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   Table of Contents      
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 3  |  Page : 199-203

Evaluation of Safety and Efficacy of Postpartum Intrauterine Contraceptive Devices (PPIUCD) in Vaginal and Caesarean Section Deliveries: A Hospital Based Study


Department of Obstetrics and Gynaecology, R.D.B.P Jaipuria Hospital, RUHS college of medical sciences, Jaipur, Rajasthan, India

Date of Submission06-Jun-2020
Date of Decision29-Jun-2020
Date of Acceptance07-Jul-2020
Date of Web Publication16-Dec-2020

Correspondence Address:
DGO, DNB (OBG) Radha Agarwal
Flat no 2, Teaching staff quarter A, Pacific Medical College and Hospital, Udaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_53_20

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  Abstract 


Background: Immediate postpartum intrauterine contraceptive device (PPIUCD) is a lucrative postpartum family planning method which provide an effective reversible contraception for women in delivery settings. PPIUCD can be inserted post-placental, intra-caesarean and within 48 hours postpartum. We conducted this study to determine the outcome, satisfaction rate and continuation rate of PPIUCD. Materials and Method: This was a prospective observational study conducted in a tertiary care teaching institute. CuT 380A was inserted within 10 minutes of placental delivery in accepters who fulfilled the Medical Eligibility Criteria and had no contraindications for PPIUCD. They were then followed up for 3 months. A Cohort of 260 vaginal and caesarean deliveries with PPIUCD in situ were studied over seven months period and follow-up results were compared between Vaginal and Caesarean groups. Result: Overall expulsion rate was 8.47%, removal rate was 14.83% and continuation rate was 76.7%. There was no significant difference in removal rate of two groups. Spontaneous expulsion occurred in 8.47% cases and were significantly higher in vaginal insertion group (p value 0.0017). Overall complication rate was low. No case of perforation or accidental pregnancy was reported. Conclusion: PPIUCD is a safe, highly effective, long acting, cost effective method of postpartum contraception, which can be used during institutional delivery visit and eliminates the need for a return visit to start contraception. PPIUCD is a strong weapon in the family planning armory and should be encouraged in both vaginal and caesarean deliveries.

Keywords: Copper T, intrauterine contraceptive device, intracaesarean insertion, postpartum contraception, PPIUCD


How to cite this article:
Agarwal R, Singh S. Evaluation of Safety and Efficacy of Postpartum Intrauterine Contraceptive Devices (PPIUCD) in Vaginal and Caesarean Section Deliveries: A Hospital Based Study. MAMC J Med Sci 2020;6:199-203

How to cite this URL:
Agarwal R, Singh S. Evaluation of Safety and Efficacy of Postpartum Intrauterine Contraceptive Devices (PPIUCD) in Vaginal and Caesarean Section Deliveries: A Hospital Based Study. MAMC J Med Sci [serial online] 2020 [cited 2021 Apr 13];6:199-203. Available from: https://www.mamcjms.in/text.asp?2020/6/3/199/303591




  Introduction Top


Maternal health is one of the most important health indicators for assessing country’s heath status. Despite widespread availability of contraceptives, the unmet need for family planning is estimated to be 12.8%. At present 55 % women are using contraception in developing world.[1] Most common method of family planning in India is female sterilization (34%).

Use of birth control methods in developing countries has decreased pregnancy related mortality by 40%.[2],[3] One of the oldest and cost-effective contraceptive methods, worldwide is Intra uterine contraceptive device (IUCD).[4] It is safe, effective, long acting, reversible method of contraception with free of cost availability, virtually no systemic side-effects and high continuation rate.[5],[6] According to WHO Medical Eligibility Criteria, an IUCD can be inserted within 48 hours postpartum, referred to as Postpartum IUCD(PPIUCD). Facility-based births in government sponsored sectors have increased from 700,000 in 2005 to more than 11 million in 2012 due to governmental boosts.[7]

In India, approach to PPIUCD insertion is more applicable as due to lack of awareness, delivery may be the first time a healthy woman comes in contact with health care personnel. The ad-on advantages of PPIUCD include reduced perforation risk, avoidance of discomfort and bleeding related to interval insertion without an increased risk of infection, uterine perforation, postpartum bleeding or uterine subinvolution.[8],[9],[10] PPIUCD can be inserted via two different routes i.e. vaginal and caesarean; called as post-placental and intra-cesarean insertion technique respectively which may have different outcomes on follow-up. There are lacunae in available literature regarding PPIUCD between vaginal and cesarean insertions.

In present the study, we evaluated outcome, complications and continuation rate of PPIUCD insertion and also compared outcome of post-placental and intracaesarean insertion.


  Materials and Method Top


This was a prospective observational study including 260 patients over seven months period admitted in our hospital from November 2017 till May 2018. The study was approved by institutional ethics committee. Informed consent was obtained from all patients. Fourteen patients post-IUCD insertion lost follow-up so were excluded from final analysis. Women of reproductive age group 18–45 years, willing for CuT insertion delivered vaginally or by elective cesarean section were included, while those who did not consent or had obstetrical and medical complications like antepartum haemorrhage (APH), postpartum haemorrhage (PPH), anemia, uterine anomaly and diabetes mellitus were excluded. Patients were followed up at immediate 48 hours, 6 weeks, 12 weeks post-insertion or as and when needed.

Insertion Technique

Normal vaginal delivery

Women were put in lithotomy position and strict aseptic precautions were taken. Cervix was visualized by using Sim’s speculum. Anterior lip of the cervix was grasped by using ring forceps gently. Modified Kelly’s forceps was used for holding IUCD, which was then introduced in the uterine cavity by one hand while using other hand to simultaneously palpate the uterus until IUCD was placed in fundus. After inspecting cervical os for strings, Sim’s speculum was removed and patient was asked to continue to rest for some time.

Intracesarean insertion

After inspecting uterine cavity and ruling out any malformations, uterus was stabilized by grasping at fundus and IUCD was held between middle and index finger. It was inserted through uterine incision in fundus. Strings were guided toward the lower uterine segment without disturbing IUCD’s fundal position and uterine closure was performed with precautions to avoid tying up strings.


  Results Top


A total of 260 patients had immediate postpartum IUCD insertions of which 14 were lost to follow-up and were excluded from final study results. Of the final sample of 236 patients, 118 patients in each group received IUD [Table 1],[Table 2],[Table 3],[Table 4],[Table 5].
Table 1 (a) Comparison of complaints at 48 hours after insertion of the IUCD

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Table 2 (a) Comparison of complaints of at 6th week insertion of the IUCD

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Table 3 (a) Comparison of complaints at 12th week of insertion of IUCD

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Table 4 Causes and time of removal of the IUCD

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Table 5 Time, distribution according to parity and different rates of expulsion of the the IUCD

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Study participants were followed up at 48 hours, 6 weeks and 12 weeks. Seventy eight patients during initial 48 hours, 78.44% during 6weeks and 83.42% at 12 weeks follow up were asymptomatic.

Twenty percent subjects experienced complications like bleeding, pain, spotting and white discharge amongst which bleeding was most common. Fourteen percentage and 4.24% patients during 48 hours, 9.48% and 4.74% on 6 weeks follow up, 6.16% and 4.26% during 12 weeks reported bleeding and pain respectively. These results were similar to a 6 month follow up study[6] however no significant difference was seen in LSCS and normal vaginal delivery (NVD) group in our study.


  Discussion Top


Cumulative bleeding incidence in our study was 6.7%. Abdominal pain was reported by 8.3% patients, which alleviated after non-steroidal anti-inflammatory drugs (NSAIDS). Different studies have reported cumulative bleeding incidence from 6.17%[11] to 15.75%[8] and pain incidence from 9% to 43.8%. This can be attributed to difference in pain perception threshold and blood parameters of different patients.

Around 4% participants reported missing string during initial 48 hours, 15.95% during 6 weeks and 14.69% during 12 weeks follow-up. No significant difference was seen in the two groups. One study reported 3.50% participants with missing string,[5] while others reported higher rates.[6],[12],[13] This difference can be attributed to technical difference and individual expertise during procedure.

Thirty-five (14.83%) participants had IUCD removed during the study period. 12.70% in LSCS group and 16.94% in NVD group with statistically insignificant results (p=0.46). Most common reason for removal was bleeding (5.51%) followed by pain (4.23%) and family pressure (3.39%) in our study similar to other Indian studies.[5] Cumulative removal rate over 6 months follow-up was almost equal in both NVD and LSCS group i.e. 6% and 5.3% respectively. Similar removal rates have been reported by other studies.[8],[14],[15]

Twenty (8.47%) participants reported IUCD expulsion during the study period, which was statistically significant (p=0.0017) in NVD group, similar to a study which reported higher expulsion in vaginal delivery group[1] while one study reported higher expulsion rate in LSCS group.[6] This may be due to difference in sample population or technical expertise. Another follow-up six month study of 1317 women in northern India has reported a cumulative expulsion rate of 10.7%.[8] Significant difference (p=0.0055) was also seen in multipara participants with less expulsion in LSCS group than NVD group. Few studies have reported zero percent expulsion rate in cesarean group.[16],[17],[18] Majority of studies have reported higher expulsion rate in vaginal delivery group.In this study PPIUCD continuation rate was 76.70% and was higher in LSCS group (p=0.005). Similarly other studies have also reported higher continuation rate in LSCS group.[1],[2],[6] One study reported different continuation rate for different groups i.e. 82.90% for post-placental insertion, 75% for post-partum insertion and 95.50% for intracesarean group.[16]

PPIUCD failure rate was nil in our study and none of the patients had perforation similar to other studies.[1],[18],[19] The most plausible explanation is thickened uterine wall during immediate post-partum period which attributes to reduced perforation tendency of IUCD’s.


  Conclusion Top


PPIUCD is safe, cost-effective method of postpartum contraception with high retention rate. In overpopulated countries like ours where there is lack of awareness of family planning measures, institutional delivery can be considered as ideal time to offer contraception. PPIUCD can be inserted within 10 minutes of delivery thus, not prolonging hospital stay and not imposing any additional financial burden making it affordable, especially in low socio-economic group. The expulsion rate was not high in our study, which can be further minimized with technical expertise. Integration of a PPIUCD counseling service at every delivery setup with provision of couple counseling will further improve the success rate. This may play a pivotal role to meet unmet need of contraception in India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gupta A, Verma A, Chauhan J. Evaluation of PPIUCD versus interval IUCD (380A) insertion in a teaching hospital of Western UP. Int J Reprod Contracept Obstet Gynecol 2016;2:204-8.  Back to cited text no. 1
    
2.
Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and health. The Lancet 2012;380:149-56.  Back to cited text no. 2
    
3.
Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive use: an analysis of 172 countries. Lancet 2012;380:111-25.  Back to cited text no. 3
    
4.
Nelson A. Intrauterine contraceptives. vol. 6. Philadelphia: Lippincott Williams and Wilkins 2004. Gynecology and Obstetrics.  Back to cited text no. 4
    
5.
Singh S, Malik R, Ahalawat R, Taneja BK. Evaluation of efficacy, expulsion and safety of post-placental and intra-cesarean insertion of intrauterine contraceptive devices. Int J Reprod Contracept Obstet Gynecol 2017;4:2005-9.  Back to cited text no. 5
    
6.
Sudha CP, Priyanka HK, Nagaiah D. A study to evaluate safety and efficacy of immediate postpartum post placental IUCD insertion. Int J Reprod Contracept Obstet Gynecol 2017;6:2284-8.  Back to cited text no. 6
    
7.
http://www.nrhm.gov.in/monitoring/progree-of-nrhm.html. Government of India: All India Summary of National Rural Health Mission Program, 2012.  Back to cited text no. 7
    
8.
Shukla M, Qureshi SC. Post-placental intrauterine device insertion − a five year experience at a tertiary care centre in North India. Ind J Med Res 2012;136:432.  Back to cited text no. 8
    
9.
Chi IC, Farr G. Postpartum IUD contraception − a review of an international experience. Advances in Contraception 1989;5:127-46.  Back to cited text no. 9
    
10.
Srivastava S, Bano I, Ishrat N. Evaluation of PPIUCD versus interval IUCD insertion. Int J Sci Res 2016;5:1780-82.  Back to cited text no. 10
    
11.
Kittur S, Kabadi YM. Enhancing contraceptive usage by post-placental intrauterine contraceptive devices (PPIUCD) insertion with evaluation of safety, efficacy, and expulsion. Int J Reprod Contracept Obstet Gynecol 2016;1:26-32.  Back to cited text no. 11
    
12.
Goswami G, Yadav K, Patel A. A prospective study to evaluate safety, efficacy and expulsion rate of post placental insertion of intra uterine device. J Evol Med Dent Sci 2015;4:9770-74.  Back to cited text no. 12
    
13.
Zhou SW, Chi IC. Immediate postpartum IUD insertions in a Chinese hospital — a two year follow-up. Int J Gynaecol Obstet 1991;35:157-64.  Back to cited text no. 13
    
14.
Kapp N, Curtis KM. Intrauterine device insertion during the postpartum period: a systematic review. Contraception 2009;80:327-36.  Back to cited text no. 14
    
15.
Fikry F, Nadim A. Postpartum intratuerine device contraception − an experience from Egypt. Contraception 2010:306-12.  Back to cited text no. 15
    
16.
Kumar S, Sethi R, Balasubramaniam S, Charurat E, Lalchandani K, Semba R, Sood B. Women’s experience with postpartum intrauterine contraceptive device use in India. Reproductive Health 2014;11:32.  Back to cited text no. 16
    
17.
Letti Muller AL, Lopes Ramos JG, Martins-Costa SH, Palma Dias RS, Valerio EG, Hammes LS et al. Transvaginal ultrasonographic assessment of the expulsion rate of intrauterine devices inserted in the immediate postpartum period: a pilot study. Contraception 2005;72:192-5.  Back to cited text no. 17
    
18.
El-Shafei MM, Mashali A, Hassan EO, El-Boghdadi L, El-Lakkany N. Postpartum and post abortion intrauterine device insertion unmet needs of safe reproductive health: three years experience of Mansoura University Hospital. Egyptian Soc Obstet Gynecol 2000;26:253-62.  Back to cited text no. 18
    
19.
Ricalde RL, Tobías GM, Pérez CR, Ramirez NV. Estudiocomparativo al azar entre los dispositivosintrauterinos Multiload Cu375 y TCu 380A, colocadosdurante el posparto. Ginecol Obstet Mex 2006;74:306-11.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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