ACOG & SMFM Guidance on the Use of IUDs and Contraceptive Implants
SUMMARY:
IUDs and etonogestrel single-rod contraceptive implants are categorized as Long-Acting Reversible Contraception (LARC). ACOG and other professional and public health entities are calling for reduced barriers and improved access to LARC. The latest ACOG practice bulletin reviews various LARC options, including clinical considerations such as use in the postpartum period and management in the setting of pelvic infections. ACOG has also released an updated ‘Quick Coding Guide’ for LARC that can be found in ‘Learn More – Primary Sources’ section.
Subdermal implant with a core containing 68 mg of etonogestrel
FDA approved for 3 years
Clinical Considerations
Nulliparous and Adolescents
LARCs should be offered routinely as safe and effective contraceptive options for nulliparous women and adolescents
Use of LARCs in adolescents supported by the AAP
IUD
MEC category 2 (advantages outweigh risks)
Risk of infection is low
No evidence of association with infertility or tubal occlusion
High satisfaction rate based on continuation rates
Expulsion rates may be higher in adolescents vs older women and multiparous vs nulliparous
Like the general population, nulliparous women and adolescents prefer LNG-IUD
Implant
MEC category 1 (no restrictions)
Continuation rates higher in adolescents compared to OCPs
SMFM Guidance on Women at High Risk for Medical Complications (2019)
Use of LARC is encouraged for women at highest risk for adverse health events as a result of a future pregnancy (GRADE 1B)
SMFM recommends discussion take place in the prenatal period regarding availability of immediate postpartum LARC and MEC guidelines should be used to determine best method for particular medical conditions (GRADE 1C)
Counseling should include discussion around expulsion rates but appear to be outweighed by benefit of higher continuation rates (GRADE 1C)
Providers who intend to utilize immediate postpartum LARC should obtain appropriate training (Best Practice)
SMFM recommends that for women who are eligible and desire LARC, following a high-risk pregnancy, immediate postpartum LARC should be used vs delayed placement due to overall superior efficacy and cost-effectiveness (GRADE 1B)
Encourage breastfeeding following immediate postpartum LARC based on current evidence (GRADE 1B)
SMFM suggests that if a women wishes and is eligible for LARC, but immediate postpartum is not feasible, consider early postpartum placement (GRADE 2C)
Contraceptive counseling should be (Best Practice)
Patient-centered
Within a shared decision-making framework
Timing of Insertion
Interval insertion
Insertion may be performed at any time during menstrual cycle if patient is not pregnant
No benefit to inserting during menses
Postabortion LARC Insertion
Routinely offer immediate insertion following first trimester and second trimester abortion (induced or spontaneous)
Postpartum LARC Insertion
Offer immediate LARC insertion (IUD and implant) prior to hospital discharge
Higher IUD expulsion rates (10-27%), but cost-benefit supports immediate insertion
Considered ACOG ‘best practice’
Waiting 4-6 weeks may result in barrier to access
Contraindications to IUD placement include chorioamnionitis, endometritis, or puerperal sepsis or ongoing postpartum hemorrhage
Effect on Breastfeeding
Copper IUD: No hormonal concerns
LNG-IUD and implant: Studies do not demonstrate a deleterious effect on breast feeding including milk volume/composition, newborn weight or exclusive breastfeeding rates
ACOG recommends shared decision making regarding concerns
Patients should be counseled regarding
Theoretical risk of reduced duration of breastfeeding
Lack of data supporting a negative association
Infection Risk and IUD
Asymptomatic women who are at low risk of STDs and have undergone routine screening
No additional screening required at the time of IUD insertion
Women who have not been screened for STDs or at increased risk for STDs
Requires CDC-recommended STD screening at the time of a single visit for IUD insertion
Do not delay IUD placement while waiting on results
Treat a positive test without removing the IUD
Purulent cervicitis is a contraindication to IUD placement
If known chlamydia or gonorrhea infection, delay IUD insertion following infection treatment until
Antibiotic course is complete
Symptoms resolved
Pelvic/cervical exam normal
Repeat testing at 3 months for gonorrhea or chlamydia to rule out reinfection
Routine antibiotic prophylaxis is not recommended prior to IUD insertion
Actinomyces on cytology is an incidental finding
No treatment or IUD removal required if patient is asymptomatic
Pregnancy with IUD in situ
Determine location of pregnancy to rule out ectopic pregnancy
Remove IUD if strings visible as benefits outweigh risks
If patient opts to retain IUD, counsel regarding risks (which are not totally eliminated by IUD removal)
Emergency contraception interventions are intended to prevent an unplanned pregnancy after unprotected or inadequately protected intercourse. Contraceptive failure or failure to use contraception are common indications for use.
CLINICAL ACTIONS:
Offer emergency contraception (EC) to all women who have had unprotected or inadequately protected intercourse and who do not desire pregnancy
There are no exclusionary health conditions –women who have contraindications to oral contraceptives can be given EC
Offer EC to all reproductive-aged women who have sustained sexual assault
No clinical examination or pregnancy testing is necessary
Treatment should be initiated as soon as possible, and should be made available up to 5 days after unprotected or inadequately protected intercourse
If menses are delayed by a week or more, a woman who has received EC should have a pregnancy test and clinical evaluation
EC may be used more than once even in the same menstrual cycle
Regular contraception should be started immediately after EC and women should abstain or use barrier contraception for 14 days or until onset of next menses
Those receiving uripristal acetate should delay starting hormonal contraception until 5 days after use
SYNOPSIS:
All of the methods below are effective only before a pregnancy is established. Hormonal EC does not pose a risk to an established pregnancy and is not associated with embryonal developmental abnormalities. Adverse effects for all of the oral methods include nausea and headache as well as irregular bleeding. Adverse effects for the copper IUD include perforation, changes in menses or dysmenorrhea. Pregnancy rates after EC range from 0% to 2.2% and may be impacted by body weight.
KEY POINTS:
Uripristal acetate, a selective progesterone receptor modulator, is given as a single 30 mg dose
Requires a prescription
Efficacy may be reduced in women with BMI ≥30
Effective up to 5 days after unprotected intercourse
FDA approved for EC
Progestin only EC, either 1 tablet Levonorgestrel in a single dose (1.5 mg) or as a split dose (1 dose of 0.75 mg of levonorgestrel followed by a second dose of 0.75 mg of levonorgestrel 12 hours later)
May be less effective in women with BMI ≥25
1 tablet formulation available over the counter without age restriction
2 tablet formulation available over the counter to women ≥17 years with photo ID
Effective for up to 3 days after unprotected intercourse
FDA approved for EC
Copper IUD insertion
Requires office visit and insertion by a clinician
Efficacy not impacted by body weight
Effective up to 5 days after unprotected intercourse
Safe and effective but not FDA labeled for use as EC
LNG-IUDs “are currently being investigated” (ACOG PB) | Recent RCT suggests LNG-IUD is not inferior to copper IUD (see ‘Related ObG Topics’)
Combined progestin-estrogen pills
Can use a variety of formulations (see ‘Learn More – Primary Sources’ WHO entry below for a list of appropriate formulations)
Two doses every 12 hours
All aim for 100 to 120 micrograms of ethinyl estradiol and 0.5 to 0.6 milligrams of levonorgestrel per dose
Requires a prescription
Effective up to 5 days after unprotected intercourse
Safe and effective but not FDA labeled for use as EC
Teenagers and Medical Care – When Is Parental Consent Not Required?
Adolescents are concerned about confidentiality and sometimes do not seek health care for this reason. Myriad federal and state laws affect confidentiality of medical records in general. However, it is the state that determines the statutes on the rights of minors to consent to healthcare services. Parents must generally consent before medical care is provided to their minor children; however, many states make important exceptions when it comes to sensitive services for which a parental consent requirement might deter an adolescent from obtaining needed care in a timely way. For example, all 50 states and the District of Columbia allow minors age 12 and older to access health care without parental consent for the treatment of STIs. Likewise, certain states and the District of Columbia allow minors to receive contraceptive services without notifying parents. The access to these services helps reduce the transmission of STIs and prevent unplanned pregnancies. In most states, minors themselves may consent for substance abuse treatment, and in about half of the states, they are specifically authorized to consent to outpatient mental healthcare.
Furthermore, minors who may give consent can be divided into to two groups: mature minors and emancipated minors.
A mature minor is an adolescent younger than the age of majority. Such a minor can consent or refuse to consent to medical treatment if it is established that the minor is sufficiently mature to understand, discern and appreciate the benefits and risks of the proposed medical treatment. The age, ability, experience, education, training, and degree of maturity or judgment of the minor, as well as the conduct and demeanor of the minor at the time of the incident involved, all play a role.
To contrast, an emancipated minor is one who is legally free of parental control. A court ruling, marriage or enlistment in the U.S military for active duty are the most common scenarios. A minor who becomes a parent becomes the decision maker for the child.
Care of mature and emancipated minors is provided without parental consent or notification, although the physician will frequently work with the adolescent to involve parents in decision making, risk reduction, and ongoing health care. Of note, both mature and emancipated minors must still follow state laws on age-restricted activities such as voting and purchasing alcohol.
Health care providers should therefore be familiar with the regulations in their state of practice as minor consent laws vary between states. Institutions should be well-versed in state law to determine the degree of disclosure to parents/guardians that is permitted and/or required. If state law is not explicit, then institutions or individual providers should establish firm policies regarding the degree of confidentiality.
It is vital (and parents or guardians and adolescents should be informed, both separately and together) that the information each of them shares with the health care provider will be treated as confidential, and of any restrictions to the confidential nature of the relationship. Lastly, electronic health record systems need to be reviewed and possibly customized to accommodate the confidentiality needs related to minor adolescents and comply with the requirements of state and federal laws.
You can find a table with the state-by-state overview, broken down by contraceptive, STI, prenatal, adoption and abortion services at the Guttmacher Institute link below in ‘Learn More – Primary Sources’.
IUDs and Implants: How to Manage Potential LARC Complications
Use of long-acting reversible contraceptive (LARC) methods, both intrauterine devices and subdermal contraceptive implants, has increased dramatically in the past ten years. Although the risk of complications is low, as use increases the absolute number of complications will increase.
CLINICAL ACTIONS:
Intrauterine device:
Pain
Lidocaine paracervical block reduces pain scores on insertion
Misoprostol does not improve pain scores and may be associated with nausea and vomiting
Strings not visualized
Rule out pregnancy and expulsion
Recommend backup contraception until IUD position can be verified
Ultrasound and X-ray of abdomen and pelvis can be used for localization
Possible expulsion
IUDs seen in the cervix are partially expelled and should be removed
Replacement or use of another method are both acceptable options
Low-lying IUDs (lower uterine segment) can be expectantly managed
Risk factors for expulsion include
Young age
Heavy menstrual bleeding and dysmenorrhea
Placement postpartum or post second trimester abortion
Presence of anatomic distortion of the uterine cavity
Uterine perforation
Is rare and generally asymptomatic
Usually occurs at the time of insertion
Do not use misoprostol routinely prior to insertion in nulliparous women but may be considered with difficult insertions
Rule out pregnancy and remove surgically unless the surgical risks of removal outweigh the benefits
PID
Can be treated with the IUD left in situ
Consider removal if no clinical improvement after 48-72 hours of antibiotics
Pregnancy with an IUD in place
Remove the IUD if the strings are visible or IUD within the cervix
IUD can be removed at time of procedure if patient elects termination
Evaluate for ectopic pregnancy
Implant:
Infection prevention
Use antiseptic technique and cover the insertion/removal site
Skin flora are the most common cause of infection
Remove implant if infection does not resolve
Bruising
Is common
Ice and anti-inflammatory medication can help
Nonpalpable implant
Locate with high frequency (>/= 10 MHz) ultrasound probe, two dimensional X-ray, or CT scan/fluoroscopy
Obtain a serum etonogestrel level if all studies are negative/equivocal
Refer to a surgeon with knowledge of the anatomy of the arm if implant is within muscle or neurovascular bundle
Pregnancy
Is rare
Remove the implant if the pregnancy is to be continued
Rule out ectopic pregnancy
SYNOPSIS:
LARCs are highly effective contraceptives with a low risk of complications. Those mentioned above should be discussed with patients as part of informed consent.
KEY POINTS:
Recognition and prompt diagnosis/treatment of the untoward outcomes described above are important aspects of care
Overall, complication rates are low and LARCs remain a very effective mode of birth control
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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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