Intrauterine device malposition and partial expulsion were more common following early insertion than after insertion at six to eight weeks postpartum.

After pregnancy, almost 50% of women have resumed intercourse prior to their six-week postpartum visit, but we know little about the safety of placing IUDs during this period. In this study, researchers randomised 294 postpartum women who desired IUDs for contraception; participants were randomised to early IUD placement (two to four weeks postpartum) or interval IUD placement (six to eight weeks postpartum).

Six-month follow up visits included pelvic examinations and transvaginal ultrasonography to evaluate IUD position.

Key findings were as follows:

• three complete expulsions occurred in the early group versus none in the interval group; this small difference was statistically noninferior for early placement
• partial expulsion (i.e. IUD protruding from external cervical os or IUD below internal cervical os on imaging) occurred slightly more often in the early group (9.4% vs 7.6%)
• IUD malposition (i.e. low-lying IUD, rotated IUD or IUD embedded in the myometrium) occurred more often in the early group (5.5% vs 0%)
• the findings for partial expulsion and IUD malposition did not meet criteria for noninferiority of early placement
• rates of IUD removal for any indication were higher in the early group (16.9% vs 11.7%)
• no uterine perforations occurred. 

Comment: Short interpregnancy intervals, particularly intervals shorter than six months, are associated with excess maternal and infant morbidity and mortality. Early postpartum IUD insertion might mitigate this risk and be a convenient choice for many women, provided that the about 17% risk for IUD removal within six months is acceptable. In my practice, I prefer immediate postpartum IUD insertion (prior to hospital discharge) for women who are worried about risk for short interpregnancy intervals.

Marie Claire O’Dwyer, MB BCh BAO, MPH, Clinical Assistant Professor in Family Medicine, University of Michigan Medical School, Ann Arbor, USA.

Averbach S, et al. Early vs interval post- partum intrauterine device placement: a randomized clinical trial. JAMA 2023; 329: 910-917.

This summary is taken from the following Journal Watch title: Women’s Health.