What is postpartum (post-partum) more than 48 hours to less than 4 weeks postpartum a contraindication to insert an Intrauterine Device (IUD)?

From the Guidelines

Inserting an IUD during the period of more than 48 hours to less than 4 weeks postpartum is generally not recommended due to increased risk of uterine perforation and expulsion, as classified as category 2 for both Cu-IUD and LNG-IUD by the US MEC guidelines 1.

Key Considerations

• The ideal timing for IUD insertion is either within 48 hours after delivery (immediate postpartum insertion) or after 4 weeks postpartum (interval insertion) 1.
• During the period between 48 hours and 4 weeks after childbirth, the uterus is still undergoing significant involution and healing, making it more vulnerable to complications 1.
• Alternative methods such as progestin-only pills, depot medroxyprogesterone acetate (DMPA), implants, or barrier methods should be considered until IUD insertion becomes safer after the 4-week mark.

Recommendations

• If a patient strongly desires an IUD during this period, the risks and benefits should be carefully discussed, and the procedure should be performed by an experienced provider with ultrasound guidance if available 1.
• The US MEC guidelines provide classifications for IUD insertion at different times postpartum, including a category 2 classification for insertion between 10 minutes after delivery of the placenta to less than 4 weeks postpartum for both Cu-IUD and LNG-IUD 1.

Evidence Summary

• A systematic review in 2018 showed that expulsion rates were 10% if the IUD was placed within 10 minutes or less after placental delivery, highlighting the importance of timing in IUD insertion 1.
• The 2024 US Selected Practice Recommendations for Contraceptive Use provide updated guidance on IUD insertion postpartum, including classifications for different times postpartum and considerations for breastfeeding and non-breastfeeding women 1.

From the Research

Postpartum IUD Insertion

• The insertion of an intrauterine device (IUD) during the postpartum period is a common practice for contraception.
• Studies have shown that the timing of postpartum IUD insertion can affect the risk of complications such as uterine perforation and expulsion 2, 3, 4, 5, 6.

Risks Associated with Postpartum IUD Insertion

• Uterine perforation rates are higher with IUD insertion at 4-8 weeks postpartum compared to 9-36 weeks postpartum 2.
• Expulsion rates are similar between the 2 groups, but may be higher with immediate postpartum insertion compared to standard insertion 4.
• Breastfeeding may be associated with a slightly elevated risk of perforation and lowered risk of expulsion 3.

Contraindications for Postpartum IUD Insertion

• Postpartum more than 48 hours to less than 4 weeks is not a contraindication to insert an IUD, but may be associated with higher expulsion rates compared to insertion at 4-6 weeks postpartum or non-postpartum insertion 6.
• The American College of Obstetricians and Gynecologists (ACOG) recommends that IUD insertion can be performed at any time postpartum, but the risks and benefits should be discussed with the patient 2, 3.

Key Findings

• The risk of uterine perforation is low, but may be higher with IUD insertion during the postpartum period, particularly between 4 days and 6 weeks postpartum 3.
• The risk of expulsion may be higher with immediate postpartum insertion compared to standard insertion, but may be lower with insertion at the time of cesarean section compared to postplacental insertion at the time of vaginal delivery 4, 5, 6.