Early vs Interval Postpartum Intrauterine Device Placement: A Randomized Clinical Trial.

Importance: The early postpartum period, 2 to 4 weeks after birth, may be a convenient time for intrauterine device (IUD) placement; the placement could then coincide with early postpartum or well-baby visits. Objective: To determine expulsion rates for IUDs placed early postpartum compared with those placed at the standard interval 6-week visit. Design, Setting, and Participants: In this randomized noninferiority trial, people who had a vaginal or cesarean birth were randomly assigned to undergo early (14-28 days) or interval (42-56 days) postpartum IUD placement. Clinicians blinded to participant study group used transvaginal ultrasonography to confirm IUD presence and position at the 6-month postpartum follow-up. The study assessed 642 postpartum people from 4 US medical centers, enrolled a consecutive sample of 404 participants from March 2018 to July 2021, and followed up each participant for 6 months postpartum. Interventions: Early postpartum IUD placement, at 2 to 4 weeks postpartum, vs standard interval placement 6 to 8 weeks postpartum. Main Outcomes and Measures: The primary outcome was complete IUD expulsion by 6 months postpartum; the prespecified noninferiority margin was 6%. Secondary outcomes were partial IUD expulsion, IUD removal, pelvic infection, patient satisfaction, uterine perforation, pregnancy, and IUD use at 6 months postpartum. IUD malposition was an exploratory outcome. Results: Among 404 enrolled participants, 203 participants were randomly assigned to undergo early IUD placement and 201 to undergo interval IUD placement (mean [SD] age, 29.9 [5.4] years; 46 [11.4%] were Black, 228 [56.4%] were White, and 175 [43.3%] were Hispanic). By 6 months postpartum, 53 participants (13%) never had an IUD placed and 57 (14%) were lost to follow-up. Among the 294 participants (73%) who received an IUD and completed 6-month follow-up, complete expulsion rates were 3 of 149 (2.0% [95% CI, 0.4%-5.8%]) in the early placement group and 0 of 145 (0% [95% CI, 0.0%-2.5%]) in the interval placement group (between-group difference, 2.0 [95% CI, -0.5 to 5.7] percentage points). Partial expulsion occurred in 14 (9.4% [95% CI, 5.2%-15.3%]) participants in the early placement group and 11 (7.6% [95% CI, 3.9%-13.2%]) participants in the interval placement group (between-group difference, 1.8 [95% CI, -4.8 to 8.6] percentage points). IUD use at 6 months was similar between the groups: 141 (69.5% [95% CI, 62.6%-75.7%]) participants in the early group vs 139 (67.2% [95% CI, 60.2%-73.6%]) in the interval group. Conclusions and Relevance: Early IUD placement at 2 to 4 weeks postpartum compared with 6 to 8 weeks postpartum was noninferior for complete expulsion, but not partial expulsion. Understanding the risk of expulsion at these time points may help patients and clinicians make informed choices about the timing of IUD placement. Trial Registration: ClinicalTrials.gov Identifier: NCT03462758.

The effect of Illinois Medicaid coverage of induced abortion on patient access at the University of Illinois in Chicago.

OBJECTIVES: Beginning January 1, 2018, Illinois House Bill 40 (HB40) requires Medicaid coverage of induced abortion. The objective of this study was to describe the impact of HB40 on gestational age at time of induced abortion at a single academic medical center in Chicago, IL. STUDY DESIGN: We used Current Procedural Terminology (CPT) codes to identify patients who induced abortion one year before (2016) and one year immediately after (2018) HB40 implementation. We collected demographic and clinical information from the electronic medical record. We used ANOVA and Chi-square tests to evaluate differences in gestational age and patient characteristics before and after the policy change. RESULTS: Patient characteristics and indication for induced abortion before (N = 274) and after (N= 249) HB40 were similar. The mean gestational age of induced abortion was higher after HB40 (83.3 days ± 38.9 days vs 91.6 days ± 38.0 days, p = 0.01). While not statistically significant, the proportion of second trimester (>14 weeks) induced abortions increased (32.8% vs 40.6%, p = 0.07). After HB40, a smaller proportion of patients paid out-of-pocket for abortion care (2.4% vs 40.5%, p < 0.001) and more patients had an abortion with sedation (37.3% vs 49.8%, p = 0.007). CONCLUSIONS: After passage of HB40, the gestational age at time of induced abortion increased by a median of eight days, access to abortion care was less costly to patients and more procedures were completed with sedation. To further the impact of HB40, increased awareness of expanded coverage continues to be essential. IMPLICATIONS: With Medicaid coverage of induced abortion in Illinois, out-of-pocket cost decreased and sedation use increased in our academic medical center. To further the impact of HB40, increased awareness of expanded coverage continues to be essential.

Parenting intentions in transgender and gender-nonconforming adults.

OBJECTIVE: To assess parenting intentions, knowledge and attitudes regarding fertility preservation, and barriers to achieving parenthood in an adult transgender population. METHODS: This was a multi-center online cross-sectional study conducted at three university-affiliated and 15 community-affiliated clinics within a major US city. Inclusion criteria included being aged 18 years and older and self-identification as transgender, gender non-conforming or non-binary. Eighty respondents completed a 36-question survey regarding their transition and plans to achieve parenthood. We compared demographic characteristics to plan for transition using Chi-Square analysis. We compared options to achieve parenthood to plans for transition using ANOVA, Spearman's rho correlation coefficient, and a Kruskal Wallis H test. RESULTS: The mean desire to become a parent was 59.9 on a scale of 1-100. There was no significant association between plan for gonadectomy and reduced preference for the use of autologous gametes for parenting [H(2) = 1.309, P = 0.520]. The desire to have children was correlated with an increasing willingness to pause cross-sex hormones (rs  = 0.40, P < 0.01). Cost was identified as the largest barrier to fertility preservation (54.1%). CONCLUSION: The majority of transgender adults surveyed desire parenthood and this could be correlated with plan for transition including willingness to suspend cross-sex hormones.

Conservative management of endometrial intraepithelial neoplasia in a patient with cirrhosis undergoing orthotopic liver transplant.

OBJECTIVE: The aim of the study was to review the management of endometrial hyperplasia in a woman undergoing liver transplantation for alcoholic cirrhosis. METHODS: This is a case presentation on a postmenopausal woman with a tissue diagnosis of endometrial intraepithelial neoplasia managed with a levonorgestrel intrauterine device, before and after liver transplantation. Full written informed consent was obtained from the patient to present her case. RESULTS: The patient experienced resolution of her endometrial intraepithelial neoplasia with conversion to atrophic endometrium after management with levonorgestrel intrauterine device. CONCLUSIONS: A large percentage of women with cirrhosis experience abnormal uterine bleeding, which may be due to the coagulopathy that accompanies liver disease, or endometrial hyperplasia or carcinoma. Although hysterectomy is the criterion standard of treatment for atypical endometrial hyperplasia in a postmenopausal woman, patients with cirrhosis severe enough to require transplant are usually poor surgical candidates. Multiple studies have shown success with conservative management of atypical hyperplasia. There is a paucity of literature on managing patients undergoing transplant with abnormal uterine bleeding and it is therefore important to highlight conservative management options for this patient population.

A prospective cohort study comparing expulsion after postplacental insertion: the levonorgestrel versus the copper intrauterine device.

OBJECTIVES: To compare the expulsion rate at 6 months after postplacental insertion by intrauterine device (IUD) type. STUDY DESIGN: This prospective cohort included participants with a postplacental IUD inserted after vaginal or cesarean delivery, aged 18-45 and ≥24 weeks' gestation. Study enrollment took place after IUD selection and insertion. Participants returned for a postpartum visit and received a short message service survey regarding IUD expulsion, removal, vaginal bleeding and breastfeeding weekly from weeks 0 to 5 and on weeks 12 and 24 postpartum. Multivariable logistic regression examined 6-month expulsion rate by IUD type adjusting for variables that differed between the groups at baseline and in the bivariate analyses. RESULTS: Of 114 participants, 75 (65.8%) chose a levonorgestrel 52-mg IUD and 39 (34.2%) chose a copper IUD; 58 (50.9%) had a vaginal delivery, and 56 (49.1%) had a cesarean delivery. Groups were similar except that copper IUD users had a higher median parity (3 vs. 2, p=.03) and a higher proportion of senior residents compared to junior residents had performed insertion (46.2% vs. 22.7%, p=.02). The expulsion rate at 6 months was similar between the levonorgestrel and copper groups (26.7% and 20.5%, respectively; p=.38). Multivariable logistic regression also demonstrated that the odds of expulsion did not differ by IUD type (adjusted odds ratio 0.98, 95% confidence interval 0.22-4.48). CONCLUSION: The expulsion rate at 6 months after postplacental insertion did not differ between the levonorgestrel and copper IUD type. IMPLICATIONS: Prior studies demonstrate a wide range of expulsion after postplacental insertion, and recent data suggest a higher expulsion rate for the levonorgestrel compared to the copper intrauterine device. However, many studies did not control for patient-level factors or delivery route. We found that when controlling for these confounding variables, the expulsion rate at 6 months postpartum did not differ by intrauterine device type.

Physician knowledge of and adherence to the revised breast cancer screening guidelines by the United States Preventive Services Task Force.

OBJECTIVE: We sought to assess knowledge and adherence to the revised US Preventive Services Task Force breast cancer screening guidelines among gynecologic care providers. STUDY DESIGN: This was a cross-sectional descriptive study based on a survey conducted among gynecologic care providers. RESULTS: Forty providers completed the survey (80%). In response to the statement "The current recommended age to initiate breast cancer screening is … .," 48.7% of providers responded in accordance with revised guidelines. For the statement "Women between the age of 50 and 74 years old are recommended to have screening mammography," 46.2% of respondents answered in accordance. In response to the statement "The United States Preventative Services Task Force recommends teaching breast self-examination," 71.8% of providers responded in accordance. A total of 37 respondents (92.5%) stated that they were aware of the revised guidelines, but 17 (42.4%) stated that they were applicable to their patient population. CONCLUSION: Knowledge of the revised guidelines appeared to be relatively low in our provider sample.