Quiz - LARC management

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This month’s quiz reviews two types of long-acting reversible contraception (LARC): a contraceptive implant and an intrauterine device (IUD).  Information on initiation and management is gleaned from a recent ACOG practice bulletin.

1. Routine antibiotic prophylaxis is recommended before IUD insertion:  

A.  Yes

B.  No

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Answer: B. No

In a meta-analysis of all known randomized controlled trials, antibiotic prophylaxis at the time of IUD insertion did not decrease the risk of pelvic inflammatory disease (PID) nor did it reduce the likelihood of IUD removal within the first 3 months.

2. Insertion of an IUD or an implant may occur at what point in the menstrual cycle (assuming pregnancy is reasonably excluded):

A.  Three days before the start of menstruation

B.  During menses

C.  Any time during the menstrual cycle

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Answer: C. Any time during the menstrual cycle 

A systematic review concluded that outcomes of continuation, effectiveness and safety were no better when a copper IUD was inserted during menses and that requiring a woman to be menstruating is an obstacle to access.

3. The primary mechanism of a contraceptive implant is:  

A.  Suppression of ovulation

B.  Thickening of cervical mucus

C.  Alteration of the endometrial lining

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Answer: A. Suppression of ovulation

Additional contraceptive efficacy may be conferred by the implant’s thickening of cervical mucus and alteration of the endometrial lining.

4. The following gynecologic procedure or procedures can be performed with an IUD in place:  

A.  Endometrial biopsy

B.  Colposcopy

C.  Cervical ablation or excision

D. Endocervical sampling

E. All of the above

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Answer: E. All of the above

As with other women who experience abnormal uterine bleeding in the perimenopausal  period, unexpected bleeding should prompt evaluation in women with IUDs. Endometrial sampling can be performed with a small endometrial suction curette; sampling should be repeated if there is insufficient tissue for diagnosis. During cervical ablation or excision procedures, IUD strings may be tucked into the cervical canal if possible, or cut.

5. IUD removal is recommended in pregnant women: 

A. When the IUD strings are visible

B.  When the strings can be removed safely from the cervical canal

C. Both A and C

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Answer: C. Both A and B

Risks of adverse pregnancy outcomes are greater in the setting of IUD retention.

References:

Committee on Practice Bulletins-Gynecology, Long-Acting Reversible Contraception Work Group. Practice Bulletin Number 186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Obstet Gynecol.2017 Nov;130(3):e251-e269.