Lindsey Tingen, MD Department of Obstetrics and Gynecology, Greenville Health System Greenville, SC

Transcription

1 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

2 Disclosure I have no meaningful conflicts of interest to declare for this educational activity.

3 Background Facts about LARCs Long Acting Reversible Contraception Gaining popularity in the US Use is increasing 2.4% in % in % in

4 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 IUD 2

5 Background ACOG now recognizes immediate postpartum IUD insertion as best practice 3,4 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 visit 10 Postpartum IUD expulsion rates 10-27% depending on study 5-8

6 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

7 Hypothesis Postpartum IUD expulsion rate at Greenville Memorial Hospital is similar to national averages

8 Methods

9 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

10 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

11 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

12 Outcomes IUD expulsions, removals, and retention at 6 months Date of Insertion Date of Expulsion/Removal Reason for Removal

13 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

14 Results

15 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 weeks (n=275, 77%)

16 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/m 2 (mean) (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)

17 Results Table 1 Demographics (continued) Fetal Number Singleton (349) Twins (8) Gestational Age at Delivery < 34 weeks (28) weeks (36) weeks (275) > 41.0 weeks (18) Duration of Labor < 24 hours (218) 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)

18 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%)

19 Results Figure 1 IUD In IUD Out IUD Expulsion Rate IUD removal Rate

20 Results Table 2 Expulsion, Removal, Retention Proportions Estimated Proportion (95% confidence interval) Proportion of Expulsions out of all Deliveries (0.0920, ) Proportions of Removals out of all Deliveries (0.0644, ) Proportions of 6 month Usage out of all Deliveries (0.8930, ) Proportions of Expulsions out of all Vaginal Deliveries (0.1403, ) Proportions of Removals out of all Vaginal Deliveries (0.0725, ) Proportions of 6 Month Usage out of all Vaginal Deliveries (0.8574, ) Proportions of Expulsions out of all Cesareans (0.0260, ) Proportions of Removals out of all Cesareans (0.0520, ) Proportions of 6 Month Usage out of all Cesareans (0.9401, )

21 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)

22 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%)

23 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 hours was identified as a risk factor when compared to duration of labor < 24 hours (p=0.019)

24 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, and 40-

25 Discussion

26 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%

27 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

28 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

29 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

30 Discussion Further research opportunities Cost-benefit analyses Quality of life studies Longitudinal research to evaluate for any long term difficulties with removals

31 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, and 40-

32 Strengths Duration of study data Single data importer Large overall sample size

33 Weaknesses Small number of actual expulsions Medical record review Actual expulsion rate may be higher

34 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, and 40-

35 References 1. Kavanaugh ML, Jerman J, Finer LB. Changes in use of long-acting reversible contraceptive methods among U.S. women, Obstet Gynecol 2015;126: Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012;120: (Level II-3) 3. Increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Committee Opinion No American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e Immediate postpartum long-acting reversible contraception. Committee Opinion No American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK, Creinin MD. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol 2010;116: (Level I) 6. Dahlke JD, Terpstra ER, Ramseyer AM, Busch JM, Rieg T, Magann EF. Postpartum insertion of levonorgestrel--intrauterine system at three time periods: a prospective randomized pilot study. Contraception 2011;84: (Level I) 7. Hayes JL, Cwiak C, Goedken P, Zieman M. A pilot clinical trial of ultrasound-guided postplacental insertion of a levonorgestrel intrauterine device. Contraception 2007;76: (Level III) 8. Celen S, Sucak A, Yildiz Y, Danisman N. Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section. Contraception 2011;84: 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

36 This information is protected under the auspices of the SC Peer Statute (South Carolina Annotated Code, and )