IUD insertion following induced abortion

CONTRACEPTION

IUD INSERTION FOLLOWING INDUCED ABORTION L. Querido. M.D.* Ketting, Ph.D.** A.A. Haspels, M.D., Ph.D., F.R.C.O.G.***

E.

ABSTRACT In a multicenter survey, women who received an IUD immediately after abortion were compared with abortion patients who started using oral contraception. Additionally, women receiving a Nova T were compared with women receiving a Multiload 250. Follow-up data were gathered after 6 weeks. Pain was a cmmcm phenomenon post-abortum. In the study group of IUD users,complaints about pain were not more frequent than among controls, but if pain was experienced, it was more intense and of longer duration among IUD users. Bleeding immediately following the induced abortion was less frequent among IUD users, but if bleeding occurred, it tended to last longer. The first menstrual period after the induced abortion was heavier and more painful among IUD users. Expulsion of the TUD occurred in 10 cases (3.3%). all of them with the Nova T, none with Multiload. The study did not generate evidence for an increased risk of PID in women receiving an IUD after an induced abortion.

Submitted for publication February 15, 1985 Accepted for publication May 15, 1985

* Medical Director Vrelinghuis Clinic Utrecht, Biltstraat 423, The Netherlands ** Research-coordinator Stimezo Netherlands, The Hague, Koningsplein 38A, The Netherlands *** Professor and Chairman, Department of Obstetrics/Gynecology, University Hospital Utrecht, Catharijnesingel 101, 3511 GV Utrecht, The Netherlands

JUNE 1985 VOL. 31 NO. 6

603

CONTRACEPTION

Introduction During the last few years the IUD has become more and more popular in The Netherlands. In 1977 6.3% of all contraceptive users had an IUD; in 1982 this share had increased to 14% (1). The same tendency could be observerd among women who had an induced abortion: in 1974 6.2% had an IUD inserted at the time of abortion, whereas in 1979 18% adopted this method of contraception (2, 3). In this study the results of IUD insertion at the time of abortion are systematically analysed. The purposes of this survey were: 1. to investigate whether women receiving an IUD immediately after induced abortion had more complaints/complications during the first 6 weeks than women starting oral contraceptive use after the procedure; 2. to investigate whether two IUDs, the Nova T and the MLCu 250, brought about different results. Material and Methods Recruitment to the study began in May 1980 and ended in January 1981. In eight Dutch abortion clinics 18 physicians participated in this study. Prior to termination of pregnancy, potential subjects were interviewed and those indicating that they wished to have an IUD inserted at the time of abortion were fully informed as to the nature of the study, including randomized insertion, the potential risks and benefits of the timing of insertion and the alternative methods of fertility regulation available. The subjects were randomly designated to one of the two IUDs, Nova T or MLCu 250. The questionnaires were previously numbered; women entering the study on even numbers received a Nova T and the odd numbers an MLCu 250. The device was inserted immediately after the evacuation of the uterine contents. A randomly selected control group of women who started oral contraceptive use after the abortion was formed. Excluded from the study were those women who refused to participate, those who received antibiotical prophylaxis and those women who started to use oral contraception in combination with the IUD. The surgical procedure undertaken was not standardized across the centers. In 95.7% of the cases the abortion was performed by means of vacuum aspiration, in the remaining cases by D 6 E. The study group consisted of 300 women, who had an IUD inserted at the time of abortion (149 Nova T, 149 MLCu 250 and in 2 cases the type of IUD was not reported). The control group consisted of 123 women. The subjects returned for follow-up at about six weeks. The study group differed from the control group demographically, because oral contraception is more frequently chosen by young women, while the IUD

604

JUNE 1985 VOL. 31 NO. 6

CONTRACEPTION

is most acceptable to women of about 25 years. As a consequence the control group is overrepresented by young, unmarried, nulliparous women, without previous abortion experience (Table I). Matching of both groups was impossible for practical reasons. Table I. Age, marital status, number of preceding pregnancies and induced abortions in the study and control group

hEi%

study group

<20 20-29 30-39 240

5.1% 55.9% 35.0% 4.0%

34.5% 44.0% 20.2% 1.2%

39.0% 49.2% 11.9%

22.9% 69.9% 7.2%

40.6% 18.3% 33.1%

69.1% 11.1% 19.7%

81.3% 18.1% 0.6%

97.3% 2.7% _--

control group

Marital status Married Never married Ever married Number of preceding pregnancies 0 1 2 or more Number of preceding induced abortjons 0 I

2 or more Total

100.0%

100.0%

(N=300)

(N=123)

Results Complaints preceding the first menstrual period Pain following induced abortion is a common complaint; it was mentioned bv about 40% of all women, most of them experiencing pain only during the first three days (Table II).

JUNE 1985 VOL. 31 NO. 6

605

CONTRACEPTION Table

II.

Pain

experienced

before

the

study no.

group %

control

173

58.4%

78

63.9%

251

60.0%

25 40

8.4% 13.5%

5 21

4.1% 17.2%

30 61

7.2% 14.7%

4-.7 days 8-14 days

26 14

8.8% 4.7%

13 4

10.6% 3.3%

39 18

9.4% 4.2%

>14

18

6.0%

1

0.9%

19

4.4%

296

100.0%

122

100.0%

418

100.0%

control

no pain pain: II II 11 II

: : : :

duration 1-3 days

unknown

days

Total Unknown:

5,

not

first

menses

in

the

study

and

group group

no.

total

%

%

no.

significant

Women with an IUD did not complain more frequently duration of pain was longer than among controls.

about pain, but the mean Also, women with an IUD

experienced

(Table

Table

Degree

severe

III.

of

pain

more

Degree of pain group (excluding

often

than

controls

III).

before the first menses in the those not reporting pain)

pain

study no.

group %

control

study

group %

no.

40

14.4% 26.1%

91

59.5%

153

100.0%

15

12.9%

25

21.6%

7 15

more

76

65.5%

15

18.9% 40.5% 40.5%

116

100.0%

37

100.0%

usual

at menses

Total Unknown:

14;

significance

Fewer women in (Table IV) Table

IV.

Blood

the

study

loss

group

reported

the

first

study no.

Total Unknown:

606

5,

significance

%

22

p <0.05

before

no blood loss yes, duration unknown yes, l-7 days yes, 8-14 days Yes, more than 14 days

total

no.

less than usual at menses as usual at menses than

and control

bleeding

menses

group

as compared

in

the

control

study

to

controls

and control

group

group

total

%

no.

%

no.

%

86 8 88 55 59

29.1% 2.7% 29.7% 18.6% 19.9%

18 2 69 21 12

14.8% 1.6% 56.6% 17.2% 9.8%

104 10 157 76 71

24.9% 2.4% 31.6% 18.2% 17.0%

296

100.0%

122

100.0%

418

100.0%

p (0.0001

JUNE 1985 VOL. 3 1 NO. 6

CONTRACEPTION

However, in the study group, twice as many women among those who actually experienced bleeding, reported a duration of more than two weeks. There was no significant difference in the amount of bleeding between both groups. Fever (measured >38"C) was found 16 times in the study group and only once among controls (i.e. 5.4% and 0.8X, respectively). Nevertheless the difference was not significant because of the relatively low absolute number of cases. In 13 cases the fever lasted for 1 to 3 days: in 2 cases it lasted longer and in another 2 cases the duration was unknown. In 7 cases the fever did not exceed 38.5"C. No evidence was found for a causal relationship between pain preceding the first menstrual period after the abortion and parity or the degree of dilatation. As far as pain, bleeding and fever were concerned, there were no significant differences between the two types of IUDs. The first menstruation after the abortion Fifty-five of 394 women studied had not had a menstrual period at the follow-up date(Table V). Table V. Number of days between treatment and first menses in the study and control group studv group

control group

total

not yet/not clear yes, no date reported yes, before day 21 yes, day 21-27 yes, day 28-34 yes, day 35-41 yes, after day 41

44 11 6 36 101 57 26

11 13 4 55 22 2 6

55 24 10 91 123 59 32

Total

281

113

394

Unknown: 29 Out of 44 women who had not vet had their first menstruation after the abortion,in 26 cases the period between treatment and follow-up had been too short for menstrual bleeding to occur. The first menstrual period following induced abortion took place earlier among women taking oral contraception than among those who had received an IUD, the difference between both groups being highly significant (p
JUNE

1985 VOL. 31 NO. 6

607

CONTRACEPTION Table VI. Intensity of pain experienced at menses in the study and control group studv group no. %

control group no. %,

total

no.

x

less than usual as usual more than usual just started

27 123 85 1

11.5% 52.1% 36.0% 0.4%

50 45 5 1

49.5% 44.6% 5.0% 1.0%

77 168 90 2

22.9% 49.9% 26.1% 0.6%

Total

236

100.0%

101

101.0%

337

100.0%

Not applicable/unknown: 86

significance p
More than one-third of women in the study group reported their menses to be more painful than usual; among controls this was only 5%. Menstrual bleeding lasted longer than usual in 55% of the women in the study group compared to only 9% of controls (p CO.0001). The same was true for the amount of bleeding; in the study group, in 52% the bleeding was heavier than usual compared to 7% in controls (p
608

JUNE 1985 VOL. 31 NO. 6

CONTRACEPTION Expulsion of the IUD occurred 10 times (3.3%) and only in women with a Nova T: in 5 cases the expulsion was partial and in 5 other cases complete. None of the MLCu 250s were expelled. According to the diagnostic crit(e;ia of the WHO Task Force on Intrauterine Devices for Fertility Regulation, a definite diagnosis of PID can be made if (a) and (b) and either (c) or (d) of the following signs are present: a. b. c. d.

Oral temperature of 38'C or higher before vaginal examination; Lower abdominal pain (suprapubic), tenderness with guarding Tenderness on movement of the cervix during vaginal examination; Uni- or bilateral adnexal tenderness and/or palpable tender adnexal mass.

Using these criteria, PID bad occurred in 11 cases: eight in the study group (2.7%) and three among controls (2.4%). Within the study group, five cases of PID occurred with an MLCu 250 in situ and three with a Nova T Discussion In spite of the fact that copper-releasing IUDs can cause heavier menstrual bleeding, in several studies it was found that post-abortal bleeding was not increased by simultaneous insertion (4, 5). Our study even shows 29.1% of those women were experiencing no bleeding at all, versus 14.8% of women in the control group. Possibly this is related to the increased release of locally synthesized protaglandins (6). As far as the repot-ted cases of fever are concerned (no significant differences between study and control group), it should be mentioned that underreporting cannot be completely excluded; it seems unlikely, that in the absence of complaints or feeling of illness, temperature will always have been taken. The first menstrual period following induced abortion clearly takes place later among women receiving an IUD (mode: day 28-34) than among women taking oral contraception (mode: day 21-27). This is not a very surprising result. It is well documented that the first menstrual period following an induced abortion usually takes place after 4-5 weeks (found in the study group); among controls the start of the withdrawal bleeding is visible. Half of the women who started oral contraceptive use reported their menstrual period to be less painful than before. This is probably a consequence of the fact that they did not use the pill before the abortion. This result raises the question whether women who have an IUD inserted at an induced abortion should be advised to use oral contraception as well during the first month or the first few months after insertion. Apart from an extra contraceptive safeguard, which might be important during this period, such a procedure has the advantages of diminishing menstrual pain and shortening the menstrual period. The Nova T, which is inserted by means of a technique slightly different from other IUDs, was a new device for most doctors cooperating in this study. The 10 women who (partially) lost their Nova T had been treated by 9 different

JUNE 1985 VOL. 31 NO. 6

609

CONTRACEPTION doctors. In five cases it was a first Nova T insertion for the doctor concerned, in two cases a second, in one case a fourth and in two cases a fifth insertion. It seems reasonable to conclude that insertion of the Nova T asks for specific training. This study did not render any evidence to support the hypothesis that women who have an IUD inserted immediately after an induced abortion run an increased risk of developing a PID relative to other abortion patients. In conclusion, this study has not generated arguments in favour of a different antibiotic prophylactic procedure at induced abortion in cases where this operation is combined with an IUD insertion. Acknowledgements The authors would like to express their gratitude to all thepersonnel working in the 8 clinics who cooperated in this study and for their contribution. Furthermore, they would like to thank the pharmaceutical firms, Organon and Schering, for the IUDs received for the purpose of this study. References 1. Giessen, G.J. van de: Onderzoek gezinsvorming 1982; voorlopige uitkomsten. Maandstatistiek van de Bevolking, 415, 30, 1983. 2. Ketting, E.: IUDs and family planning in The Netherlands. In: Progress in Contraceptive Delivery Systems. IUDs and Family Planning, vol. II, MTP Press Ltd., Falcon House, Lancaster, England, 1980. 3. Ketting, E.: De permanente registratie abortus Nederland. Verslag over het jaar 1980. Den Haag, Stimezo Nederland, 1981. 4. Larsson, B. and L. Hamberger: Insertions of Copper-7 IUDs in connection with induced abortions during the first trimester. Contraception 12: 69, 1975. 5. Solheim, F. and J. Rydnert: Vacuum aspiration and therapeutic abortion. Effect of Cu IUD at operation and postoperative blood loss. Contraception 13: 707, 1976. 6. Gustavii, B.: Studies on the mode of action of intraamniotically and extraamniotically injected hypertonic saline in therapeutic abortion. Acta Obstet. Gvnecol. Stand. suppl. 25, 1973. 7. WHO Task Force on Intrauterine Devices for Fertility Regulation. IUD Insertion following termination of pregnancy. A clinical trial of the TCU 22OC, Lippes loop D and Copper 7. Stud. Fam. Plann. 14: 99, 1983.

610

JUNE 1985 VOL. 31 NO. 6