New Guidelines on LARC Released by ACOG

Troy Brown, RN

October 24, 2017

An updated practice bulletin from the American College of Obstetricians and Gynecologists (ACOG) expands on previous recommendations regarding long-acting reversible contraception (LARC), including intrauterine devices (IUDs) and contraceptive implants. The new recommendations explain that LARC is safe and effective in adolescents and nulliparous women, and for insertion immediately after childbirth or abortion.

ACOG's Committee on Practice Bulletins‒Gynecology and the Long-Acting Reversible Contraception Work Group, in collaboration with Eve Espey, MD, and Lisa Hofler, MD, published the practice bulletin online October 24 in Obstetrics & Gynecology. It replaces the practice bulletin published in July 2011.

"We have many more contraception options for women of all ages and life stages, especially in the realm of LARC," Dr Espey said in a news release. "Many women may not know they're a good fit for an [intrauterine device (IUD)] or implant, or that IUDs now come in varying sizes and hormone levels. Counseling will help women to align their contraceptive choice with other health care priorities, whether that's preventing pregnancy during adolescence or making a plan for contraceptive use following pregnancy."

Several studies have shown a significant reduction in unintended pregnancies and in abortion rates when women receive education about LARC and are provided with them free of charge. Such contraceptives are more costly than short-acting contraceptives such as oral contraceptives and diaphragms, and often require the patient to come to the provider for two visits. However, they are more effective, in part because they require little ongoing effort by the user and can remain in place for several years. Once removed, fertility returns rapidly. ACOG now recommends that LARC be placed immediately after childbirth or abortion whenever possible.

"[T]wo-visit IUD insertion protocols are a barrier to contraceptive access and do not appear to improve quality of care. A study of Medicaid-insured women who requested IUDs in an urban clinic that required two visits found that only 54.4% actually had an IUD inserted," the authors write.

Recommendations

Specific recommendations in the updated committee opinion include:

  • Offer insertion of an IUD immediately after first-trimester uterine aspiration or medication-induced abortion, and on the same day as first-trimester or second-trimester induced or spontaneous abortion. Routine antibiotic prophylaxis before IUD insertion is not recommended.

  • Offer IUDs and the contraceptive implant routinely for nulliparous women and adolescents, and at any time during the menstrual cycle provided reasonable exclusion of pregnancy.

  • Offer immediate postpartum IUD insertion (ie, within 10 minutes after placental delivery in vaginal and cesarean births). Offer immediate postpartum placement of the contraceptive implant (ie, before hospital discharge), regardless of whether or not the woman is breastfeeding.

  • Provide sexually transmitted infection (STI) screening recommended by the Centers for Disease Control and Prevention during a single visit for IUD insertion for women with a history suggesting increased risk for STIs. Do not delay IUD insertion pending test results. Treat for positive test results without removing the IUD.

  • Women with a history of ectopic pregnancies may be offered IUDs.

  • Offer LARC to most women, as they are safe and effective and have few contraindications. Offer the copper IUD to women who request emergency contraception and are appropriate for IUD placement. Counsel women regarding expected bleeding changes and reassure them that these changes are normal.

  • It is safe to perform endometrial biopsy, colposcopy, cervical ablation or excision, and endocervical sampling while an IUD is in place. A cytological finding of actinomyces is incidental and no antimicrobial treatment is necessary in asymptomatic women; the IUD can remain in place.

  • Remove the IUD in pregnant women provided the strings are visible or it can be removed safely from the cervical canal.

  • It is not necessary to remove an IUD or implant before its expiration date in women who are menopausal.

The authors have disclosed no relevant financial relationships.

Obstetrics & Gynecology. Published online October 24, 2017. Full text

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