Review

Authors: Rachel E Bridwell, Brit Long, Tim Montrief...

An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally "safe" (performed in a safe, clean environment with experienced providers and no legal restrictions) or "unsafe" (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.

Topics: Female; Pregnancy; Humans; Abortion, Induced; Gestational Age; Hazardous Substances; Physical Examination

PubMed: 36409940
DOI: 10.5811/westjem.2022.8.57929

Authors: Michael J Fassett, Susan D Reed, Kenneth J Rothman...

OBJECTIVE

The APEX-IUD (Association of Perforation and Expulsion of Intrauterine Devices) study evaluated the association of postpartum timing of intrauterine device (IUD) insertion, breastfeeding, heavy menstrual bleeding, and IUD type (levonorgestrel-releasing vs copper) with risks of uterine perforation and IUD expulsion in usual clinical practice. We summarize the clinically important findings to inform counseling and shared decision making.

METHODS

APEX-IUD was a real-world (using U.S. health care data) retrospective cohort study of individuals aged 50 years and younger with IUD insertions between 2001 and 2018 and with electronic health record data. Cumulative incidences of uterine perforation and IUD expulsion were calculated. Adjusted hazard ratios (aHRs) and 95% CIs were estimated from proportional hazards models with control of confounding.

RESULTS

Among the study population of 326,658, absolute risk of uterine perforation was low overall (cumulative incidence, 0.21% [95% CI 0.19-0.23%] at 1 year and 0.61% [95% CI 0.56-0.66% at 5 years]) but was elevated for IUDs inserted during time intervals within 1 year postpartum, particularly among those between 4 days and 6 weeks postpartum (aHR 6.71, 95% CI 4.80-9.38), relative to nonpostpartum insertions. Among postpartum insertions, IUD expulsion risk was greatest for insertions in the immediate postpartum period (0-3 days after delivery) compared with nonpostpartum (aHR 5.34, 95% CI 4.47-6.39). Postpartum individuals who were breastfeeding had a slightly elevated risk of perforation and lowered risk of expulsion than those not breastfeeding. Among nonpostpartum individuals, those with a heavy menstrual bleeding diagnosis were at greater risk of expulsion than those without (aHR 2.84, 95% CI 2.66-3.03); heavy menstrual bleeding also was associated with a slightly elevated perforation risk. There was a slightly elevated perforation risk and slightly lower expulsion risk associated with levonorgestrel-releasing IUDs compared with copper IUDs.

CONCLUSION

Absolute risk of adverse outcomes with IUD insertion is low. Clinicians should be aware of the differences in risks of uterine perforation and expulsion associated with IUD insertion during specific postpartum time periods and with a heavy menstrual bleeding diagnosis. This information should be incorporated into counseling and decision making for patients considering IUD insertion.

FUNDING SOURCE

Bayer AG.

CLINICAL TRIAL REGISTRATION

EU PAS register, EUPAS33461.

Topics: Female; Humans; Intrauterine Device Expulsion; Intrauterine Devices; Intrauterine Devices, Copper; Levonorgestrel; Menorrhagia; Retrospective Studies; Uterine Perforation; Middle Aged

PubMed: 37535968
DOI: 10.1097/AOG.0000000000005299

Review

Authors: Natalie S Whaley, Anne E Burke

Intrauterine devices (IUDs) are effective, reversible forms of contraception with high patient satisfaction and continuation. IUDs can be safely used by most women and should be considered the first-line method of contraception for all women. This descriptive review will discuss the clinical issues associated with IUDs - including management of side effects, noncontraceptive uses and insertion and removal. When the burdens of cost are removed, women are more likely to select and IUDs. Health policy changes that increase insurance coverage for contraception will improve access to IUDs. IUDs remain an underutilized form of contraception in USA and efforts to improve availability and access to long-acting reversible contraception methods is needed to optimize their use.

Topics: Contraception; Female; Humans; Intrauterine Devices

PubMed: 26626857
DOI: 10.2217/whe.15.77

Authors: Katrine Folmann Finne, Anders Peter Gerholt Skovsen

Intra-abdominal displacement of an intrauterine device (IUD) is a rare but serious complication. This is a case report of a 44-year-old woman who was referred to a surgical department with intermittent abdominal pain. Gynaecological examination and ultrasound failed to identify the patient's IUD. An abdominal CT scan confirmed the diagnosis of the intra-abdominally migrated IUD and the device was extracted by laparoscopy. Surgical removal of the migrating IUD is recommended to prevent long-term complications such as intra-abdominal adhesions, organ perforation, and fistula formation.

Topics: Female; Humans; Adult; Uterine Perforation; Laparoscopy; Device Removal; Intrauterine Devices; Abdominal Pain

PubMed: 36896615
DOI: No ID Found

Review

Authors: Sam Rowlands, Emeka Oloto, David H Horwell...

Uterine perforation is an uncommon complication of intrauterine device insertion, with an incidence of one in 1,000 insertions. Perforation may be complete, with the device totally in the abdominal cavity, or partial, with the device to varying degrees within the uterine wall. Some studies show a positive association between lactation and perforation, but a causal relationship has not been established. Very rarely, a device may perforate into bowel or the urinary tract. Perforated intrauterine devices can generally be removed successfully at laparoscopy.

PubMed: 29386934
DOI: 10.2147/OAJC.S85546

Authors: Yasir A Bahadur, Maha M Eltaher, Ashraf H Hassouna...

PURPOSE

To retrospectively assess the incidence of sub-serosal and uterine perforation of intra-uterine tandem in intracavitary high-dose-rate (HDR) brachytherapy for cervical cancer, and to evaluate its dosimetric implications on computed tomography (CT)-based treatment planning.

MATERIAL AND METHODS

Computed tomography images and brachytherapy plans of cervical cancer patients treated from February 2006 to December 2012 were reviewed for sub-optimal implants (sub-serosal and uterine perforation), and their correlation with cancer FIGO stage and patients' age. For each patient, the plans showing sub-optimal insertion of intra-uterine tandem were analyzed and compared to plans with adequate insertion. The difference in dose coverage of clinical-target-volume (CTV) and variation of the dose delivered to organs-at-risk (OARs) rectum and bladder were evaluated.

RESULTS

A total of 231 brachytherapy plans for 82 patients were reviewed. We identified 12 (14.6%) patients and 14 (6%) applications with uterine perforation, and 12 (14.6%) patients and 20 (8.6%) applications with sub-serosal insertion of tandem. Data analysis showed that advanced stage correlates with higher incidence of sub-optimal implants (p = 0.005) but not the age (p = 0.18). Dose-volume-histograms (DVHs) analysis showed large variations for CTV dose coverage: D90 significantly decreased with average of -115.7% ± 134.9% for uterine perforation and -65.2% ± 82.8% for sub-serosal insertion (p = 0.025). The rectum and bladder dose assessed by D2cc increased up to 70.3% and 43.8%, respectively, when sub-optimal insertion of uterine tandem occurred.

CONCLUSIONS

We report a low incidence of uterine perforation and sub-serosal insertion of uterine tandem in intracavitary HDR brachytherapy for cervical cancer. However, the effects on treatment plan dosimetry can be considerably detrimental. Therefore, we recommend image-guided insertion, at least for the challenging cases.

PubMed: 25829936
DOI: 10.5114/jcb.2015.48898

Randomized Controlled Trial

Authors: J F W Rikken, C R Kowalik, M H Emanuel...

STUDY QUESTION

Does septum resection improve reproductive outcomes in women with a septate uterus?

SUMMARY ANSWER

Hysteroscopic septum resection does not improve reproductive outcomes in women with a septate uterus.

WHAT IS KNOWN ALREADY

A septate uterus is a congenital uterine anomaly. Women with a septate uterus are at increased risk of subfertility, pregnancy loss and preterm birth. Hysteroscopic resection of a septum may improve the chance of a live birth in affected women, but this has never been evaluated in randomized clinical trials. We assessed whether septum resection improves reproductive outcomes in women with a septate uterus, wanting to become pregnant.

STUDY DESIGN, SIZE, DURATION

We performed an international, multicentre, open-label, randomized controlled trial in 10 centres in The Netherlands, UK, USA and Iran between October 2010 and September 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with a septate uterus and a history of subfertility, pregnancy loss or preterm birth were randomly allocated to septum resection or expectant management. The primary outcome was conception leading to live birth within 12 months after randomization, defined as the birth of a living foetus beyond 24 weeks of gestational age. We analysed the data on an intention-to-treat basis and calculated relative risks with 95% CI.

MAIN RESULTS AND THE ROLE OF CHANCE

We randomly assigned 80 women with a septate uterus to septum resection (n = 40) or expectant management (n = 40). We excluded one woman who underwent septum resection from the intention-to-treat analysis, because she withdrew informed consent for the study shortly after randomization. Live birth occurred in 12 of 39 women allocated to septum resection (31%) and in 14 of 40 women allocated to expectant management (35%) (relative risk (RR) 0.88 (95% CI 0.47 to 1.65)). There was one uterine perforation which occurred during surgery (1/39 = 2.6%).

LIMITATIONS, REASONS FOR CAUTION

Although this was a major international trial, the sample size was still limited and recruitment took a long period. Since surgical techniques did not fundamentally change over time, we consider the latter of limited clinical significance.

WIDER IMPLICATIONS OF THE FINDINGS

The trial generated high-level evidence in addition to evidence from a recently published large cohort study. Both studies unequivocally do not reveal any improvements in reproductive outcomes, thereby questioning any rationale behind surgery.

STUDY FUNDING/COMPETING INTEREST(S)

There was no study funding. M.H.E. reports a patent on a surgical endoscopic cutting device and process for the removal of tissue from a body cavity licensed to Medtronic, outside the scope of the submitted work. H.A.v.V. reports personal fees from Medtronic, outside the submitted work. B.W.J.M. reports grants from NHMRC, personal fees from ObsEva, personal fees from Merck Merck KGaA, personal fees from Guerbet, personal fees from iGenomix, outside the submitted work. M.G. reports several research and educational grants from Guerbet, Merck and Ferring (location VUMC) outside the scope of the submitted work. The remaining authors have nothing to declare.

TRIAL REGISTRATION NUMBER

Dutch trial registry: NTR 1676.

TRIAL REGISTRATION DATE

18 February 2009.

DATE OF FIRST PATIENT’S ENROLMENT

20 October 2010.

Topics: Cohort Studies; Female; Humans; Infant, Newborn; Iran; Netherlands; Pregnancy; Premature Birth; Uterus; Watchful Waiting

PubMed: 33793794
DOI: 10.1093/humrep/deab037