UW MEDICINE │ POSTPARTUM IUD INSERTION

SARAH PRAGER, MD, MAS

ASSOCIATE PROFESSOR, UNIVERSITY OF WASHINGTON

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

Everything You'd Ever Want to

Know about Immediate Postpartum

LARC Insertion

I am a Nexplanon insertion trainer

I participate in PPIUD trainings

for Population Services International (PSI)

DISCLOSURES

OBJECTIVES

• Impact of immediate postpartum LARC

insertion on Washington State population

health outcomes

• How to promote LARC use among your

patients and set up the infrastructure to

provide it in the immediate postpartum period

• How to receive appropriate reimbursement

IUD and Implant Epidemiology

Attitude Regarding IUDs

Favorable

Satisfaction at One Year

Satisfied

Forrest JD. Obstet Gynecol Surv. 1996; 51(12)

US Public Opinions - IUDs

• Perfect use

• Typical use

• Efficacy

• Effectiveness

Efficacy x compliance x continuation

Fecundability x coital frequency

Contraceptive Effectiveness

2 0.3 0.2 0.6 0.2 0.05

18

9

6

0.8 0.2 0.05

Condoms Pill/ Patch/ Ring

DMPA Copper IUD LNG-IUS Implanon

Percent of women with unintended pregnancy in the first year of use

Perfect Typical

Adapted from Trussell J. Contracept. 2011; 83(5)

Comparative Effectiveness

Contraceptive Failure Rates

Winner et al. NEJM 2012, prospective cohort

12%

10%

8%

6%

4%

2%

0%

Co

ntr

acep

tive

Failu

re

LARC DMPA PPR

Year 1 Year 2 Year 3

pill, patch, ring injectable

0 1 2 3 4 5

LNG-IUS

Copper IUD

Injection

Pill

Sterilization

Diaphragm

Spermicide

Cervical cap

Thousands in dollars

Cost of female contraceptive methods at 5 years

Chiou CF, et al. Contracept. 2003; 68(1)

Cost Effectiveness

Epidemiology of Postpartum LARC

Significant clinical

differences

between interval and

immediate

postpartum insertion

for IUDs

Technical aspects of

insertion and clinical

indications remain

the same for

implants regardless

of the time of

insertion

IUD Implant

Immediate Postpartum LARC Insertion:

IUD v. Implant

Provider and patient both present without anyone making a special trip

Negligible time investment for insertion

Cervix is open

Fewer “Accessories” than for interval insertion

Many side effects in the early post-insertion period masked by postpartum status

Public health value of provision far outweighs cost of expulsion

ADVANTAGES OF PPIUD

Washington. Postpartum IUD cost-effectiveness. Fertil Steril 2015.

COST BENEFIT ANALYSIS IN THE U.S.

Decision Tree

COST BENEFIT ANALYSIS IN THE US: RESULTS

Immediate PP Insertion

DEFINITIONS

Immediate Postplacental

Insertion

Transcesarean Insertion

Delayed PP Insertion

Interval Placement

Within 48 hours of delivery

Within 10 minutes of placental extraction

Through uterine incision at time of cesarean delivery

Typically placed 4–6 weeks postpartum

Placement not related to timing of childbirth

• Immediate post placental (within 10 minutes of placental extraction)

– No Chorioamnionitis (during labor)

– No more than 18 (24) hours from rupture of membranes to

delivery of baby

– No unresolved postpartum hemorrhage

Candidates for PPIUD

• Immediate postpartum (10 minutes after placental extraction to 48 hours after

delivery)

– No puerperal sepsis

– No postpartum endometritis/myometritis

– No continued excessive postpartum bleeding

– No extensive genital trauma where the repair would be disrupted

by immediate postpartum placement of an IUD

Candidates for PPIUD

Chi Contraception 1985

9.5%

31.5% 28.8%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Ad

juste

d C

um

ula

tive

Exp

uls

ion

Ra

tes

*p<0.001 (≤10 minutes compared to all other groups)

PPIUD Insertion: WHY 10 MINUTES?

37.3%

Chi et al. Contraception 1985

6.9%

12.0%

p<0.001

POSTPLACENTAL IUD & PROVIDER EXPERIENCE

Objectives (CASE): Continuation Rate

Acceptability

Safety

Expulsion Rate

~1600 PPIUDs inserted

305 women interviewed/examined at 6–12 months after PPIUD insertion

PPIUD ZAMBIA

Jan 2009 – Jul 2010:

October 2010:

PPIUD ZAMBIA

Counseling How did you hear about it?

Timing When was it inserted?

Postplacental 24.3%

Postpartum (or “MADIUD”— Morning After Delivery) 71.1%

Couldn’t remember timing 4.6%

During antenatal care 65.9%

During early labor 17%

Post-delivery 8.9% (before discharge)

Blumenthal, European Journal of Contraception & Reproductive Health Care, 2016

PPIUD ZAMBIA

Expulsion & Continuation

Acceptability/Satisfaction

5.6% expulsion!

10.8% postplacental

4.1% MADIUD

3% requested removal (~ interval client removal rate)

90% IUDs in situ

94.1 VERY SATISFIED (57.7%) or SATISFIED (36.4%)

Safety NO Adverse Events

Blumenthal, European Journal of Contraception & Reproductive Health Care, 2016

Prospective cohort of 235 women

who received postplacental IUD

74% had vaginal deliveries

26% had cesarean sections

Follow-up at 6 weeks, 6 months, 12 months

Celen et al. Contraception, 2004.

DOES IT STAY IN?

Celen et al. Contraception, 2004.

Did not separate out c/s vs. vaginal delivery

DOES IT STAY IN?

Review of 5 clinics over 17 years

3,172 cesarean deliveries

5.5% expulsion at one year

84.5% continuation

No perforations

“No benefit to addition of suture”

Matched with 905 cesareans with no IUD

No difference in vaginal bleeding, infection,

duration of lochia

Xu Adv Contracep 1992.

CESAREAN DELIVERY

Women enrolled to have LNG-IUS placed immediately after vaginal delivery vs. at the 6-8 week postpartum visit

50/51 women received immediate PPIUD

46/51 women received delayed IUD

Expulsion occurred within 6 months:

12/50 (immediate)

2/46 (delayed)

IUDs replaced as desired

Continuation at 6 months:

43/51 (immediate)

39/51 (delayed)

Chen B. Postplacental or Delayed Insertion of the Levonorgestrel

Intrauterine Device After Vaginal Delivery. Obstet Gynecol, Nov 2010

PPIUD WITH LNG-IUS

AK Whitaker et al. Contraception 89 (2014);534–539

PPIUD WITH LNG-IUS AFTER CESAREAN

AK Whitaker et al. Contraception 89 (2014);534–539

PPIUD WITH LNG-IUS AFTER CESAREAN

1 No restriction for the use of the contraceptive method

for a woman with that medical condition

2 Advantages of using the method generally outweigh

the theoretical or proven risks

3

Theoretical or proven risks of the method usually

outweigh the advantages – or that there are no other

methods that are available or acceptable to the

women with that medical condition

4 Unacceptable health risk if the contraceptive method

is used by a woman with that medical condition

CDC. Morb Mortal Wkly Rep. 2010; 59(RR-4)

US Medical Eligibility Criteria: Categories

Condition Sub-

condition

Implant LNG-IUD Copper IUD

Postpartum

(BF or not BF,

including post

C/S)

< 10 minutes

after delivery

of the placenta

1 1/2 1

10 minutes

after delivery

of the placenta

to 4 weeks

1 2 2

After 4 weeks

postpartum

1 1 1

Puerperal

Sepsis

1 4 4

CDC. Morb Mortal Wkly Rep. 2010; 59(RR-4)

CDC Medical Eligibility Criteria for

Contraception Use: Postpartum Timing

CLINICAL GUIDANCE AND HELPFUL HINTS

2

1

HOW DO YOU DO IT?

Postplacental IUD Insertion

Drawing by Tracy Angulo

FORCEPS PPIUD INSERTION

Hand on fundus

High fundal placement

Reduced/eliminated chance of perforation

Know where to aim

Direct forceps straight up toward abdomen

NOT toward the head

DROP YOUR WRIST!!!

Cut strings at external os

Different depths of postpartum uterus

Different length strings

KEY POINTS WITH PPIUD INSERTION

COMMON IUDS

Mirena

Copper T

Know where sterile insertion packs and gloves are kept

Know where devices are kept

Forceps: Ring/Vulsellum or Kelly

KNOW THE ORIENTATION OF THE TIP

OF THE FORCEPS WITH RESPECT TO

THE ORIENTATION OF THE HANDLES!!!!!

EQUIPMENT FOR PPIUD

Complication

• Expulsion

Management

• Verify expulsion (ultrasound and/or x-ray)

• Replace if patient desires

Complications and Management

Complication

• “Missing” strings

Management

• Verify IUD in uterus (ultrasound and/or x-ray)

• Reassure patient

Complications and Management

Complication

• Elongating strings

Management

• Trim strings

Complications and Management

Complication

• Infection (rare)

Management

• Treat with antibiotics

• Removed IUD if no improvement

Complications and Management

Complication

• Perforation (no reported cases)

Management

• Remove IUD immediately

• Laparoscopy may be required for removal if

perforation not immediately recognized

Complications and Management

Easy to do

Take an on-line training module and practice with a low-

cost pelvic module

Use resources from ACOG for billing/coding assistance

Ask for help from someone who already has implemented

this practice

How Can I Implement This in MY Hospital?

Inserting Long Acting

Reversible Contraception (LARC)

Immediately After Childbirth Expiration Date: This activity was originally released on September 30, 2014 and is available for continuing

education credit until September 30, 2016.

CNE

Upon successful completion of this educational activity 1.6 contact hours (including 1.5 hours of

pharmacology) will be awarded.

Cardea Services is an approved provider of continuing nursing education by the Washington State Nurses Association

Continuing Education Approval & Recognition Program (CEARP), an accredited approver by the American Nurses

Credentialing Center’s Commission on Accreditation.

CME

Cardea designates this enduring material for a maximum of 1.6 AMA PRA Category 1 Credit(s)™.

Physicians should claim credit commensurate with the extent of their participation in the activity.

This credit may also be applied to the CMA Certification in Continuing Medical Education.

Cardea is accredited by the Institute for Medical Quality/California Medical Association for issuing AMA PRA Category 1

Credit(s)™ for physicians.

Activity

Description

Target

Audience

Learning

Objectives Faculty Fees

Please turn on your computer

speakers to hear audio on this

and subsequent pages.

http://www.cardeaservices.org/resourcecenter/inserting-long-acting-reversible-contraception-larc-immediately-after-childbirth

Medicaid Reimbursement for Postpartum LARC By State Medicaid Reimbursement for Postpartum (In-Hospital) LARC

Alabama: Click here for more information

California: Click here for more information

Colorado: Click here for more information *See page 9

Connecticut: Click here for more information

District of Columbia: Click here for more information

Georgia: Click here for more information

Illinois: Click here for more information

Indiana: Click here for more information

Iowa: Click here for more information

Louisiana: Click here for the Health Plan Advisory and see page 18 here for the Hospital Services Provider Manual

Maryland: Click here for more information

Missouri: Click here for more information

Montana: Click here for more information

New Mexico: Click here for more information

New York: Physicians, Inpatient, Midwives, Nurse Practitioners

Ohio: Click here for more information *See page 34

Oklahoma: Click here for more information

South Carolina: January 2012 Bulletin, August 2013 Update

Texas: Click here for more information.

Washington: Click here for more information *See page 74

Please forward any corrections, updates, or newly published guidance to Mica Bumpus at MBumpus@acog.org

Last Updated: June 2, 2016

Medicaid Reimbursement for Postpartum LARC By State Medicaid Reimbursement for Postpartum (In-Hospital) LARC

PPIUD is safe

PPIUD results in reasonable continuation rates

at 6 and 12 months

Especially for patients unlikely to return for postpartum care

Expulsion rate may be lower after cesarean

vs. vaginal delivery

LNG-IUS may have a higher expulsion rate

than copper IUDs

We have no data on expulsion rates for Skyla or Liletta

LNG-IUDs

CONCLUSIONS

pragers@uw.edu

THANK YOU! QUESTIONS?