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Post Placental IUCD Insertion – A Systemic Review At Secondary Health

Centre

Article · April 2015

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 Post Placental IUCD Insertion – A Systemic Review
At Secondary Health Centre

ISSN 2319-9725

Mishu Mangla
MBBS, MS
Deepak Singla
MBBS, MD

Abstract: Objectives: Due to large unmet need of family planning in our country there is need for an
effective contraceptive technique that can provide long term contraception. Intra uterine
contraceptives are one such device that can be used in immediate post partum period thereby
preventing large no of unintended pregnancies. Present study aims to study the safety and efficacy of
post placental IUCD’s in a secondary health centre.
Methods: Women who have undergone post placental IUCD insertion at Community Health Centre,
Gohana during the period from September to December 2014 were included in the study. Patients
were again reviewed at 6 weeks for various side effects and acceptance.
Result: Out of 345 women enrolled in the study, 45 were lost to follow up. Among the remaining,
complications noted during follow up were irregular or excessive bleeding during menses (15%),
missing IUD thread (10%) and lower abdominal pain (6%). No incidence of misplaced IUD or
uterine perforation was seen.
Conclusion: Post partum IUCD is a safe and reversible method of contraception. It is safely and
easily inserted during immediate post partum period which provides contraception at a time during
which pregnancy can be a risk to mental and physical health.
Keywords: Post partum IUCD, normal vaginal delivery, complications
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1. Introduction:

India stands second in the world in terms of population after china and the population of India
is still growing exponentially. It is presently sustaining 17 % of world population on 2.4% of
total surface area of the world. Currently the population has grown upto 121 million.
Although family planning programme has been in place from 1950’s, there is still a large
unmet need of family planning. Though data is not available for all countries this unmet need
is about 13% in south asian region and about 24% in African region as per WHO (1). In our
country about 65% of women have an unmet need of family planning during first year, post
partum (2). This can be attributed to low level of knowledge, misconceptions and false myths
regarding spacing methods specially for Cu-T , limited availability of medical facilities. Also
due to scarcity of available medical resources, immediate post partum period offers a unique
opportunity both for health care worker and patient to plan for contraception.

Intrauterine contraceptive device is not only reliable but also reversible method of
contraception. About 127 million people worldwide are using IUDs (3). However safety and
acceptance of post placental IUD has not been studied previously in secondary health centre.
With the above background, this study was aimed for finding the safety and efficacy of post
placental IUCD as a method of contraception. This observational study was conducted in
Community Health Centre, Gohana, dist. Sonepat during a period of 4 months from
September 2014 to December 2014.

2. Material And Methods:

Women who have undergone post placental IUCD insertion at Community Health Centre,
Gohana during the period from September to December 2014 i.e. a total of 345 women were
included in the study. Before insertion counseling regarding post placental IUCD insertion,
its benefits, and side effects was done and a written informed consent was taken from the
patients who were willing for immediate post placental ( i.e. within 10 min of delivery of
placenta ) Cu-T insertion. Patients were again reviewed at 6 weeks for various side effects
and acceptance.

INCLUSION CRITERIA – delivered vaginally and gave consent of PPIUCD insertion.

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EXCLUSION CRITERIA- patients with anaemia, pelvic infection, foetal loss and with
following complications were excluded from study

1. Rupture of membranes of > 24 hrs. prior to delivery.

2. Post-partum hemorrhage.

3. H/o pelvic inflammatory disease.

FOLLOW UP – A follow up of all women enrolled in the study was scheduled at 6 wks post-
partum and their compliance, expulsion rates and complications attributed to it were noted.

3. Results:

Total 345 women satisfying the inclusion criteria and undergoing post partum IUD insertion,
were included in this study. All these women were asked to follow up after 6 wks post
partum. Out of 345 women enrolled in the study, 45 were lost to follow up.

All the women were aged between 20 to 28 years and 124 women were primiparous and 176
were multiparous. Major complication noted during follow up was irregular or excessive
bleeding during menses which was seen in about 45 (15%) of women. Further counselling
was done in such women and treatment in the form of mefanamic acid (500 mg TDS) was
provided during this period. Another complication noted was that of missing IUD thread seen
in 30 (10%) women. Pelvic ultrasound was performed in such women and IUD expulsion
was confirmed in 15 women. Remaining had coiled threads and re insertion after removal of
IUD was done. No incidence of uterine perforation was noted. Lower abdominal pain was
noted in 18(6%) of women. Treatment in the form of antibiotics and analgesics was given to
these women. No incidence of misplaced IUD was seen.

4. Discussion:

Copper T has a clear and distinct advantage over any other family planning method during
postpartum period. Apart from being reversible it doesn’t interfere with breast feeding and is
free from side effects of hormonal contraceptives. Also it is independent of coital act and
doesn’t require user compliance. Moreover during immediate post partum period women is

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more likely to understand need for contraception. This is especially important in a developing
country like ours where chances of women returning for contraceptive advice after delivery
are very less. So immediate post partum period is a unique opportunity for health care
provider to explain and counsel regarding the use of such contraception.

Timing of insertion, training of inserting personal, counseling of the patient are important
factors for IUCD insertion (4). The risk of expulsion is least if inserted immediately post
partum i.e. within 10 min of delivery of placenta and maximum upto 48 hrs (5). In our study
Copper T was inserted in all the patients within 10 mins of delivery of placenta. The
expulsion rate was 5% which is significantly lower than 9% found in the 4 multisite studies in
UN POPIN (4). For insertions done after this period, the expulsion rate tends to be higher.

The main side effect noted in our study was irregular and prolonged vaginal bleeding, found
in 15% of cases. This rate is significantly higher than reported in many previous studies i.e.
8.2% and 3.1% respectively in two studies conducted by Celen S et al (6, 7). Welkovic et al
found no difference in the incidence of excessive bleeding (8) in study of post placental
IUDs.

However we found a higher incidence of pelvic infection i.e. 6% compared to 4.3% in a study
conducted in Bundelkhand region of India (9) and no incidence of infection in study by
Welkovic et al (8). This difference may be attributed to poor hygiene, high prevalence of
STD’s. 10% women in our study had lost strings at 6 wks, similar to a 12.7% risk of missing
threads found in a study conducted by Gautam et al in 2014 (9). An ultrasound confirmed that
copper T was in situ. No cases of perforation of uterus or misplaced IUCD were noted in our
study. This finding corroborates with Shafei MM (10) et al and Ricalde et al (11) where no
perforation with copper T was observed. No cases of pregnancy were noted as in study of
Gupta et al (12).

5. Conclusion:

Post partum IUCD is a safe and reversible method of contraception. It is safely and easily
inserted during immediate post partum period which provides contraception at a time during
which pregnancy can be a risk to mental and physical health. This can emerge as a good
spacing method.

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Complications % Number

Irregular or excessive 15 44
bleeding

Missing thread 10 31

Lower abdominal pain 6 17

Uterine perforation 0 00

Misplaced IUCD 0 00

Spontaneous Expulsion 5 15

Table 1

Expulsion %

Within 24 hrs 2

24 hrs – 7 days 10

7 days – 6 wks 3

Table 2

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References:

1. Global Health Observatory. Unmet need for family planning. Geneva: World Health
Organization; available at:
www.who.int/entity/gho/mdg/maternal_health/situation_trends_family_planning/en.

2. Post-partum1. IUCD reference manual. New Delhi: Family Planning Division,

Ministry of Health and Family Welfare, Government of India; 2010.

3. Nelson A. Gynaecology and Obstetrics. In: 2. Intrauterine contraceptives, vol. 6.

Philadelphia: Lippincott Williams and Wilkins; 2004.

4. United Nations Population information network (POPIN), 3. UN Population division,

Department of Economic and Social Affairs with support from UNPopulation Fund.
Network Intrauterine devices. Family Health International. Winter 1996; 16, no.2.

5. Post partum IUCD reference manual, New Delhi: Family Planning Discussion,
MOHFW, Govt. of India; 2010.

6. Celen S, Sucak A, Dauisman N. Immediate post placental insertion of an IUCD

during cesarean section. Contraception 2012, 84; 240-243.

7. Celen S, Moroy P, Sucak A, Dauisman N. Clinical outcomes of post placental

insertion of IUCD. Contraception 2004; 69; 279-282.

8. Welkovic S, Costa L, Faundes A, Ximenes R, Costa C. 8. Postpartum bleeding &

infection after postplacental IUD insertion. Contraception 2001; 63: 155-8.

9. Gautam R, Arya K.N., Kharakwal S, Singh S, Trivedi M. Overview of immediate

PPIUCD application in Bundelkhand Region. Journal of Evolution of Medical and
Dental Sciences 2014; Vol 3, Issue 36, August 18; 9518-9526. DOI:
10.14260/JEMDS/2014/3230.

10. El-Shafei MM, Mashali A, Hassan EO, El-Boghdadi, ElLakkany N. Postpartum and
postabortion intrauterine device insertion unmet needs of safe reproductive health:
three years experience of a Mansoura University Hospital. Egypt Society Obstet
Gynecol 2000; 26 : 253-62

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11. Ricalde L, Tobías G.M., Pérez C. Randomized comparative study between

intrauterine device Multiload Cu375 and TCu 380A, placed postpartum. Gineclo Obst
Mex 2006; 74: 306-11

12. 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
Gynaecol. 2013; 2; 204-8.

International Journal of Innovative Research and Studies Page 87

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