Postoperative prophylactic antibiotics
The American College of Obstetricians and Gynecologists (ACOG) and the Society for Family Planning (SFP) recommend prophylactic antibiotic treatment for women with mid- to early-stage abortions, and a meta-analysis by Sawaya et al. also showed that prophylactic antibiotic treatment reduced the risk of post-abortion infection by 42%. There was no difference in the risk of infection between abortion alone and immediate post-abortion IUI.
Therefore, post-abortion antibiotics are recommended, but no increase in antibiotic dosage or longer duration of antibiotic use is required for IUD. In case of bleeding, perforation of the uterus, accumulation of blood in the uterine cavity and infection, immediate IUD should not be performed, but temporary contraceptive medication should be given and the complications should be treated before performing the IUD.
IUD immediately after abortion
The condition of the cervix and bilateral adnexa should be clarified by body check and ultrasound before the procedure. After the clearance of the uterus, it should be clear that the pregnancy has been expelled and the cervix should be disinfected again with iodophor.
The size of the uterus needs to be assessed before the IUD is performed (the uterus shrinks after the curettage and the volume is smaller than that of the curettage), and the fundus can be probed with a medical cannula or a dilator, avoiding the use of sharp instruments to avoid the risk of uterine perforation.
The following is the workflow for immediate post-abortion IUD in early mid-pregnancy
Clear completion of the abortion (visible chorionic tissue and/or no uterine occupancy or residue on ultrasound), low bleeding and no contraindications to IUI consider ultrasound-guided operation (mid-trimester pregnancy clearance, uterine fibroids, uterine malformations or other complications).
Expose the cervix, fix the cervical forceps, sterilize the cervix to include the two wings of the IUD in the mid-shaft, push and place it at the bottom of the uterus If you use round forceps for the IUD, you need to open the handle when withdrawing and withdraw from the side so as not to pull the ring out, leave the tail line 3 cm for early pregnancy abortion and cut the tail line close to the ectocervix for mid-pregnancy abortion to remove the cervical forceps, stop bleeding and remove the speculum.
These women are especially in need of long-lasting, effective contraceptive methods, and an IUD immediately after abortion is ideal. IUDs are also a good option for women who choose to have a midterm abortion because they are not considering another pregnancy due to their health problems and fetal complications.
Ultrasound Guidance
Clinicians recommend ultrasound guidance for immediate post-abortion IUDs, but there are no studies to confirm the benefit of this method. Ultrasound monitoring is primarily used to assist in determining the fundus of the uterus, and even without intraoperative ultrasound guidance, it is feasible to repeat the ultrasound after the IUD to clarify the position of the ring.
Ultrasound monitoring for midtrimester abortions reduces the risk of ring dislodgement, and ultrasound guidance has become routine for midtrimester abortions in the United States.
Associated Risks
Bleeding
A randomized controlled trial showed that immediate post-abortion IUD placement did not increase the risk of intraoperative postoperative bleeding or spot bleeding, with a higher proportion of patients requiring medication for abdominal cramps within 14 days postoperatively, but no difference after 2 weeks. A study comparing bleeding from IUDs performed 3 to 10 days after menstruation with those performed immediately after abortion suggested that complications such as spotting and bleeding were less in the latter than in the former.
Uterine perforation?
The incidence of uterine perforation is about 0 per 1,000 to 1.3 per 1,000. A multicenter randomized trial followed 578 women who had an IUD after abortion, and no uterine perforation was seen 6 months after the procedure. If no intraoperative perforation was found but postoperative suggests the possibility of this complication, gynecologic examination is needed to find the caudal filament and ultrasonography to clarify the position of the ring; if no ring is seen, abdominal X-ray is feasible, and if the ring is left in the abdominal cavity, it can be removed laparoscopically.
The main complaints of women after IUD are abdominal pain, irregular vaginal bleeding or infection, but these are not specific complications of IUD and do not need to be removed and will not be relieved after IUD removal, only symptomatic treatment is needed. Patients with endometritis also do not require IUD removal unless antibiotic treatment is ineffective.
Follow-up visits
Most women are reluctant to return to the hospital for follow-up after abortion due to social factors such as privacy. A retrospective study of 77 women found that patient satisfaction was as high as 80% at the 9-month post-abortion follow-up.
In summary, a large body of research data suggests that immediate post-abortion IUD contraception is safe and feasible, highly effective in avoiding repeat abortions, and does not increase the risk of uterine perforation, infection, or fetal retention by a large amount. Clinicians should further implement post-abortion family planning services (PAFPS), and in the absence of complications, IUDs can be used immediately after early and mid-trimester abortions.