Articles
Register for Postpartum Intrauterine Device Contraception - An Experience From Egypt
Farouk Fikry, MD, Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
&
Amr Nadim, MD, Assistant Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Abstract:
This study was conducted to evaluate the safety and effectiveness of immediate postpartum intra-uterine contraceptive device (IUCD) insertion. The study included 340 cases. TCu 380A IUCD was inserted immediately after delivery of the placenta in 129 vaginal deliveries. In another 100 cases of vaginal deliveries, IUCD was inserted within 6 to 48 hours postpartum. In 111 cases IUCD was inserted during cesarean section. All cases were followed up for one year. Spontaneous expulsion occurred in 23 (6.8%) of cases. The most common disadvantage was missed threads in 98 (28.8%). Lengthening of the threads by 10 cm nylon attachment in the cesarean section cases was later employed to overcome the intrauterine folding or the threads. Misplaced IUCD occurred in 20 (5.9%) of cases. Pregnancy occurred in 2 cases (0.6%). There was no significant difference between the three groups studied in the incidence of complications. It was concluded that postpartum insertion of IUCD is a safe, convenient and effective method of IUCD application.
Introduction:
The idea of immediate postpartum insertion of the IUCD was introduced in the mid sixties in the United States. This timing is advantageous due to the relatively easy insertion, and the relative absence of pain. Furthermore, it is not associated with increased risk of complications
(1). In fact, there are fewer bleeding problems, lower perforation rates and a lower incidence of infection
(2,3). The previously reported major problem facing the postpartum insertion of the device was the high expulsion rate, which accordingly led to an overall lower continuation rate than for the interval insertion of the intrauterine devices
(4). The current study was conducted to re-evaluate the safety, effectiveness and convenience of postpartum insertion of IUCDs.
Patients and Methods:
This clinical trial was conducted at Ain Shams Maternity Hospital, Cairo, Egypt, in the period from January 1996 to May 2000. A consecutive sampling method was adopted to eliminate those with the following exclusion criteria: - prolonged rupture of membranes, chorio-amnionitis, marked anemia, history of bleeding tendency or coagulation, intrapartum or postpartum hemorrhage, history of recurrent pelvic infections, and disagreement to participate in the study during the counseling process.
The study sample included a total of 340 women who wanted to practice family planning and agreed to participate in this study. Cases of vaginal deliveries were randomly assigned to the first 2 of the following study groups:
- Group 1: Postplacental insertion group included 129 cases of vaginal deliveries. IUCD was inserted within 10 minutes after placental separation.
- Group 2: Immediate postpartum insertion group included 100 cases of vaginal deliveries. IUCD was inserted within 6-48 hours postpartum.
- Group 3: Lower segment cesarean section insertion group included 111 cases. IUCD was inserted manually after placental separation, through the uterine incision.
Pre insertion counseling:
Counseling was mainly conducted during the antenatal period or early in labour. It was mainly directed so that the patients are well informed and convinced in order to make reasoned and impressed decisions about their fertility control.
Post insertion Counseling:
Before discharge, all participants were instructed about probable side effects and complications. Each woman was shown the TCu 380A device, was told about its 10 years of protection and its safety for breast-feeding. They were also informed about the recognition and checking of the IUCD threads and were instructed to recognize its expulsion. They were also told to return immediately for a re-insertion or another contraceptive method if expulsion occurred. Women were told about the warning signs of potential complications such as late periods, irregular bleeding, abdominal pain, dyspareunia, offensive vaginal discharge, missing threads or feeling of the IUCD in the vagina.
Insertion Techniques:
Prior to the insertion process, the genital tract was explored to exclude lacerations, retained products, blood clots or congenital abnormalities of the uterine cavity.
Manual Insertion:
Manual insertion was only appropriate in group1 in whom insertion was performed within 10 minutes of delivery of the placenta. Under complete aseptic precautions, the sterile device pack was opened and the contraceptive device grasped between the index and middle fingers. The threads were placed in the palm of the gloved hand
(fig.1). The other hand was used to stabilize the uterus externally while the devise was placed in the fundus of the uterus. After placing the IUCD, the inserting hand was rotated 15 degrees to avoid dislodging the IUCD, then gently withdrawn from the uterine cavity.
Insertion using Ring or Kelley's forceps:
In the post placental insertions the traditional ring forceps was used (fig.
2). The specially designed Kelly's forceps was used for the second group cases.
Insertion during cesarean section:
After delivery of the placenta, blood clots were removed and bleeding controlled. The IUCD was placed manually in the uterine fundus. The threads were directed towards the cervix
(fig.
3). To overcome the complication of missed threads, which was noted during, follow up the IUCD threads were lengthened by tying 10 cm sterile suture material to their ends
(fig.
4). This made it possible to push the threads into the partially dilated cervical canal
(fig
5, fig.
6). This modification was adopted in the latter part of the work. Care was taken not to include the device threads in the lower uterine segment sutures.
Follow up visits:
Follow up visits were scheduled at 6 weeks, 6 months and one-year postpartum.
In case of expulsion, another contraceptive method was offered, or a re-insertion after 6 weeks postpartum. During each follow up visit, any side effects attributable to the IUCD were asked about. If the threads were too long, they were cut short. If they were not seen, the patient was referred for an ultra-sound examination to ensure proper placement of the IUCD.
Results:
The vaginal post-placental insertion group:
The age ranged from 18-40 years with a mean age of 28.32+6.07 years. 39 (30.2%) women were primiparous and 90 (69.8%) were multiparous. 18 cases (13.9%) had previously used IUCD. General anesthesia was used in 39 (30.2%). Manual insertion was carried out in 44 cases (34.1%), and the ring forceps was used for insertion in 85 cases (65.9%). Cervical visualization was difficult in 39 (30.2%) uncooperative patients; this made the insertion difficult in 11 cases (8.5%).
At 6 weeks follow up, spontaneous expulsion had occurred in 9 cases (6.9%). The threads were seen in 64 cases (49.6 %) and were trimmed short if necessary. 46 (35.6%) had missing threads on speculum examination, 11 cases (8.5%) had misplaced IUCD diagnosed by ultrasound examination and were removed. Four women (3.1%) reported vaginal bleeding, 2 of them requested removal of the IUCD at the 6 months visit. Discontinuation occurred in a total of 22 (17.05%) cases at 6 months. At one year all the remainders, 107 (82.9%) satisfactorily continued using the IUCDs. No cases of pelvic inflammatory disease were diagnosed. Only 4 (3.1%) cases had non-specific vaginitis.
The vaginal immediate postpartum insertion group:
The age ranged from 18-40 years with mean age of 30.15 + 7.3 years. 44 women (44%) were primiparous, while 56 (56%) were multiparous. 24 women (42.8%) of the multiparous women gave history of previous IUCD use. The timing of IUCD insertion ranged between 6-48 hours postpartum. It was 6 hours in 58 (58%) of cases, 6-24 in 23 cases (23%), and 24-48 hours in 19 cases (19%). Kelley's forceps was used for insertion of IUCD in all cases. Anesthesia was not needed for any of them.
At the first visit, 9 women (9%) reported spontaneous expulsion. The IUCD was removed in another 8 cases (8%). The cause of its removal was misplaced IUCD in 5 cases, (5%) and vaginal bleeding in 3 cases (3%). At the 6 months visit 2 more cases had spontaneous expulsion, and 6 cases had their IUCDs removed. Only 1 case had non-specific vaginitis. By one year the remaining 75 (75%) cases retained their IUCDs.
The cesarean section group:
The age ranged from 20-35 years with a mean age of 27.5 + 7.2 years. 90 (81.1%) women were primiparous and 21 (18.9%) were multiparous. 10 cases (9.0%) had previously used IUCD. Cesarean section operations were elective in 86 cases and during the first stage of labour in 25.
At the first visit after 6 weeks of insertion, 11 cases (9.9%) had vaginal bleeding. The IUCD was misplaced in 1 case (0.9%) and was removed. Spontaneous expulsion had not occurred at this visit. The threads were not seen in 27 cases (24.3%), correct position was diagnosed by ultrasound examination and the condition was explained. Elongated threads were shortened. Pelvic inflammatory disease was not diagnosed in this group.
At the 6 months visit spontaneous expulsion had occurred in 3 cases (2.7%) and the IUCD was removed because of bleeding in 11 cases (9%), and because of pregnancy in another case (0.9%). By the end of one year 106 (96.4%) were satisfactorily continuing the use of IUCDS.
Comparison between the studied groups showed two important results, the first to be mentioned is that complications and continuation rate did not differ significantly between the groups that were delivered vaginally. So the short time difference in application of the IUCD between the 2 methods did not affect significantly the complication rates. The second important result is the significantly lower incidence of misplacement and expulsion rates among the post cesarean section group. This is obviously due to better placement of IUCD under vision during cesarean section.
Discussion:
Postpartum insertion of intrauterine contraceptive device has a certain appeal since at this time women are highly motivated to consider family planning. Also in developing countries this timing is an asset since the women's return for family planning is not a sure matter. The early start of contraception after delivery is of utmost importance since the return of fertility cannot be accurately judged. The main advantages of postpartum insertion include convenience to the woman and her service provider and the ease of insertion. Another advantage is the cost savings associated with providing family planning at birth rather than at a subsequent visit. Furthermore, there is no difference in the complications rates
(6) between postpartum and interval IUCD insertions.
The most significant problem with postpartum insertions is the high expulsion rate, which made this venture condemned and opposed by some authors. It seems that the high expulsion rate is multifactorial
(5). One of these factors is the age of the women. In the current study, 75% of the expulsions occurred in women under 30 years of age, which is in agreement with the WHO report in 1987. Another factor is the parity where many authors confirmed that the expulsion rate was much higher in primiparous women
(1,7). On the contrary, Morrison and associates (3) reported that age and parity did not affect the expulsion rate. The incidence of expulsion rate has also been attributed to the method of insertion. Several studies concluded that manual insertions had lower expulsion rates than the forceps insertions
(1,9,10). A much lower expulsion rate for devices inserted at cesarean section compared to those inserted after vaginal delivery was documented by studies from Mexico, China and Belgium.
(16,17,18). Mariscal et al. (13), monitored uterine placement of IUCD after immediate postpartum insertions by sonography to determine a correlation between the distance of the IUCD from the uterine fundus and the incidence of expulsion. They could not demonstrate that good fundal placement influenced the incidence of expulsion. Thierty et al.
(14), in spite of their earlier support raised the question of how an IUCD can retain its fundal location without inversion, translocation or somersaulting in a large and involuting postpartum uterus. Liu et al.
(19) proved that surgical suturing of the IUCD to the uterine wall did not improve the device's performance or expulsion rate. In the present report post cesarean section group had the lowest incidence rates of expulsions and misplaced IUCD. Spontaneous expulsion after postpartum insertion occurred on the whole in 6.8% of cases, being 8.7% in vaginal insertions versus 2.7% in cesarean section insertions. Misplaced IUCD occurred in 5.9% of cases being 8.3% in vaginal insertions versus 0.9% after cesarean section insertions. This is an indication of the better placement of the IUCD under vision during cesarean section and the proposed modification of elongating the IUCD threads.
As regards infection, the WHO recommends that IUCD insertion should be discouraged when cesarean section follows prolonged labour and or ruptured membranes because of the potential risk of chorio-amnionitis
(6). The general policy of administration of prophylactic antibiotics to all our delivery cases, contributed to the absence of any infection or pelvic inflammatory disease. Only 4 (1.5%) cases of the vaginal insertions group developed mixed vaginal infection and in one case the IUCD had to be removed.
Also in this study 5.9% of women of all groups complained of vaginal bleeding, being 3.1% in those with post-placental insertion, 5% in those with postpartum insertion, and 9.9% in cesarean section cases. Several studies (1,2,11,22) have shown a lower incidence of excessive or irregular bleeding with the immediate postpartum insertions compared to the interval insertions.
There were no cases of uterine perforation in the 340 women participating in this study. This is in agreement with other studies, which have shown uterine perforation to be a very rare event
(11,21). Cole et al. (10) reported one case of uterine perforation among 3800 post placental insertions.
Pregnancy occurred in two cases (0.6%) in the present work. This is in agreement with the reported rates, which range from 1-2.8 per 100 users at 24 months. These rates are comparable to the rates quoted for interval IUCD users
(24).
Conclusions:
It can be concluded that postpartum IUCD insertion is generally a safe and effective family planning method. It is not associated with increased risk of uterine perforation or pelvic infection. It does not have adverse impacts on either uterine involution or breast-feeding.
Cu T 380A can be chosen for postpartum IUCD insertions. Lengthening of the IUCD threads was found to be beneficial in cesarean section group.
It is apparent that postpartum insertion of IUCD can make a significant positive contribution to family planning, maternity and child health care. This is of utmost importance in developing countries where women are better off obtaining a contraceptive method before hospital discharge.
Tables and Figures:
|
Table 1: Side effects and complications attributed to IUCD use in the studied groups within the first 6 months of insertion. |
||||
| Side effects or complications | Post placental insertion N=129 | Postpartum insertion N=100 | During cesarean section insertion N=111 | Total |
| Vaginal Bleeding | 4 (3.1%) | 5 (5%) | 11 (9.9%) | 20 (5.9%) |
| Misplaced ICD | 11 (8.5%) | 8 (8%) | 1 (0.9%) | 20 (5.9%) |
| Infection | 4 (3.1%) | 1 (1%) | -(0.0%) | 5 (1.5%) |
| Spontaneous expulsion | 9 (6.9%) | 11 (11%) | 3 (2.7%) | 23 (6.8%) |
| Pregnancy | 1 (0.7%) | 0 | 1 (0.9%) | 2 (0.6%) |
| Missed Thread | 46 (35.6%) | 25 (25%) | 27 (24.3%) | 98 (28.8%) |
| X2-P |
* 4.99 - > 0.05 |
340 | ||
|
** 25.8 - < 0.0001 |
||||
|
* Comparison between post placement and postpartum insertion |
||||
|
Table 2: Continuation of IUCD one year after its insertion among the studied groups. |
||||
| Continuation of IUCD | Post placental insertion N=129 | Postpartum insertion N=100 | During cesarean section insertion N=111 | Total |
| Removed for complications | 13 (10.07%) | 14 (14%) | 2 (1.8%) | 29 (8.5%) |
| Spontaneous expulsion | 9 (6.9%) | 11 (11%) | 3 (2.7%) | 23 (6.8%) |
| Continued use | 107 (82.9%) | 75 (75%) | 106 (95.5%) | 288 (84.7%) |
| X2-P |
* 2.22 - > 0.05 |
340 | ||
|
** 17.81 - < 0.0001 |
||||
|
* Comparison between post placement and postpartum insertion |
||||
| Clicking the images will open a larger view in a new window. | ||
 Fig.1: Showing TCu 380A with the lengthened thread held between the index and middle fingers. |
 Fig.2: Showing TCu 380A with the lengthened thread held by the ring forceps. |
 Fig.3: Shows the normal threads of TCu 380A in the lower uterine segment away from and high above the cervical canal after fundal insertion of the IUCD. |
 Fig.4: Shows the 10 cm elongated thread of the TCu 380A. |
 Fig.5: Shows the TCu 380A already inserted in the uterine fundus and the elongated threads before being pushed into the cervix. |
 Fig.6: Shows the elongated thread of TCu 380A inside the cervix. |
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