Sweeney Heather E, Bainvoll Liat, Mandelbaum Rachel S, Sangara Rauvynne N, Violette Caroline J, Klar Maximilian, Matsushima Kazuhide, Paulson Richard J, Cahoon Sigita S, Nguyen Brian T, Bender Nicole M, Ouzounian Joseph G, Matsuo Koji
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Sweeney, Ms Bainvoll, and Drs Mandelbaum, Sangara, Violette, and Matsuo).
Keck School of Medicine, University of Southern California, Los Angeles, CA (Ms Bainvoll).
AJOG Glob Rep. 2023 Jan 4;3(1):100157. doi: 10.1016/j.xagr.2022.100157. eCollection 2023 Feb.
Several studies have investigated the effectiveness of intrauterine device placement at cesarean delivery as a contraceptive method. However, national-level use and outcomes of a postplacental intrauterine device at cesarean delivery are currently understudied in the United States.
This study aimed to examine the trends, characteristics, and outcomes of patients who received a postplacental intrauterine device at cesarean delivery.
This retrospective cohort study used the National Inpatient Sample. The study cohort included patients who underwent cesarean delivery from October 2015 to December 2018. The exclusion criteria included hemorrhage, chorioamnionitis, uterine anomaly, hysterectomy, and permanent surgical sterilization. Eligible cases were grouped on the basis of the use of a postplacental intrauterine device at cesarean delivery. The primary outcome measures were temporal trends and characteristics associated with the use of a postplacental intrauterine device at cesarean delivery, assessed using the generalized estimating equation model in multivariable analysis. The secondary outcome measure was perioperative morbidity (leukocytosis, endometritis, myometritis, and sepsis). Propensity score matching was used to balance the baseline characteristics.
Among 2,983,978 patients who met the inclusion criteria, 10,145 patients (0.3%) received a postplacental intrauterine device at cesarean delivery. The use of a postplacental intrauterine device increased from 0.1% in the fourth quarter of 2015 to 0.6% in the fourth quarter of 2018 (<.001). In a multivariable analysis, the use of a postplacental intrauterine device increased by 14% every quarter-year (adjusted odds ratio, 1.14; 95% confidence interval, 1.13-1.15). In addition, (1) patient characteristics of young age, non-White race, obesity, tobacco use, lowest quartile median household income, and insured with Medicaid; (2) hospital characteristics of large bed capacity and urban teaching setting in Northeast region; and (3) pregnancy characteristics of early gestational age at cesarean delivery, hypertensive disease, previous cesarean delivery, multifetal pregnancy, grand multiparity, placenta previa, and nonelective cesarean delivery represented the independent characteristics associated with the use of a postplacental intrauterine device (all <.05). A regression tree model identified 35 discrete patterns of the use of a postplacental intrauterine device based on 8 factors (time, race or ethnicity, primary expected payer, obesity, hospital bed capacity, hospital teaching status, hospital region, and previous cesarean delivery). There were 9 patterns, representing 8.8% of the study population, exhibiting a use rate of ≥1.0%, whereas there were 7 patterns, representing 16.0% of the study population, exhibiting no use of a postplacental intrauterine device (absolute rate difference from the highest group to the lowest group, 4.7%). In a propensity score-matched model, postplacental intrauterine device placement at cesarean delivery was not associated with increased risk of measured morbidity (any, 1.8% vs 1.7%; odds ratio, 1.06; 95% confidence interval, 0.66-1.69; =.812), including postpartum endometritis (1.2% vs 1.0%; odds ratio, 1.19; 95% confidence interval, 0.67-2.14; =.554).
The use of a postplacental intrauterine device at cesarean delivery increased significantly in recent years in the United States.
多项研究调查了剖宫产时放置宫内节育器作为一种避孕方法的有效性。然而，在美国，目前对剖宫产时胎盘娩出后放置宫内节育器的全国性使用情况和结局研究不足。
本研究旨在探讨剖宫产时接受胎盘娩出后宫内节育器的患者的趋势、特征和结局。
这项回顾性队列研究使用了全国住院患者样本。研究队列包括2015年10月至2018年12月期间接受剖宫产的患者。排除标准包括出血、绒毛膜羊膜炎、子宫异常、子宫切除术和永久性手术绝育。符合条件的病例根据剖宫产时是否使用胎盘娩出后宫内节育器进行分组。主要结局指标是剖宫产时使用胎盘娩出后宫内节育器的时间趋势和特征，在多变量分析中使用广义估计方程模型进行评估。次要结局指标是围手术期发病率（白细胞增多、子宫内膜炎、子宫肌炎和败血症）。使用倾向评分匹配来平衡基线特征。
在2983978例符合纳入标准的患者中，10145例（0.3%）在剖宫产时接受了胎盘娩出后宫内节育器。胎盘娩出后宫内节育器的使用从2015年第四季度的0.1%增加到2018年第四季度的0.6%（P<.001）。在多变量分析中，胎盘娩出后宫内节育器的使用每季度增加14%（调整后的优势比，1.14；95%置信区间，1.13 - 1.15）。此外，（1）患者特征包括年轻、非白人种族、肥胖、吸烟、家庭收入中位数处于最低四分位数以及参加医疗补助保险；（2）医院特征包括床位多以及东北地区的城市教学医院；（3）妊娠特征包括剖宫产时孕周早、患有高血压疾病、既往剖宫产史、多胎妊娠、多产、前置胎盘以及非择期剖宫产，这些是与使用胎盘娩出后宫内节育器相关的独立特征（均P<.05）。回归树模型基于8个因素（时间、种族或民族、主要预期支付方、肥胖、医院床位数、医院教学状况、医院地区和既往剖宫产史）确定了35种胎盘娩出后宫内节育器使用的离散模式。有9种模式，占研究人群的8.8%，使用率≥1.0%，而有7种模式，占研究人群的16.0%，未使用胎盘娩出后宫内节育器（最高组与最低组的绝对率差为4.7%）。在倾向评分匹配模型中，剖宫产时放置胎盘娩出后宫内节育器与所测量的发病率增加无关（任何发病率，1.8%对1.7%；优势比，1.06；95%置信区间，0.66 - 1.69；P =.812），包括产后子宫内膜炎（1.2%对1.0%；优势比，1.19；95%置信区间，0.67 - 2.14；P =.554）。
近年来，美国剖宫产时胎盘娩出后宫内节育器的使用显著增加。
