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ABSTRACT: BACKGROUND: Concern about pain during placement of an intrauterine device (IUD) represents a barrier to use, especially among nulliparous women. We hypothesized that nitroprusside gel applied intracervically prior to IUD placement would reduce insertion-related pain. STUDY DESIGN: We performed a randomized, double-blinded, placebo-controlled pilot study to evaluate the efficacy and tolerability of 10-mg nitroprusside gel (1 mL) or identical placebo gel applied intracervically in nulliparous women immediately prior to IUD placement. Subjects completed a series of 100-mm visual analogue scales at several time points. The primary outcome was subject-reported pain with IUD insertion. Secondary outcomes included provider-reported ease of insertion, subject-reported pain at other time points, side effects, adverse events and need for additional dilation. RESULTS: A total of 24 women were randomized. Baseline characteristics were similar between groups. The mean pain score with IUD deployment was 73 mm (SD 17 mm) in the placebo group and 59 mm (SD 26 mm) in the nitroprusside group (p=.15). There was no difference in ease of insertion reported by providers. Two subjects required dilation, one in each group. There were two vasovagal reactions in the nitroprusside group and none in the placebo group. CONCLUSIONS: Intracervical administration of 10-mg nitroprusside gel immediately prior to IUD insertion does not appear to provide a clinically relevant improvement in patient-reported pain with IUD insertion among nulliparous women.
Contraception 12/2012; · 2.72 Impact Factor
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ABSTRACT: BACKGROUND: Many women who intend to use long-acting, reversible contraceptives (LARCs) postpartum do not follow through with initiating use. The objectives of this study were to determine whether support from a contraceptive personal assistant could increase the uptake of LARCs by 3 months postpartum, and to identify risk factors for nonuptake of LARCs among women who planned LARC use. STUDY DESIGN: This is a randomized, controlled trial of 50 low-income postpartum women who desired LARC. The intervention group received telephone contact from a personal assistant who provided contraception education, facilitation of insurance coverage, appointment scheduling and assistance with childcare and transportation. The control group received routine follow up. Women were surveyed immediately and 3 months postpartum regarding contraceptive use and anticipated barriers to LARC use. RESULTS: A similar proportion of women in both groups received LARC [control 16/24 (67%), intervention 18/25 (72%), p=.76]. More primiparous (86.4%) than multiparous (55.5%) women obtained LARC (p=.04). In addition, women with more prenatal visits were more likely to have initiated LARC (odds ratio, 95% confidence interval for each increased visit: 1.50, 1.15-1.96). No other demographic factors were related to LARC uptake. CONCLUSIONS: Providing telephone assistance to help navigate barriers did not increase postpartum uptake of LARCs. A personal history of clinic visit no-shows and/or infrequent prenatal visits were related to poor uptake of LARCs postpartum.
Contraception 12/2012; · 2.72 Impact Factor
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ABSTRACT: Adolescents contribute disproportionately to the epidemic level of unintended pregnancy in the USA. Intrauterine devices (IUDs) are highly effective but underutilized in this age group.
We searched our electronic clinic database to identify females ≤19 years old who underwent attempted IUD insertion between January 2007 and June 2009. This retrospective cohort study primarily compared the insertion and postinsertion experiences between nulliparous and parous teens.
Of the 307 charts reviewed, the majority of subjects were white (73.4%) and nulliparous (77.5%), with a median age of 18 years (range 15-19). The vast majority (96.4%, 296/307) had a successful IUD insertion upon first attempt; all of the 11 unsuccessful IUD insertion attempts were among nulliparous teens. Follow-up was available for 56% (172/307). During the first 12 months of use, there were 2.9% (5/172) IUD expulsions and 24.4% (42/172) removals, with no differences between nulliparous and parous teens. IUD continuation at 6 months was 83.3%. Pelvic inflammatory disease was diagnosed in 4.6% (8/172) of post-IUD insertions. There were no pregnancies reported in those teens with IUD continuation, while six were reported in subjects who underwent IUD removal. Independent predictors of IUD discontinuation were a history of chronic pelvic pain or dysmenorrhea, and bleeding and/or pain complaints at any post-IUD visit.
Overall, adolescents experience minimal complications with IUD use, with similar rates of successful insertion as adults. IUD discontinuation rates were not significantly different between nulliparous and parous teens. While discontinuation was higher than reported in adults, it was lower than reported among teens using other forms of contraception.
Contraception 05/2012; 86(5):443-51. · 2.72 Impact Factor
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ABSTRACT: Despite lack of efficacy data, the majority of first-trimester surgical abortions are performed with a paracervical block. Women may be unnecessarily exposed to a painful injection and potentially noxious medication. Our objective was to estimate the effect of a paracervical block and the effect of gestational age on patient pain perception.
This was a randomized, single-blind trial of patients undergoing abortion receiving paracervical block or sham stratified by gestational age (early: less than 8 weeks of gestation, n=60; late: 8-10 6/7 weeks of gestation, n=60). Premedicated with ibuprofen and lorazepam, all participants received 2 mL 1% buffered lidocaine injected at the tenaculum site followed by a slow, deep injection of 18 mL at four sites (block) or no injection (sham) with a 3-minute wait. The primary outcome was dilation pain (100-mm visual analog scale). Secondary outcomes included pain at additional time points, satisfaction, need for more analgesics, and adverse events.
Full enrollment occurred (n=120). We used intent-to-treat analysis. Demographics did not differ between groups. Paracervical block administration was painful (mean 55 mm compared with sham 30 mm, P<.001) but decreased dilation pain (42 mm compared with 79 mm, P<.001) and aspiration pain (63mm compared with 89 mm, P<.001). These results were consistent for both gestational age strata; however, paracervical block benefit was greater at an earlier gestation. Satisfaction scores with pain control and the procedure were significantly higher in the block group.
Although paracervical block is painful, it reduces first-trimester abortion pain regardless of gestational age, but the benefit on dilation pain was greater at earlier gestations.
ClinicalTrials.gov, www.clinicaltrials.gov, NCT01094366.
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Obstetrics and Gynecology 05/2012; 119(5):1030-7. · 4.73 Impact Factor
