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Dilemmas in family planning - IUDs

In this occasional series, the Faculty of Family Planning and Reproductive Health shares answers it has given to questions posed by family planning clinicians

In this occasional series, the Faculty of Family Planning and Reproductive Health shares answers it has given to questions posed by family planning clinicians

For women who have undergone a termination of pregnancy, when should an IUD be inserted?

The Clinical Effectiveness Unit (CEU) guidance provides recommendations on IUD insertion following termination of pregnancy1. These recommendations are based on the WHO Medical Eligibility Criteria for Contraceptive Use. WHO advises that, for women who are postpartum, the risks of inserting an IUD between 48 hours and four weeks postpartum generally outweigh the benefits (WHO category 3). WHO adds that there is an increased risk of perforation for IUD insertions performed during this period but does not cite any references to support this statement.

CEU guidance recommends that an IUD can be inserted safely immediately after a first- or second-trimester termination of pregnancy. Evidence supports the view that this is safe and practical and the risk of perforation if insertion is within 30 days of the procedure is low2,3.

Readmission rates for pelvic infection are not increased by IUD insertion immediately following a first-trimester termination4.

As data is lacking on IUD insertion following medical abortion, the CEU suggests that an IUD is inserted immediately (within 48 hours) following first- or second-trimester medical termination or delayed until four weeks after termination (as WHO advises for postpartum women).

What infections detected by pre-insertion swabs should be treated?

Clinicians must establish if women have abnormal discharge or clinical signs such as uterine, adnexal or cervical motion tenderness, which might indicate that treatment for pelvic inflammatory disease (PID) is required. Alternatively, women may be asymptomatic carriers who present with normal vaginal secretions, which upon testing are positive for an organism.

Asymptomatic carriers of group B streptococcus do not require treatment, even prior to IUD insertion. Symptomatic women with group B streptococcus should be treated5. Symptomatic women with additional organisms should be treated as for PID.

Asymptomatic genital carriage of group A streptococcus is rare. Genital infection with group A streptococcus has been reported in women using an IUD. However, serious infections rarely originate in the genitourinary tract6. The CEU considers that group A streptococcus should be treated, especially prior to IUD insertion, because of its rarity and uncertain significance.

WHO recommends that the benefits of inserting an IUD in women with bacterial vaginosis generally outweigh the risks (WHO category 2). No evidence was identified that investigated treating bacterial vaginosis before IUD insertion. Treatment is indicated in symptomatic women, women undergoing some surgical procedures and pregnant women.

The British Association for Sexual Health and HIV states that between 10% and 20% of women of reproductive age may harbour candida species in the absence of symptoms. The association suggests that these women do not require treatment.

The CEU recommends that women and their partner(s) should be treated for Trichomonas vaginalis1. WHO recommends that the benefits of inserting an IUD in women with T. vaginalis generally outweigh the risks (WHO category 2).

No information could be found on the detection of actinomyces-like organisms pre-IUD insertion. Asymptomatic women with actinomyces-like organisms can continue to use an IUD if they wish. Antibiotic treatment is not indicated.

For symptomatic women (that is, women who complain of abnormal discharge or have tenderness), clinicians should test for organisms implicated in PID so that treatment can be initiated. The WHO Medical Eligibility Criteria for Contraceptive Use recommends that an

IUD should not be inserted in a woman with current PID, or who has had it within the past three months (WHO category 4)7.

However, FFPRHC guidance advises that, after considering other contraceptive methods, a woman may use an IUD within three months of treated pelvic infection, provided she has no signs or symptoms1. Treatment of PID should provide broad-spectrum coverage and should cover N. gonorrhoea, C. trachomatis and anaerobic infection.

These questions and answers are from Family Planning Masterclass: Evidence-based answers to 1000 questions, edited by Gillian Penney, Susan Brechin and Anna Glasier, published by RCOG Press, priced £48. ISBN 1-904752-33-0

To order a copy go to www.rcogbookshop.com

References

1 Faculty of Family Planning and Reproductive Health Care. The copper intrauterine device as long-term contraception. J Fam Planning Reprod Health Care 2004; 30:29-42

2 Tuveng JM et al. Postabortal insertion of IUD. Adv Contracept 1986;2:387-92

3 Heartwell S, Schlesselman S. Risk of uterine perforation among users of intrauterine devices. Obstet Gynecol 1993;61:31-5

4 World Health Organization Task Force on IUDs in Fertility Regulation. IUD insertion following termination of pregnancy: a clinical trial of Cu22)C, Lippes Loop D and Copper 7. Stud Fam Plann 1983;14:99-108.

5 Bernaldo et al. Group A streptococcal bacteremia: a 10-year prospective study. Medicine 1997;76:238-48

6 Centers for Disease Control and Prevention Division of Bacterial and Mycotic Diseases. Prevention of perinatal group B streptococcal disease. MMWR Morbid Mortal Wkly Rep 2002;51:1-28

7 Association for Genitourinary Medicine, Medical Society for the Study of Veneral Diseases. National Guideline on the Management of Vulvovaginal Candidiasis. AGUM & MSSVD; 2002.

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