Re: Immediate post-partum insertion of intrauterine contraception and implants: A review of the safety and guidelines for use by Mwalwanda CS and Black KI. Aust N Z J Obstet Gynaecol 2013; 53: 331-337

Abstract

We were very pleased to see the review article by Mwalwanda and Black 1 on such an important topic. As stated by the authors, there is a paucity of studies relating to the immediate postpartum use of levonorgestrel intrauterine system (LNG-IUS), but it is important to also note that there is limited evidence regarding subdermal implant use in the same setting. Data regarding infant safety, breast milk and breast feeding with implant use are robust and plentiful. Our concern is that the studies regarding continuation rates, acceptability, maternal safety and side effects are lacking when referring to immediate postpartum use of the implant.Regarding continuation rates and acceptability, the authors refer to a study by Lewis et al., 2 with 73 teenagers using an implant in the postpartum period. While this study raised some very important issues such as early repeat pregnancy (two participants were already pregnant at the six-week postpartum visit), and the duration of follow-up was excellent (24 months), the implant was not inserted in the immediate postpartum period. We have inferred that the implant was inserted at the six-week postpartum visit, as this is not clearly stated in the original paper.Regarding maternal safety, the authors refer to a pilot study by Brito et al. 3 This is the only cited research involving 'immediate' (24-48 h) postpartum implant use, and we have several points of concern relating to this study. The limited number of participants (20 implant users) was noted by the authors, but the short duration of follow-up (12 weeks) with minimal contact during this time (6 weeks and 12 weeks) was not. Of greater concern is that the results from this study concerning side effects are not consistent with other published data. For example:Fourty-five percent of participants (9/20) reported headache as a side effect of implant use, compared with 15.3-24.7% of implant users in the general population 3,4 Twenty-five percent reported nervousness compared with 3.5-5.6% in the general population 3,4 Ten percent reported hair loss compared with 2.5% in the general population 3,5 Average duration of lochia in both groups was very short (13 + 3 and 12 + 4 days) compared with 24-36 days in a recently published systematic review. 3,6 In conclusion, there is a need for further research into the immediate postpartum use of subdermal implants, to assess continuation rates, acceptability, maternal safety and side effects. The Brito et al. 3 study illustrates that it is still unclear whether immediate postpartum implant use has the same side effects as interval insertion. These data would be invaluable in enabling us to tailor postpartum contraception to a woman's preference.While we welcome this very useful review article, we are disappointed that the lack of evidence regarding immediate postpartum implant use is not more clearly highlighted.