Background
Immediate placement of an intrauterine device after vaginal delivery is safe and convenient,
but longitudinal data describing clinical outcomes have been limited.
Objective
We sought to determine the proportion of TCu380A (copper) intrauterine devices expelled,
partially expelled, malpositioned, and retained, as well as contraceptive use by 6
months postpartum, and determine risk factors for expulsion and partial expulsion.
Study Design
In this prospective, observational study, women who received a postplacental TCu380A
intrauterine device at vaginal delivery were enrolled postpartum. Participants returned
for clinical follow-up at 6 weeks, and for a research visit with a pelvic exam and
ultrasound at 6 months. We recorded intrauterine device outcomes and 6-month contraceptive
use. Partial expulsion was defined as an intrauterine device protruding from the external
cervical os, or a transvaginal ultrasound showing the distal end of the intrauterine
device below the internal os of the cervix. Multinomial logistic regression models
identified risk factors associated with expulsion and partial expulsion by 6 months.
The area under the receiver operating characteristics curve was used to assess the
ability of a string check to predict the correct placement of a postplacental intrauterine
device. The primary outcome was the proportion of intrauterine devices expelled at
6 months.
Results
We enrolled 200 women. Of 162 participants with follow-up data at 6 months, 13 (8.0%;
95% confidence interval, 4.7–13.4%) experienced complete expulsion and 26 (16.0%;
95% confidence interval, 11.1–22.6%) partial expulsion. Of 25 malpositioned intrauterine
devices (15.4%; 95% confidence interval, 10.2–21.9%), 14 were not at the fundus (8.6%;
95% confidence interval, 5.2–14.1%) and 11 were rotated within the uterus (6.8%; 95%
confidence interval, 3.8–11.9%). Multinomial logistic regression modeling indicated
that higher parity (odds ratio, 2.05; 95% confidence interval, 1.21–3.50; P = .008) was associated with expulsion. Provider specialty (obstetrics vs family medicine;
odds ratio, 5.31; 95% confidence interval, 1.20–23.59; P = .03) and gestational weight gain (normal vs excess; odds ratio, 9.12; 95% confidence
interval, 1.90–43.82; P = .004) were associated with partial expulsion. Long-acting reversible contraceptive
method use at 6 months was 80.9% (95% confidence interval, 74.0–86.6%). At 6 weeks
postpartum, 35 of 149 (23.5%; 95% confidence interval, 16.9–31.1%) participants had
no intrauterine device strings visible. Sensitivity of a string check to detect an
incorrectly positioned intrauterine device was 36.2%, and specificity of the string
check to predict a correctly positioned intrauterine device was 84.5%. This corresponds
to an area under the receiver operating characteristics curve of 0.5.
Conclusion
This prospective assessment of postplacental TCu380A intrauterine device placement,
with ultrasound to confirm device position, finds a complete intrauterine device expulsion
proportion of 8.0% at 6 months. The association of increasing parity with expulsion
is consistent with prior research. The clinical significance of covariates associated
with partial expulsion (provider specialty and gestational weight gain) is unclear.
Due to the observational study design, any associations cannot imply causality. The
proportion of partially expelled and malpositioned intrauterine devices was high,
and the area under the receiver operating characteristics curve of 0.5 indicates that
a string check is a poor test for assessing device position. Women considering a postplacental
intrauterine device should be counseled about the risk of position abnormalities,
as well as the possibility of nonvisible strings, which may complicate clinical follow-up.
The clinical significance of intrauterine device position abnormalities is unknown;
future research should evaluate the influence of malposition and partial expulsion
on contraceptive effectiveness and side effects.
Key words
- copper intrauterine device
- intrauterine device
- intrauterine device complication
- intrauterine device expulsion
- intrauterine device retention
- long-acting reversible contraception
- postpartum contraception
- postpartum intrauterine device
- postplacental intrauterine device
- TCu380A intrauterine device
- vaginal delivery
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Article Info
Publication History
Published online: June 02, 2018
Accepted:
May 24,
2018
Received in revised form:
May 18,
2018
Received:
January 22,
2018
Footnotes
This research was sponsored by a grant from the Society of Family Planning Research Fund (SFPRF15-15). This study was funded in part by Women’s Reproductive Health Research award (Dr Sonalkar): K12-HD001265-18, and a Society of Family Planning Research Fund Midcareer Mentor Award (Dr Schreiber). Intrauterine devices were donated, in part, by Teva Pharmaceuticals, the Ryan LARC Grant, and the philanthropic efforts of Dr Ann Steiner’s LARC Project. The funding sources had no role in study design; data collection, analysis, or interpretation; manuscript writing, or the decision to submit for publication.
Disclosure: Dr Gurney is a Nexplanon trainer for Merck. Dr Schreiber is a consultant for Bayer Pharmaceuticals and receives research funding from Bayer Pharmaceuticals, ContraMed, Medicines360, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Drs Sonalkar and Sammel, and Ms McAllister report no conflict of interest.
Cite this article as: Gurney EP, Sonalkar S, McAllister A, et al. Six-month expulsion of postplacental copper intrauterine devices placed after vaginal delivery. Am J Obstet Gynecol 2018;219:183.e1-9.
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