Postabortion IUD

Postabortion intrauterine contraception is the placement of a copper or levonorgestrel device immediately after a first or second-trimester abortion, or within 12 days of it, provided there is no genital tract infection or significant injury. Both device classes give immediate protection, suit patients who want long-acting cover at a visit when unmet need is high, and do not delay return of ovulation, which can occur within 2 weeks of an abortion.

Devices. Copper T 380A (380 mm² copper, up to 12 years); levonorgestrel 52 mg (5 years); levonorgestrel 19.5 mg (5 years); levonorgestrel 13.5 mg (3 years).

Applicable abortions. Induced or spontaneous abortion, surgical or medical, and treated ectopic pregnancy.

Effectiveness. The first-year failure rates are those of each device at interval insertion: about 6 to 8 per 1,000 women for the copper T 380A and about 2 per 1,000 for the levonorgestrel 52 mg device.

Return to fertility. Immediate on removal.

Ideal candidates. Patients who want long-acting contraception after an abortion, particularly those with limited access to follow up, adolescents, and patients with a previous short interval between pregnancies.

Eligibility categories.

Do not insert, delay until treated and resolved.

• Suspected or confirmed infection: fever, lower abdominal tenderness, cervical motion tenderness, purulent or foul-smelling discharge.
• Significant injury to the genital tract, including cervical laceration needing repair, uterine perforation or unresolved haemorrhage.
• Retained products of conception, or an incomplete evacuation.
• Cavity distortion by fibroids or anomalies.

Examination. Confirm the uterus is firm and not tender, the cervix is intact and there is no purulent discharge. Confirm complete evacuation by inspection of tissue or ultrasound.

Investigations. No routine blood tests. Offer HIV testing and STI testing where risk is increased, without delaying insertion in a patient who has no signs of infection. Haemoglobin is useful after heavy bleeding.

Pregnancy exclusion. Immediately after surgical evacuation, pregnancy is excluded by the procedure itself. After medical abortion, insert only once complete expulsion is confirmed clinically or by ultrasound. A patient within 5 days of an abortion can be taken as not pregnant; after that, rely on history and a sensitive pregnancy test.

Special groups.

• Adolescents and nulliparous patients: category 2 for any intrauterine device; do not withhold on age alone.
• HIV: acceptable when clinically well on antiretroviral therapy; no interaction with antiretroviral medicines.
• Sickle cell disease and anaemia: a levonorgestrel device is preferred because it reduces blood loss.
• Second-trimester abortion: expulsion is more frequent; arrange follow up.

Counselling points. Provide counselling and obtain consent before the procedure, not during or after sedation. The patient may decline at any point. Explain that the device does not protect against STIs or HIV and that condoms remain advised where risk exists.

Copper regimen line. Copper T 380A, 380 mm² copper intrauterine device; transcervical insertion; immediately after evacuation or within 12 days of the abortion if no infection or significant injury; no backup; effective up to 12 years; no interaction with medicines; no adjustment for weight, liver or kidney disease.

Levonorgestrel regimen line. Levonorgestrel 52 mg intrauterine device (or the 19.5 mg device for 5 years or the 13.5 mg device for 3 years); transcervical insertion; same timing; no backup when inserted within 7 days of the abortion, and backup for 7 days when inserted later; no adjustment for weight, kidney disease or enzyme inducers; avoid initiation in severe decompensated cirrhosis, liver tumours and current breast cancer.

Delayed insertion. If infection is suspected, treat first and insert after resolution, using interval insertion rules. If insertion is not done within 12 days, wait for the next menses or insert at any time when reasonably certain the patient is not pregnant.

Technique.

• Use sterile no-touch technique, with the device loaded in its sterile package.
• Complete the evacuation, confirm haemostasis and inspect the cervix.
• After surgical evacuation, grasp the cervix with a tenaculum, sound the uterus to confirm the cavity depth, and insert using interval technique. Use ultrasound control if the uterus is large or the sound is uncertain.
• After second-trimester abortion, use a long inserter or placental forceps to reach the fundus and leave the threads uncut until the uterus has involuted.
• After medical abortion, insert once complete expulsion is confirmed, using interval technique.

Antibiotics. No additional prophylaxis is needed for the device. Continue any antibiotic course already given for the abortion.

Switching. From a short-acting method used correctly, insert at the abortion visit. From a hormonal method, no backup is needed.

Follow up. Review at 3 to 6 weeks. Check threads, bleeding, pain and discharge. After second-trimester abortion, also confirm position by ultrasound if threads are not seen.

Return advice. Fever, rigors, foul discharge, severe or increasing pain, heavy bleeding, a felt or expelled device, or a missed period.

Expulsion. More frequent than at interval insertion, and higher after second-trimester abortion. Confirm by ultrasound, exclude pregnancy, and reinsert once pregnancy is excluded and any infection resolved, or provide another method.

Perforation. Higher after abortion because the uterine wall is soft. If suspected during insertion, stop, remove the device and instruments, start intravenous fluids, give prophylactic antibiotics, observe vital signs and abdominal signs, and refer for surgical review if pain is severe, vital signs change or peritonism develops.

Infection. Danger signs are fever, rigors, foul discharge, pain and shock. Give ceftriaxone 500 mg intramuscularly once, doxycycline 100 mg orally twice daily for 14 days and metronidazole 500 mg orally twice daily for 14 days, with the device in place. Reassess at 48 to 72 hours; remove the device if there is no improvement, while continuing antibiotics.

Bleeding. Postabortion bleeding is expected for up to 2 weeks. Prolonged or heavy bleeding needs examination and ultrasound for retained products or expulsion. For irregular bleeding after exclusion of these, give ibuprofen 400 mg orally three times daily with food for 5 days (maximum 2.4 g daily) or mefenamic acid 500 mg orally three times daily for 5 days.

Pregnancy with a device in place. Exclude ectopic pregnancy by ultrasound. If intrauterine and threads are visible in the first trimester, offer removal; if threads are absent, locate the device by ultrasound.

Referral and escalation. Refer urgently for sepsis, haemorrhage, suspected perforation, ectopic pregnancy, or a device not located after ultrasound.