The edition · Obstetrics & Gynaecology
Immediate postpartum LARC prevents pregnancies but expels five times as often after vaginal birth
An umbrella review of nine systematic reviews found six-month pregnancy rates far lower with immediate insertion and expulsion risk five times higher after vaginal delivery, ACOG has published a new clinical practice guideline on cervical cerclage, and metformin failed to prevent gestational diabetes while lengthening gestation.
The edition in brief
An umbrella review of nine systematic reviews and 92 comparisons examined immediate against delayed insertion of long-acting reversible contraception after delivery and after abortion. Immediate insertion gave higher initiation, higher use at six months and lower six-month pregnancy rates (relative risk 0.16, 95% CI 0.04-0.71, moderate certainty). The trade-off is expulsion: immediate intrauterine device insertion raised expulsion risk substantially, most sharply after vaginal delivery (RR 5.09, 95% CI 2.04-12.73, high certainty) and in the first trimester after medical abortion (RR 2.02). ACOG has published a new clinical practice guideline on cervical cerclage, covering indications, surgical technique, alternatives and management, with recommendations classified by strength and evidence quality using a modified GRADE framework. An individual participant data meta-analysis of ten trials and 2,297 pregnancies tested whether metformin prevents gestational diabetes in pregnancies without diabetes. It did not, on either WHO 1999 or NICE 2015 criteria (adjusted odds ratio 1.00 for both), reaching significance only under IADPSG thresholds on adjusted analysis. But it was associated with longer gestation by 0.30 weeks and lower odds of preterm birth (adjusted odds ratio 0.64, 95% CI 0.47-0.89). A meta-analysis of 21 studies and 5,650 women found continuous glucose monitoring in gestational diabetes improved glycaemic measures and was associated with 8-35% reductions in caesarean delivery, macrosomia, neonatal hypoglycaemia and hyperbilirubinaemia, alongside 21% more medication use.
Immediate LARC prevents more pregnancies, and falls out more often
Immediate postpartum or postabortion LARC insertion substantially reduces six-month pregnancy rates and should remain the default, but expulsion is five times more likely after vaginal delivery, so counsel explicitly and arrange an easy route back.
ACOG has published a clinical practice guideline on cervical cerclage
No new drug regulation in obstetrics today, but ACOG has published a graded clinical practice guideline on cervical cerclage covering indications, technique and alternatives — worth checking your unit protocol against.
Continuous glucose monitoring improved outcomes in gestational diabetes
Continuous glucose monitoring in gestational diabetes improved glycaemic control modestly and was associated with 8-35% fewer adverse maternal and neonatal outcomes, apparently by prompting earlier escalation of treatment.
Metformin did not prevent gestational diabetes, but pregnancies lasted longer
Metformin did not prevent gestational diabetes in pooled participant-level data from ten trials, but was associated with longer gestation and fewer preterm births — a secondary finding that warrants its own trial rather than a change in practice.
Teach the threads before she leaves the ward
When inserting an intrauterine device immediately after a vaginal birth, teach thread-checking and name the higher expulsion risk before discharge, and arrange rather than advise the follow-up check.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this one is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for obstetrics & gynaecology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free