Postpartum IUD Placement, with Dr. Sarah Prager
/This week we are joined by Dr. Sarah Prager, a professor at the University of Washington in OB/GYN and Complex Family Planning. She shares with us some particular expertise in an ever-more common procedure - the postpartum IUD placement. There’s definitely a few pearls in the podcast that are worth listening for!
Definitions:
Immediate postplacental insertion: within 10 minutes of placental extraction
Immediate postpartum insertion: 10 minutes to 48 hours after delivery
Delayed postpartum insertion: 48 hours to 6-8 weeks after delivery
Interval placement: IUD placement not related to recent delivery
Trans-cesarean insertion: IUD placed through the hysterotomy at the time of cesarean delivery
Exclusion criteria:
Chorioamnionitis/uterine infection
Prolonged rupture of membranes (18-24 hours)
Excessive postpartum bleeding that is unresolved
Extensive genital trauma that would be negatively impacted by IUD placement
Expulsion rates:
10% if placed in the first 10 minutes
Up to 25-30% if placed after 48 hours
Limited data on 10 minutes to 48 hours
Pilot study in Zambia showed 4% expulsion with “morning after delivery” IUD placement
Provider experience matters!
Study from 1985 showed providers cut their expulsion rates almost in half comparing the beginning to the end of the study
Take home message: don’t get discouraged! Your expulsion rate will decrease with experience!
Copper vs. LNG-IUD
Most older data is with various copper IUDs (primarily the Copper T 380A – ParaGard)
Some limited data with specifically Mirena brand LNG-IUD.
Recent data often pooled LNG-IUD, without separating different IUDs
Limited comparative data
Possibly higher expulsion rates with LNG-IUD than Copper IUD
Could be due to method used for insertion – inserter vs. no inserter
LNG-IUD inserters are long enough to reach the fundus of a PP uterus, ParaGard IUD inserters are not
There is a dedicated PP inserter for Copper IUD (longer, stiffer, but not available in USA at this time); unclear if it changes outcomes
Recent study out of Kaiser showed slightly lower expulsion rates for breastfeeding vs. non-breastfeeding people.
Largest study to date with mostly LNG-IUD
Expulsion rates:
10.7% expulsion by 5 years with placement 0-3 days
3.9% for 3 days to 6 weeks
3.2%for 6-14 weeks postpartum
4.9% for interval placement
Medical Eligibility Criteria:
CDC: category 1 or 2 at any time, regardless of type of IUD or breastfeeding status.
Of course, category 4 if uterus is infected
WHO: category more nuanced depending on type of IUD and timing of placement
Method of placement:
With the inserter
Need a long enough inserter
Often can use the LNG-IUD inserters
Also need the inserter to be stiff enough – sometimes doesn’t work with LNG-IUD inserters
Dedicated copper IUD inserter both longer and stiffer
With an instrument
Can use a ring forceps
Can use a Kelly placenta forceps (longer)
With your hand
No difference in expulsion seen compared with instrument
Personal bias – WAY more painful! No-one likes a hand in their uterus
Not reported in the early studies that compared this to using a ring
Clinical tips and tricks for successful insertion with an instrument:
Place a ring on the anterior lip of the cervix
Hold the IUD gently in a ring forceps (don’t click down if LNG-IUD – don’t want to disrupt the LNG delivery system!)
Know the orientation of the IUD with respect to the orientation of the ring handles to make sure you place IUD with the proper orientation in the uterus!!!
Once the IUD is in the lower uterine segment, gently let go of the ring on the cervix and place the non-dominant hand on the uterine fundus
Drop your wrist! Drop your shoulder! Aim for the fundal hand
Angle different from interval insertions – basically aim for the umiblicus
Will not go wrong if you aim for the fundus! Feel it with your fundal hand!
Let go of the IUD and gently remove the ring without pulling on the IUD or strings
If strings are visible, cut at the os
Can also pre-cut the strings of LNG-IUDs so they are about 10 cm
Cutting strings can sometimes pull the IUD lower or out
Can use ultrasound if you want!
If using an inserter:
Pre-deploy the IUD – you do not need the narrow profile with an open cervix!
Personal bias – don’t use the inserter
If using your hand:
Change your gloves
Precut the strings
Hold between the index and middle fingers with the strings laying across your palm
Make sure you don’t pull it out when you remove your hand!
If trans-cesarean placement:
Close 1/3 – ½ the hysterotomy then place
Precut the strings shorter before directing down into the cervix
Personal bias again toward instrument placement, but usually hand and inserter also work fine
Follow-up care:
See patients at 1-2 weeks postpartum and trim strings as needed.
May need to do this again at 6-week visit
If strings not visible at follow-up, do an ultrasound to verify presence of IUD in the uterus
If IUD there, NO NEED FOR ROUTINE ULTRASOUND TO CHECK CONTINUED PRESENCE OF THE IUD
Counsel patient that efficacy unchanged, but removal may be more complicated if strings don’t emerge from the cervix
This should have been a counseling point during consent!