical meaningful effect.
  • Optimal IUD insertion timing should reflect individual desire for IUD contraception and patient convenience to ensure that insertion can occur.
  • Individuals at higher risk for uterine perforation should undergo careful follow-up, which may include ultrasound confirmation of IUD placement and advice to return for pelvic pain or change in bleeding pattern, which are symptoms of perforation.
  • Highest uterine perforation rates were among insertions 4 days to 6 or fewer weeks postpartum, the period during which uterine involution occurs.
  • Immediate postpartum IUD insertion occurs under direct visualization at caesarean delivery or with or without ultrasound guidance at vaginal deliveries, after which the cervical canal is wide open.
  • Low IUD-related uterine perforation risk for insertions 0 to 3 days postpartum must be weighed against the known high risk for expulsion and IUD malpositioning, probably related to a larger uterine cavity.
  • Corrective surgery typically consists of laparoscopy or laparotomy with general anesthetic to retrieve the IUD from the abdominal cavity for complete perforation, or hysteroscopy for partial perforation to remove the embedded IUD from the uterine wall.
  • Study limitations include potential misclassification of outcome and exposures and loss to follow-up.

Clinical Implications

  • Risk for uterine perforation with IUD insertion 4 days to 6 or fewer weeks postpartum is nearly 7-fold that of insertion nonpostpartum but is still incredibly rare.
  • Optimal IUD insertion timing should be based on individual desire for IUD contraception and patient convenience to ensure that IUD insertion can occur.
  • Implications for the Health Care Team: Individuals at higher risk for uterine perforation should undergo careful follow-up, which may include ultrasound confirmation of IUD placement and advice to return for pelvic pain or change in bleeding pattern. Breastfeeding is highly beneficial for babies and the risk for IUD perforation is relatively small.

 

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