Lara C. Pullen, PhD

April 30, 2014

CHICAGO — The placement of the levonorgestrel IUD within 72 hours of vaginal delivery was associated with a high expulsion rate and should be reserved for women who are unlikely to return for a postpartum clinic visit, according to a new study.

"If you are taking care of women who are unlikely to ever come back for their standard postpartum visit, then the benefits of this method may be more meaningful," explained Gretchen Stuart, MD, MPHTM, from the University of North Carolina School of Medicine in Chapel Hill.

Dr. Stuart presented her poster here at the American Congress of Obstetricians and Gynecologists 2014 Annual Clinical Meeting.

The parallel randomized trial, conducted at the Women's Hospital of North Carolina, compared insertion of the IUD before hospital discharge with insertion 4 to 6 weeks later.

The benefits of providing intrauterine conception immediately after childbirth — either in the delivery room or on the floor prior to hospital discharge — include the prevention of unplanned pregnancy, increased interpregnancy intervals, and decreased rates of unintended pregnancy.

Although IUDs can be placed immediately after placental delivery, there are advantages to delaying placement until the morning after delivery. Delayed placement allows the mother to stabilize after birth, have time to receive counseling, and initiate breast-feeding.

Progesterone withdrawal is believed to be the trigger for lactogenesis. Consequently, some physicians are reluctant to insert the levonorgestrel IUD immediately after childbirth because progestin-containing contraceptives might decrease breastfeeding success.

Dr. Stuart and her colleagues originally designed the study to examine the effect on breast-feeding of the timing of levonorgestrel IUD insertion. The investigators terminated the study, however, because of a high expulsion rate. The rate they found was consistent with the more than 30% expulsion rate documented in a handful of published studies.

"We were not able to achieve our final outcome because of the expulsion rate," explained Dr. Stuart. She did note, however, that they did not have any major adverse events. The early group included 1 bleeding event, 1 infection, and 1 primary lactation failure, all of which may or may not have been related to the levonorgestrel IUD.

In their poster, the researchers caution that the reported expulsion rates should not be extrapolated to all IUDs placed immediately after childbirth.

"I am very interested in this. I do want this study to happen," said Noah Nattell, MD, a resident from Department of Obstetrics and Gynecology at Mount Sinai Beth Israel in New York City after reviewing the poster.

"We need more robust trials to see if women are able to breast-feed," he told to Medscape Medical News. He also noted that in this study, the levonorgestrel IUD was inserted the day after delivery, and thus the expulsion rate was quite high.

Dr. Stuart and Dr. Nattell have disclosed no relevant financial relationships.

American Congress of Obstetricians and Gynecologists (ACOG) 2014 Annual Clinical Meeting: Abstract 15S. Presented April 28, 2014.


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