Post-Abortion IUC Insertion

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Post-Abortion IUC Insertion

• Eleanor Drey, MD, EdM
• Assistant Clinical Professor
• Obstetrics, Gynecology and Reproductive Sciences
• University of California, San Francisco
• Sarah Prager, MD, MAS
• Assistant Clinical Professor
• Obstetrics and Gynecology
• University of Washington

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Disclosures

• Eleanor Drey, MD, EdM
• Consultant and Speaker, Organon
• Research Grant, Ortho

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Copper vs. Levonorgestrel IUC Summary

• Cu T380A (ParaGard)
• regular menses
• heavier bleeding
• 10 years use
• no follicular cysts
• no PID protection
• no therapeutic role
• effective EC

• Levonorgestrel (Mirena)
• irregular bleeding
• reduced or no menses
• 5 years use
• cysts may form
• some PID protection
• DUB and HRT role
• not for EC

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Why insert IUC immediately following abortion?

• Patients motivated
• Increased patient comfort
• Cervix open enough for abortion to be done
• Pre-medicated for pain control for abortion
• No longer pregnant at time of placement
• May not return for interval placement

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Is it safe to insert IUC immediately following
abortion?

• Does it increase risk of infection/PID?
• Does it increase risk of bleeding after the
  abortion?
• Does it increase risk of perforation or
  expulsion?

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Immediate Postabortion Intrauterine
Contraception in Nulliparous Adolescents.
Goldman, Israel J Med Sci, 1979
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1983 WHO Study PIDpost abortion insertion
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1983 WHO Study Expulsion of TCu220c post
abortion
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Immediate Post abortion IUC Insertion versus
2-week Delay of Insertion
all pNS
Moussa, Contraception, 2001
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Rates of complications after interval IUC
insertion
Complication occurrence interval occurrence post-abortion
Bleeding 4-15 5-27
Infection 0.1 0.2-1.3
Perforation 0.1 0.1
Expulsion 5 4-8 (1st trimester)
Continuation 80 75-86
Johns Hopkins School of Public Health/Population
Information Project Managing Contraception
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Conclusions Immediate Post-abortion IUC Insertion

• IUD placement after abortion is safe
• PID rate not increased
• Expulsion rate after first-trimester abortion is
  less than or equal to interval insertion
• IUDs inserted after abortion provide effective
  contraception
• Pregnancy rate same as interval insertion
• Limited data about post-second-trimester
• No data about antibiotics or uterotonics

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How do LNG and Copper IUC compare?
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RCT of Mirena vs. NovaT after First-Trimester
Abortion

• 305 patients received Mirena
• 133 patients received NovaT (200 mm2 copper on
  same frame as Mirena)
• Multi-center in Denmark, Finland, Hungary,
  Norway, Sweden.
• Not blinded
• Inserted after abortion at less than 12 weeks
• Pakarinen, 2003, Contraception
  

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Results of Mirena vs. NovaTExpulsion after Post
abortion Insertion
plt0.01
Pakarinen, 2003.
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Cumulative Termination Rates Per 100 women LNG
vs. Cu T
Hormonal
Bleeding Problems
Expulsion
LNG IUS N1821
Nova T N937
Andersson et al. Contraception 19944956
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Post-Abortion Mirena Compared with Norplant and
Traditional Methods

• 2 expulsions at 12 months (4)
• No pregnancies in Mirena or Norplant groups
• 4 pregnancies in group using traditional methods

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Ortayli, Contraception, 2001
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How do you do post-abortion IUC insertion?
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SFGH IUC Placement Protocol Operative Technique

• All DE procedures done under ultrasound guidance
• Methergine for bleeding/atony
• Methergine is not routinely given
• IUC placement under ultrasound guidance after DE
  (second trimester)
• Ring forceps used for T380a if gt14 weeks
• Ring forceps used to guide Mirena inserter if
  difficult to place

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When not to insert IUC immediately post-abortion

• If the patients bleeding post-procedure is not
  well controlled
• If the patient appears to be infected
• If you are concerned about perforation

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The Womens Option Centerat San Francisco
General Hospital

• Abortions up to 23 weeks
• gt2000 terminations per year
• Contraceptive failure common
• Diverse patients

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WOC Post-Abortion IUC InsertionPatient
Satisfaction

• 90 of patients are very or somewhat satisfied
  (65 very)
• Patient quotes
• I am not going to forget to take a pill, and Im
  not going to get poked every 3 months.
• Im thrilled. Its so easy. I dont have to
  think about it.
• My husband is a sex maniac, so I am more
  comfortable knowing its there

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What are the benefits to immediate post-abortion
insertion?

• Patients leave with long-term, highly efficacious
  contraception
• Dont have to depend on patient follow-up
• More comfortable insertion

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Thanks to

• Gillian Dean, MD, Assistant Professor, Einstein
  Univ.
• Philip Darney, MD, MSc, Professor, UCSF/SFGH
• Mathew Reeves, MD, Assistant Professor, Pittsburgh