Post-Abortion IUC InsertionEleanor Drey, MD, EdM

Assistant Clinical ProfessorObstetrics, Gynecology and Reproductive Sciences

University of California, San Francisco

Sarah Prager, MD, MAS

Assistant Clinical ProfessorObstetrics and GynecologyUniversity of Washington

Disclosures

Eleanor Drey, MD, EdM

Consultant and Speaker, Organon

Research Grant, Ortho

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

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

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?

“Immediate Postabortion Intrauterine Contraception in Nulliparous Adolescents.”

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Expulsion Bleeding

Pain

InflammationPregnancy

Cumulative Events at 12 months (%)

Lippes A

Cu7

CuT

Goldman, Israel J Med Sci, 1979

1983 WHO Study: PIDpost abortion insertion

0

0.2

0.4

0.6

0.8

1

1.2

1.4

TCu220c Lippes Copper7

Discontinuation for PID (%)

390 days

750 days

1983 WHO Study: Expulsion of TCu220c post abortion

0

5

10

15

20

25

30

390 750

Days after insertion

Expulsion of TCu220c(%)

<9 weeks

9-12 weeks

13-20 weeks

*p<0.01 *p<0.01

*p<0.05*p<0.05

Immediate Post abortion IUC Insertion versus 2-week Delay of Insertion

0

2

4

6

8

10

12

2 weeks 6 weeks 10 weeks

Weeks after insertion

Cumulative Expulsion Rate (%)

Immediate

2-weekDelay

Moussa, Contraception, 2001

*all p=NS

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

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

How do LNG and Copper IUC compare?

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

Results of Mirena vs. NovaT:Expulsion after Post abortion Insertion

Cumulative Expulsion Rates (%)

02468

1012141618

1 yr 3 yrs 5yrs

Nova T

Mirena

Pakarinen, 2003.

*p<0.01

Cumulative Termination Rates Per 100 women: LNG vs. Cu T

0

5

10

15

20

1 3 5

Andersson et al. Contraception 1994;49:56

0

5

10

15

20

1 3 5

LNG IUS N=1821

HormonalBleeding ProblemsExpulsion

Nova T N=937

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 0

20

40

60

80

100

12 months

Continuation Rate (%)

Norplant

Mirena

Traditional

Ortayli, Contraception, 2001

*p<0.01

How do you do post-abortion IUC insertion?

SFGH IUC Placement Protocol: Operative Technique

• All D&E procedures done under ultrasound guidance• Methergine for bleeding/atony

– Methergine is not routinely given

• IUC placement under ultrasound guidance after D&E (second trimester)

• Ring forceps used for T380a if >14 weeks• Ring forceps used to guide Mirena inserter if difficult

to place

When not to insert IUC immediately post-abortion:

• If the patient’s bleeding post-procedure is not well controlled

• If the patient appears to be infected

• If you are concerned about perforation

54%

13%

33%

1st Trimester13-19 Weeks20-23 Weeks

The Women’s Option Centerat San Francisco General Hospital

• Abortions up to 23 weeks

• >2000 terminations per year

• Contraceptive failure common

• Diverse patients

WOC Post-Abortion IUC Insertion:Patient Satisfaction• 90% of patients are very or

somewhat satisfied (65% “very”)

• Patient quotes:– “I am not going to forget to

take a pill, and I’m not going to get poked every 3 months.”

– “I’m thrilled. It’s so easy. I don’t have to think about it.”

– “My husband is a sex maniac, so I am more comfortable knowing it’s there”

0

1020

30

40

50

60

70

Very Satisfied

Somewhat SatisfiedSomewhat Unsatisfied

Very Unsatisfied

Patient Satisfaction

What are the benefits to immediate post-abortion insertion?

• Patients leave with long-term, highly efficacious contraception

• Don’t have to depend on patient follow-up

• More comfortable insertion

Thanks to :

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