Relias Media - Continuing Medical Education Publishing

The trusted source for

healthcare information and

CONTINUING EDUCATION.

  • Sign In
  • Sign Out
  • MyAHC
    • Home
      • Home
      • Newsletters
      • Blogs
      • Archives
      • CME/CE Map
      • Shop
    • Emergency
      • All Products
      • Publications
      • Study Guides
      • Webinars
      • Group Sales
    • Hospital
      • All Products
      • Publications
      • Study Guides
      • Webinars
      • Group Sales
    • Clinical
      • All Products
      • Publications
      • Study Guides
      • Webinars
      • Group Sales
    • All Access
      • My Subscription
      • Subscribe Now
    • My Account
      • My Subscriptions
      • My Content
      • My Orders
      • My CME/CE
      • My Transcript
    Home » Etonogestrel Contraceptive Implant and VTE in Postpartum Women
    ABSTRACT & COMMENTARY

    Etonogestrel Contraceptive Implant and VTE in Postpartum Women

    September 1, 2020
    No Comments
    Reprints
    Facebook Twitter Linkedin Share Share

    Related Articles

    Etonogestrel Contraceptive Implant and VTE in Postpartum Women

    The Etonogestrel Contraceptive Implant and Obesity

    Tamoxifen for the Management of Bleeding Irregularities in Contraceptive Implant Users

    Keywords

    contraceptive

    Implants

    etonogestrel

    postpartum

    progestin-only

    thromboembolism

    venous

    By Rebecca H. Allen, MD, MPH, Editor

    Associate Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI

    SYNOPSIS: In this national retrospective cohort study of postpartum women, use of the etonogestrel contraceptive implant immediately postpartum was not associated with an increased rate of readmission for venous thromboembolism within 30 days of delivery.

    SOURCE: Floyd JL, Beasley AD, Swaim LS, et al. Association of immediate postpartum etonogestrel implant insertion and venous thromboembolism. Obstet Gynecol 2020;135:1275-1280.

    The current labeling of the etonogestrel implant (Nexplanon) suggests delaying insertion until 21 days postpartum because of the risk of venous thromboembolism (VTE). This study was conducted to ascertain the rate of readmission for VTE during the first 30 days after delivery in women with and without the etonogestrel implant. The investigators used data from the 2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database, which included 36 million hospital discharges. Using ICD-10 codes, delivery hospitalizations were identified, as well as admissions containing a diagnosis code for both delivery and subdermal contraceptive insertion. Women with a history of VTE or who were taking anticoagulation medications were identified and excluded. Further data were collected, including age, insurance, mode of delivery, medical conditions, and tobacco use. The primary outcome was the rate of readmission for deep vein thrombosis and pulmonary embolism in women readmitted up to 30 days postpartum with and without immediate postpartum etonogestrel implant insertion.

    Analysis of the 3.38 million deliveries noted that only 8,639 (0.0025%) of these women underwent postpartum contraceptive implant insertion immediately after delivery. Women who received the implant were younger (25 vs. 29 years of age), more likely to have public health insurance (82% vs. 43%), more likely to be smokers (15% vs. 6%), and more likely to have hypertension (22% vs. 12%). There were no differences in terms of rates of diabetes, thrombophilia, systemic lupus erythematosus, or cesarean delivery. A total of seven VTE cases occurred in the implant group compared to 1,192 in the non-implant group. There was no difference in the rate of VTE among those who received an implant and those who did not (0.85/1,000 deliveries vs. 0.35/1,000 deliveries; odds ratio [OR], 2.41; 95% confidence interval [CI], 0.58-9.89). The difference remained unchanged when adjusting for age, smoking history, peripartum infection, and occurrence of postpartum hemorrhage (OR, 1.81; 95% CI, 0.44-7.45).

    COMMENTARY

    The U.S. Medical Eligibility Criteria for Contraceptive Use (USMEC) from the Centers for Disease Control and Prevention rates the etonogestrel implant as category 1 (no restrictions on use) in non-breastfeeding women and category 2 (benefits outweigh the risks) in breastfeeding women, for women less than 21 days postpartum.1 This is in contrast to the current labeling for the etonogestrel implant as mentioned earlier. The authors of this study did not find any increased risk of VTE with etonogestrel implant insertion immediately postpartum, which supports the USMEC recommendations. The study does have limitations in that it only followed patients up to 30 days postpartum and there may be cases of VTE that occurred beyond that. The rate of postpartum VTE has been found to persist until 12 weeks, albeit dropping from nine per 10,000 deliveries in the first week postpartum to 0.1-0.2 per 10,000 deliveries in the 12th week.2 Further, the study only examined inpatient readmission for VTE. There could have been subjects treated as outpatients, thus underestimating the risk of VTE. Additionally, database studies are limited by the accuracy of the discharge codes entered.

    Further limitations include the number of VTE events found in the study despite using a national database. Although the rates were consistent with other data, there still were only seven events in the etonogestrel implant arm, making the confidence intervals quite wide and, thus, less precise.2 A post hoc power analysis indicated that the study only had 61% power to detect a difference between the two groups. Moreover, the study did not account for other contraceptive methods that women in the non-implant group might have been using in the immediate postpartum period, such as depot medroxyprogesterone acetate (DMPA), the progestin-only pill, or the levonorgestrel intrauterine device (IUD). Of these other progestin-only methods, only DMPA has been associated with a slightly increased risk of VTE in the general population in previous studies.3 In a recent study examining DMPA use in the immediate postpartum period (within seven days of delivery), investigators found the risk of VTE to be slightly elevated compared to the control group (0.42/10,000 women-days vs. 0.15/10,000 women-days; adjusted OR 1.94; 95% CI, 1.38-2.72).4 Nevertheless, the authors concluded that, although the OR was elevated, the absolute risk was very low, and the USMEC ratings stating the method was safe to use less than 21 days postpartum were appropriate. Providing contraception in the immediate postpartum period is an important option for patients for several reasons. It is convenient, patients have health insurance coverage at that time, and they may not be able to follow up postpartum in the office. Overall, progestin-only methods are considered safe immediately postpartum. This study found nothing to contradict the ratings of the USMEC, and the drug labeling of the etonogestrel implant likely is more conservative than necessary. In our practice, we continue to offer our patients immediate postpartum IUD and implant insertion, DMPA administration, and progestin-only pill prescriptions.

    REFERENCES

    1. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65:1-103.
    2. Tepper NK, Boulet SL, Whiteman MK, et al. Postpartum venous thromboembolism: Incidence and risk factors. Obstet Gynecol 2014;123:987-996.
    3. Tepper NK, Whiteman MK, Marchbanks PA, et al. Progestin-only contraception and thromboembolism: A systematic review. Contraception 2016;94:678-700.
    4. Tepper NK, Jeng G, Curtis KM, et al. Venous thromboembolism among women initiating depot medroxyprogesterone acetate immediately postpartum. Obstet Gynecol 2019;133:533-540.

    Post a comment to this article

    Report Abusive Comment

    www.reliasmedia.com

    OB/GYN Clinical Alert

    View PDF
    OB/GYN Clinical Alert (Vol. 37, No. 5) – September 2020
    September 1, 2020

    Table Of Contents

    Is Vaginal Progestogen Equivalent to Intramuscular Progestogen for Preventing Preterm Birth in High-Risk Women?

    Apical Suspension at the Time of Vaginal Hysterectomy

    Maternal and Pregnancy Characteristics Associated with Periviable Interventions

    Etonogestrel Contraceptive Implant and VTE in Postpartum Women

    Begin Test

    Buy this Issue/Course

    Financial Disclosure: OB/GYN Clinical Alert’s Editor Rebecca H. Allen, MD, MPH, reports that she receives grant/research support from Bayer, and is a consultant for Bayer, Mylan, and Merck. Peer Reviewer Sarah J. Betstadt, MD, MPH, reports that she is on the speakers bureau for Merck. Nurse Planner Jeanine Mikek, MSN, RN, CEN; Editorial Group Manager Leslie Coplin; Editor Jason Schneider; Executive Editor Shelly Mark; and Accreditations Director Amy M. Johnson, MSN, RN, CPN, report no financial relationships relevant to this field of study.

    Shop Now: Search Products

    • Subscription Publications
    • Books & Study Guides
    • Webinars
    • Group & Site
      Licenses
    • State CME/CE
      Requirements

    Webinars And Events

    View All Events
    • Home
      • Home
      • Newsletters
      • Blogs
      • Archives
      • CME/CE Map
      • Shop
    • Emergency
      • All Products
      • Publications
      • Study Guides
      • Webinars
      • Group Sales
    • Hospital
      • All Products
      • Publications
      • Study Guides
      • Webinars
      • Group Sales
    • Clinical
      • All Products
      • Publications
      • Study Guides
      • Webinars
      • Group Sales
    • All Access
      • My Subscription
      • Subscribe Now
    • My Account
      • My Subscriptions
      • My Content
      • My Orders
      • My CME/CE
      • My Transcript
    • Help
    • Search
    • About Us
    • Sign In
    • Register
    Relias Media - Continuing Medical Education Publishing

    The trusted source for

    healthcare information and

    CONTINUING EDUCATION.

    Customer Service

    customerservice@reliasmedia.com

    U.S. and Canada: 1-800-688-2421 x 2

    International +1-404-262-5476 x 2

    Accounts Receivable

    1-800-688-2421 x 3
    ReliasMedia_AR@reliasmedia.com

    Sales

    1-800-688-2421 x 1

    Mailing Address

    • 1010 Sync St., Suite 100
      Morrisville, NC 27560-5468
      USA

    © 2022 Relias. All rights reserved.

    Do Not Sell My Personal Information  Privacy Policy  Terms of Use  Contact Us  Reprints  Group Sales

    For DSR inquiries or complaints, please reach out to Wes Vaux, Data Privacy Officer, DPO@relias.com

    Design, CMS, Hosting & Web Development :: ePublishing