Can a copper Intrauterine Contraceptive Device (IUCD) be inserted in a pregnant mother with cerebral venous thrombosis?

Copper PPIUCD Use in Pregnant Women with Cerebral Venous Thrombosis

A copper intrauterine contraceptive device (IUCD) should not be inserted in a pregnant woman with cerebral venous thrombosis (CVT) as pregnancy is a contraindication for IUD insertion. 1

Rationale for Contraindication

The U.S. Selected Practice Recommendations for Contraceptive Use (2024) clearly states that pregnancy is a Category 4 contraindication for copper IUD insertion, meaning the device should not be used due to unacceptable health risks 1. This classification applies regardless of the woman's medical conditions, including cerebral venous thrombosis.

Key considerations:

1. Pregnancy status:

   • Pregnancy itself is an absolute contraindication (Category 4) for copper IUD insertion
   • Attempting to insert an IUD during pregnancy could lead to:
     • Pregnancy complications
     • Spontaneous abortion
     • Septic abortion
     • Premature delivery

2. Cerebral venous thrombosis management:

   • CVT during pregnancy requires therapeutic anticoagulation
   • According to the American Society of Hematology guidelines, pregnant women with acute venous thromboembolism (including CVT) should receive antithrombotic therapy with low-molecular-weight heparin (LMWH) 1
   • The focus should be on managing the CVT rather than contraception during active pregnancy

Postpartum Considerations

For women with a history of CVT who require contraception after delivery:

1. Timing of IUD insertion:

   • Copper IUD insertion should be delayed until ≥4 weeks postpartum 1
   • Earlier insertion (10 minutes after placental delivery to <4 weeks) carries a Category 2 classification (benefits generally outweigh risks but requires careful consideration)

2. Anticoagulation management:

   • Women with previous CVT typically require postpartum prophylaxis for 6 weeks with prophylactic or intermediate-dose LMWH or vitamin K antagonists 1
   • Copper IUDs do not interact with anticoagulation therapy and may be preferred over hormonal contraception in women with thrombotic disorders

Risk Factors and Special Considerations

When considering future contraception for women with history of CVT:

• Hormonal contraception risks: Combined hormonal contraceptives significantly increase the risk of CVT (OR 5.59) and should be avoided 1
• Copper IUD advantages: Non-hormonal method that doesn't increase thrombosis risk
• Recurrence risk: The risk of recurrent venous thrombotic events during subsequent pregnancies in women with prior CVT is relatively low when appropriate prophylaxis is used 2

Management Algorithm for Contraception in Women with CVT

1. During pregnancy with active CVT:

   • Focus on CVT treatment with LMWH
   • Avoid IUD insertion (contraindicated)

2. Postpartum period:

   • Continue anticoagulation as recommended
   • Consider copper IUD insertion after 4 weeks postpartum
   • Ensure no postpartum sepsis (Category 4 contraindication)

3. For future contraception:

   • Copper IUD is preferred over hormonal methods
   • Avoid combined hormonal contraceptives due to increased thrombosis risk

Conclusion

The insertion of a copper PPIUCD in a pregnant woman with cerebral venous thrombosis is contraindicated. Management should focus on appropriate anticoagulation therapy for the CVT during pregnancy, with consideration of copper IUD placement in the postpartum period (after 4 weeks) as a safe contraceptive option for women with history of thrombotic disorders.