1. The 5-year cumulative incidence of IUD-related uterine perforation was higher in the postpartum cohort relative to non-postpartum.
2. Among postpartum women, uterine perforation was greater in breastfeeding women compared to those not breastfeeding.
Evidence Rating Level: 2 (Good)
Study Rundown: Many studies have reported the effect of intrauterine devices (IUD) on increased risk of uterine perforations. However, the impact of pregnancy and breastfeeding on said outcome is less known. This cohort study aimed to assess the impact of childbirth on IUD-related uterine perforations and the impact of breastfeeding vs. no breastfeeding on uterine perforations in postpartum women. The primary outcome was first presentation of any complete or partial IUD-related uterine perforation in women who underwent an IUD insertion between 2001 and 2018. According to study results, the five-year cumulative incidence of IUD-related uterine perforations was increased among postpartum patients compared to non-postpartum. Among patients in the postpartum group, those who breastfed had greater risk of uterine perforations. Among the reported uterine perforations, approximately half were assessed as complete perforations. Overall, this study was strengthened by a large sample size with individuals from multiple sites across the USA, adding to its generalizability.
Relevant Reading: Immediate versus Delayed IUD Insertion after Uterine Aspiration
In-depth [retrospective cohort study]: This study included patients from multiple health care facilities across the USA. Included were those ≤ 50 years of age with an IUD insertion between Jan 1, 2001, and Apr 30, 2018. Overall, 326 658 individuals were involved in the full cohort while 94 817 were involved in the postpartum cohort. The primary outcome of cumulative incidence at five years was lowest in the non-postpartum group (0.29%, 95% confidence interval [CI] 0.26-0.34). Compared to the non-postpartum group, the likelihood of perforation for post-partum group was greater within three days of being postpartum (adjusted hazard ratio [aHR] 2.73, 95% CI 1.33-5.63) and between four days and six weeks postpartum (aHR 6.71, 95% CI 4.80-9.38). In the breastfed post-partum group, the cumulative incidence was 1.37% (95% CI 1.24-1.52). Moreover, the perforation risk was increased with breastfeeding compared to no breastfeeding (aHR 1.37, 95% CI 1.12-1.66). In total, there were 1008 uterine perforations in the full cohort (51.2% complete) and 673 uterine perforations in the breastfeeding postpartum sub cohort (62% complete). Findings from this study suggest that even though perforation remains a relatively uncommon occurrence, the risk of IUD-related perforation is greater in postpartum women and greatest in those who are breastfeeding postpartum.
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