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Contraceção intrauterina no pós-parto e o seu impacto na saúde materna: Uma revisão sistemática da literatura
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Authors
Abstract(s)
Introdução: O período pós-parto representa um momento crítico para a saúde materna
e crucial na prevenção de gravidezes não planeadas. A contraceção intrauterina (CIU) surge
como uma opção eficaz, reversível e de longa duração, podendo ser inserida em diferentes
momentos após o parto. No entanto, há um debate sobre a melhor época para sua colocação
e seus impactos na saúde materna, incluindo eficácia, efeitos adversos e satisfação das
utilizadoras. Diante dessa incerteza, esta revisão sistemática pretende analisar o impacto da
inserção da contraceção intrauterina no pós-parto, comparando diferentes tempos de
inserção e as suas implicações clínicas.
Métodos: Foi realizada uma revisão sistemática conforme os critérios PRISMA. A
pesquisa foi conduzida nas bases de dados PubMed, Web of Science, Scopus e Lilacs,
utilizando descritores relacionados à CIU, pós-parto e saúde materna. Foram incluídos
estudos publicados entre 2001 e 2024, que avaliaram a inserção da CIU em mulheres
puérperas até 12 semanas após o parto, com comparação entre diferentes tempos de
inserção ou ausência de inserção. Foram excluídos estudos com gestantes de alto risco,
artigos de revisão, protocolos, cartas ao editor, relatos de caso e estudos sem texto integral
disponível.
Resultados: Foram incluídos 36 estudos na análise. Os tempos de inserção variaram
entre: até 10 minutos pós-placenta (13 estudos); até 48 horas pós-parto (3 estudos); 2 ou 3
tempos de inserção distintos (17 estudos) e outros tempos de inserção (3 estudos). A eficácia
foi avaliada pela taxa de continuidade e ocorrência de gravidez não planeada. A maioria dos
estudos indicou altas taxas de continuidade nos primeiros 6 a 12 meses, variando entre
47,5% e 91,5%. O risco de gravidez foi muito baixo (menos de 1% ao ano na maioria dos
estudos). Os efeitos adversos mais frequentes foram: distúrbios menstruais (relatados em
até 28,1% das mulheres); Dor, quer seja abdominal, pélvica, cólica ou dismenorreia
(ocorrência variando entre 4,4% e 37,6%); Infeção e doença inflamatória pélvica (DIP)
(frequência abaixo de 2% na maioria dos estudos). A expulsão do dispositivo (taxas entre
2,1% a 52,9%) e a sua remoção precoce, principalmente devido a efeitos adversos ou crenças
socioculturais também foram amplamente documentadas. A satisfação foi elevada na
maioria dos estudos, variando entre 56,3% e 100%.
Discussão: Esta revisão sistemática analisou a eficácia, efeitos adversos e satisfação em
relação à inserção de contraceção intrauterina (CIU) no pós-parto. Os resultados
demonstraram que a taxa de continuidade do método é elevada e a taxa de falha contracetiva
foi baixa, com diversos estudos não reportando gestações, o que confirma a alta eficácia do
método já relatado por outros estudos. De um modo geral, a maioria dos artigos corrobora
que os efeitos adversos mais comuns incluem distúrbios menstruais, dor, infeções e complicações relacionadas à posição do dispositivo. Sugerindo-se que a ocorrência destes
efeitos adversos está mais associada ao uso do dispositivo intrauterino do que propriamente
ao momento da sua inserção. Verificou-se que a taxa de remoção é influenciada por
múltiplos fatores, como o tipo de parto, efeitos adversos relacionados com a inserção e até
mesmo características individuais das utilizadoras. A expulsão foi mais frequente nas
primeiras semanas após a inserção e ocorreu mais em partos vaginais do que em cesarianas.
A satisfação com o método foi elevada, com a maioria dos estudos reportando taxas
superiores a 75%, sendo que muitas utilizadoras demonstraram intenção de continuar o uso
e recomendar o DIU/SIU. Entre as limitações desta revisão, destacam-se a heterogeneidade
dos estudos incluídos e desfechos avaliados. Para pesquisas futuras, recomenda-se a
realização de ensaios clínicos randomizados multicêntricos, investigações sobre estratégias
para reduzir a taxa de expulsão e otimização da implementação desta estratégia contracetiva
em diferentes contextos de saúde.
Conclusão: A inserção da CIU no pós-parto revelou-se uma estratégia útil para ampliar o
acesso à contraceção, para além disso, a sua inserção no pós-parto imediato e precoce
apresenta vantagens como conveniência, alta eficácia e adesão ao método, especialmente
quando realizada durante a cesariana. No entanto, a expulsão do dispositivo é um fator
limitante, principalmente em partos vaginais. A longo prazo, a CIU no pós-parto
demonstrou ser uma alternativa segura e eficaz, contribuindo para a redução das taxas de
gravidez não planeada e melhorando o planeamento familiar. A decisão sobre o momento
da inserção deve ser individualizada, considerando o tipo de parto, preferência da paciente
e risco de complicações.
Introduction: The postpartum period is a critical time for maternal health and crucial in the prevention of unplanned pregnancies. Intrauterine contraception (IUC) has emerged as an effective, reversible, and long-lasting option that can be inserted at different times after childbirth. However, there is debate about the best time to insert it and its impact on maternal health, including efficacy, adverse effects, and user satisfaction. Given this uncertainty, this systematic review aims to analyse the impact of intrauterine contraception insertion in the postpartum period, comparing different insertion times and their clinical implications. Methods: A systematic review was carried out according to the PRISMA criteria. The search was conducted in the PubMed, Web of Science, Scopus and Lilacs databases, using descriptors related to IUC, postpartum and maternal health. Studies published between 2001 and 2024 were included, which evaluated IUC insertion in postpartum women up to 12 weeks after delivery, comparing different insertion times or lack of insertion. Studies with high-risk pregnant women, review articles, protocols, letters to the editor, case reports and studies without full text available were excluded. Results: 36 studies were included in the analysis. Insertion times varied between up to 10 minutes post-placenta (13 studies); up to 48 hours post-partum (3 studies); 2 or 3 different insertion times (17 studies) and other insertion times (3 studies). Efficacy was assessed by continuation rate and occurrence of unplanned pregnancy. Most studies indicated high continuation rates in the first 6 to 12 months, ranging from 47.5% to 91.5%. The risk of pregnancy was very low (less than 1% per year in most studies). The most frequent adverse effects were menstrual disorders (reported in up to 28.1% of women), pain whether abdominal, pelvic, colic or dysmenorrhea (occurrence ranged from 4.4% to 37.6%). infection and pelvic inflammatory disease (PID) (frequency below 2% in most studies). Device expulsion (rates ranging from 2.1% to 52.9%) and its early removal, mainly due to adverse effects or sociocultural beliefs, have also been widely documented. Most studies had high satisfaction, ranging from 56.3% to 100%. Discussion: This systematic review analysed the efficacy, adverse effects and satisfaction of intrauterine contraception insertion in the postpartum period. The results showed that the continuation rate of the method is high, and the contraceptive failure rate was low, with several studies reporting no pregnancies, which confirms the high efficacy of the method already reported by other studies. In general, most of the articles confirm that the most common adverse effects include menstrual disorders, pain, infections and complications related to the position of the device. It is suggested that the occurrence of these adverse effects is more associated with the use of the intrauterine device than with the time of its insertion. It was found that the removal rate is influenced by multiple factors, such as the type of delivery, adverse effects related to insertion and even individual characteristics of the users. Expulsion was more frequent in the first few weeks after insertion and occurred more in vaginal deliveries compared with cesarean sections. Satisfaction with the method was high, with most studies reporting rates of over 75%, and many users showed an intention to continue using and recommending the IUD/IUS. The limitations of this review include the heterogeneity of the studies included and the outcomes assessed. For future research, we recommend multicentre randomized clinical trials, investigations into strategies to reduce the expulsion rate and optimization the implementation of this contraceptive strategy in different healthcare settings. Conclusion: The insertion of the IUC in the postpartum period has proved to be a useful strategy for increasing access to contraception. In addition, its insertion in the immediate and early postpartum period has advantages such as convenience, high efficacy and adherence to the method, especially when performed during cesarean section. However, expulsion of the device is a limiting factor, especially in vaginal deliveries. In the long term, postpartum IUC has proven to be a safe and effective alternative, contributing to a reduction in unplanned pregnancy rates and improving family planning. The decision on the timing of insertion should be individualized, considering the type of delivery, patient preference and risk of complications.
Introduction: The postpartum period is a critical time for maternal health and crucial in the prevention of unplanned pregnancies. Intrauterine contraception (IUC) has emerged as an effective, reversible, and long-lasting option that can be inserted at different times after childbirth. However, there is debate about the best time to insert it and its impact on maternal health, including efficacy, adverse effects, and user satisfaction. Given this uncertainty, this systematic review aims to analyse the impact of intrauterine contraception insertion in the postpartum period, comparing different insertion times and their clinical implications. Methods: A systematic review was carried out according to the PRISMA criteria. The search was conducted in the PubMed, Web of Science, Scopus and Lilacs databases, using descriptors related to IUC, postpartum and maternal health. Studies published between 2001 and 2024 were included, which evaluated IUC insertion in postpartum women up to 12 weeks after delivery, comparing different insertion times or lack of insertion. Studies with high-risk pregnant women, review articles, protocols, letters to the editor, case reports and studies without full text available were excluded. Results: 36 studies were included in the analysis. Insertion times varied between up to 10 minutes post-placenta (13 studies); up to 48 hours post-partum (3 studies); 2 or 3 different insertion times (17 studies) and other insertion times (3 studies). Efficacy was assessed by continuation rate and occurrence of unplanned pregnancy. Most studies indicated high continuation rates in the first 6 to 12 months, ranging from 47.5% to 91.5%. The risk of pregnancy was very low (less than 1% per year in most studies). The most frequent adverse effects were menstrual disorders (reported in up to 28.1% of women), pain whether abdominal, pelvic, colic or dysmenorrhea (occurrence ranged from 4.4% to 37.6%). infection and pelvic inflammatory disease (PID) (frequency below 2% in most studies). Device expulsion (rates ranging from 2.1% to 52.9%) and its early removal, mainly due to adverse effects or sociocultural beliefs, have also been widely documented. Most studies had high satisfaction, ranging from 56.3% to 100%. Discussion: This systematic review analysed the efficacy, adverse effects and satisfaction of intrauterine contraception insertion in the postpartum period. The results showed that the continuation rate of the method is high, and the contraceptive failure rate was low, with several studies reporting no pregnancies, which confirms the high efficacy of the method already reported by other studies. In general, most of the articles confirm that the most common adverse effects include menstrual disorders, pain, infections and complications related to the position of the device. It is suggested that the occurrence of these adverse effects is more associated with the use of the intrauterine device than with the time of its insertion. It was found that the removal rate is influenced by multiple factors, such as the type of delivery, adverse effects related to insertion and even individual characteristics of the users. Expulsion was more frequent in the first few weeks after insertion and occurred more in vaginal deliveries compared with cesarean sections. Satisfaction with the method was high, with most studies reporting rates of over 75%, and many users showed an intention to continue using and recommending the IUD/IUS. The limitations of this review include the heterogeneity of the studies included and the outcomes assessed. For future research, we recommend multicentre randomized clinical trials, investigations into strategies to reduce the expulsion rate and optimization the implementation of this contraceptive strategy in different healthcare settings. Conclusion: The insertion of the IUC in the postpartum period has proved to be a useful strategy for increasing access to contraception. In addition, its insertion in the immediate and early postpartum period has advantages such as convenience, high efficacy and adherence to the method, especially when performed during cesarean section. However, expulsion of the device is a limiting factor, especially in vaginal deliveries. In the long term, postpartum IUC has proven to be a safe and effective alternative, contributing to a reduction in unplanned pregnancy rates and improving family planning. The decision on the timing of insertion should be individualized, considering the type of delivery, patient preference and risk of complications.
Description
Keywords
Contraceção Intrauterina Pós-Parto Saúde Materna