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Continuation rates of postpartum intrauterine contraceptive device (IUCD) insertion: randomised trial of post placental versus immediate postpartum insertion
... A higher expulsion rate in the immediate group compared to the early group was also reported in other published observational studies 11,18 . Only two randomized trials 19,20 have compared the expulsion rates of the device CuT380A based on the timing of insertion. In the trial by Ahuja and Rahtore 19 , 108 women were recruited into the two groups. ...
Background & objectives:
Postpartum intrauterine contraceptive device (PPIUCD) is well accepted and recommended for contraception. However, anxiety at the time of delivery may restrict the acceptance of a PPIUCD for its immediate insertion. So far there is limited evidence to conclude anything concrete on the association between the expulsion rates and the timing of insertion following a vaginal delivery. Thus, this study was undertaken to compare the expulsion rates in immediate and early insertions and their safety and complications.
Methods:
This prospective comparative study was carried out over 17 months on women delivering vaginally in a tertiary care teaching hospital in South India. A copper device (CuT380A) was inserted using Kelly's placental forceps either within 10 min of placental delivery (immediate group, n=160) or between 10 min upto 48 h postpartum (early group, n=160). Ultrasound was done before discharge from the hospital. The expulsion rates and any other complications at six-week and three-month follow up were studied. Chi-square test was used to compare the difference in expulsion rates.
Results:
The expulsion rate was five per cent in the immediate compared to 3.7 per cent in the early group (no significant difference). In ten cases, the device was found to be in the lower uterus upon ultrasound before discharge. These were repositioned. There was no case with perforation, irregular bleeding or infection up to the three-month follow up. Higher age, higher parity, lack of satisfaction and motivation to continue were predictors of expulsion.
Interpretation & conclusions:
In the present study PPIUCD was found to be safe with overall expulsion in 4.3 per cent. It was marginally, though not significantly, higher in the immediate group.
... Por ser a fase com maior número de participantes e menor número de expulsões, a fase 4 foi analisada de forma mais concisa. Com relação a essa etapa, a taxa de expulsão geral assemelha-se as taxas previamente disponíveis na literatura, variando entre 3-24% (10,(17)(18) . ...
Introdução: Os períodos gestacional e puerperal são ideais para o aconselhamento do planejamento familiar. A Federação Brasileira das Associações de Ginecologia e Obstetrícia (FEBRASGO) aconselha o uso dos dispositivos intrauterinos no puerpério, após o parto transpélvico ou cesárea. A inserção após o parto se divide em imediata (até 10 minutos após a dequitação placentária), precoce (entre 10 minutos e 48 horas de pós-parto) ou tardia (após 4 semanas de pós-parto). Sua principal complicação é a expulsão, e está relacionada ao momento da inserção. Objetivo: Analisar o perfil epidemiológico das participantes e comparar as taxas de expulsão entre dois dispositivos intrauterinos, o DIU-TCu380A e o Sistema Intrauterino Liberador de Levonorgestrel (SIU-LNG), inseridos durante o pós-parto e transcesárea, sob diferentes técnicas e períodos. Métodos: Os dispositivos foram oferecidos a 206 puérperas da Maternidade Victor Ferreira do Amaral de Curitiba - PR, 117 optaram pelo SIU-LNG e 89 pelo DIU-TCu308A. Foram incluídas 155 participantes, 15 (9,67%) inserções ocorreram durante a cesárea e 140 (90,32%) após o parto transpélvico. Após 45 dias da inserção, foi realizada uma avaliação ginecológica e ultrassonográfica do dispositivo. Em relação à inserção após o parto transpélvico, o estudo foi dividido em 4 fases de acordo com a técnica de inserção utilizada. A primeira fase (n: 34; 21,93%) utilizou o aplicador do produto. A segunda (n: 12; 7,74%), utilizou o aplicador com o pinçamento do colo uterino. A terceira (n: 14; 9,03%) utilizou a Pinça Cheron 25cm. E a quarta fase (n: 80; 51,61%), a Pinça Collin Coração Curva 24cm. Resultados: A idade média das participantes foi de 27,1 anos (±5,9) e a paridade 2,1 filhos (±1,1). As taxas de expulsão foram de 44% (n: 15), 42% (n: 5) e 36% (n: 5) nas três primeiras fases, e 13,75% (n: 11) na última fase (p=0,00028). O SIU-LNG apresentou 14,6% de expulsões (n: 7) e o DIU-TCu380A 12,5% (n: 5)(p=0,7751). No pós-parto, a taxa de insucesso de ambos os dispositivos foi de 13,8% (n: 11) e na cesárea de 6,6% (n: 1)(p=0,403). Conclusão: A população estudada apresentou faixa etária entre 21 e 30 anos e possuía até 2 filhos. A maioria (56,2%) estava em união estável e 92% declarou-se satisfeita ou muito satisfeita com o uso do DIU. A técnica de inserção utilizada na fase 4 obteve melhores resultados. As variáveis relacionadas ao tipo de inserção, o tempo de inserção e o dispositivo usado não interferiram na taxa de expulsão. Descritores: Medidas em epidemiologia, Anticoncepção, Período pós-parto, Dispositivos intrauterinos, Expulsão de dispositivo intrauterinoABSTRACTIntroduction: The gestational and puerperal period are ideal for family planning. The Brazilian Federation of Gynecology and Obstetrics Associations advises the intrauterine devices in puerperium after transpelvic delivery or during cesarean. Postpartum insertion is divided into immediate (up to 10 minutes after placental clearance), early (between 10 minutes and 48 hours postpartum) or late (after 4 weeks postpartum). Expulsion is the main complication, and is related to the time of insertion. Objective: Analyze the epidemiological profile and compare the expulsion rates between two intrauterine devices, the IUD-TCu380A and the Levonorgestrel Releasing Intrauterine System (SIU-LNG), inserted during postpartum and transceiver, under different techniques and periods. Methods: The devices were offered to 206 postpartum women of Victor Ferreira do Amaral Maternity of Curitiba - PR, 117 opted for SIU-LNG and 89 for IUD-TCu308A. Were included 155, 15 (9.67%) insertions occurred in cesarean and 140 (90.32%) after transpelvic delivery. After 45 days insertion, was performed a gynecological and ultrasonographic evaluation. The insertion after transpelvic delivery was divided into 4 phases according to the insertion technique. The first phase (n: 34; 21.93%) used the product applicator. The second (n: 12; 7.74%) used the applicator with cervical clamping. The third (n: 14; 9.03%) used Cheron Tweezers 25cm. And the fourth phase (n: 80; 51.61%), Collin Heart Curved Tweezers 24cm. Results: The participants' mean age was 27.1 (±5.9) and parity 2.1 (±1.1). The expulsion rates were 44% (n: 15), 42% (n: 5) and 36% (n: 5) in the first three phases, and 13.75% (n: 11) in the last phase (p=0.00028). SIU-LNG presented 14.6% of expulsions (n: 7) and IUD-TCu380A 12.5% (n: 5) (p=0.7751). Postpartum failure rate was 13.8% (n: 11) and cesarean 6.6% (n: 1) (p=0.403). Conclusion: Approximately 2/3 of women were up to 30 years old and up to 2 children. The insertion technique used in phase 4 obtained better results. Variables related to insertion type, insertion time and the device used did not affect the expulsion rate.Keywords: Epidemiologic studies, Contraception, Postpartum period, Intrauterine devices. Intrauterine device expulsion
Introduction:
Using an intrauterine device (IUD) is many times safer than pregnancy and more effective in preventing pregnancy than oral contraceptives, condoms, spermicidal, any barrier method, or natural family planning. Benefits of healthy timing and spacing of pregnancy are many. Postpartum contraception is becoming popular after introduction of PPIUCD services.
Objective:
To study the incidence, management, clinical outcome of missing strings cases in post-placental and intra-cesarean IUCD.
Materials and methods:
This study was a retrospective observational study, carried out in the district of Balangir, Odisha, India. Status of women who had post-placental and intra-cesarean IUCD insertion in various institutions between January 2010 and December 2012 having follow-up as per the protocol was taken for the study. All the complications were recorded and studied. Incidence, clinical outcome, and management of missing strings were analyzed.
Results:
Records of 1343 clients were studied. Six hundred and seventeen cases had failed to report for follow-up as per the study design. Seven hundred and twenty-six cases had follow-up as per the protocol. Of them, 36 had expulsion, and rest 690 cases were taken for the study. There were 209 missing strings at 3 months. At the end of the study, there was spontaneous descend in 138 cases. More than 50 % cases were asymptomatic. Ultrasonography was the method of diagnosis, and simple sounding of the uterus alone could also establish IUD in uterine cavity. Removal rate was higher in missing strings group, Continuation rate is higher in String visible group.
Conclusion:
Post-placental intra-cesarean Copper T 380A insertion is a safe and effective method of reversible contraception; missing string is emerging as a potential distracter of its use. It is important that every user must be followed up and the providers must be competent in managing complication. Better after care in form of effective follow-up and complication management is needed to maintain popularity. Introduction of compensation scheme will also help improving the acceptance.
Women who want to start intrauterine contraception (IUC) during the postpartum period might benefit from IUC insertion immediately after delivery. Postplacental insertion greatly reduces the risk of subsequent pregnancy and eliminates the need for a return visit to start contraception. Without the option of immediate insertion, many women may never return for services or may adopt less effective contraception.
Our aim was to examine the outcomes of IUC insertion immediately after placenta delivery (within 10 minutes), especially when compared with insertion at other postpartum times. We focused on successful IUC placement (insertion), subsequent expulsion, and method use.
We searched for trials until 1 April 2015. Sources included PubMed (MEDLINE), the Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, Web of Science, EMBASE, LILACS, ClinicalTrials.gov, and ICTRP. For the original review, the authors contacted investigators to identify other trials.
We sought randomized controlled trials (RCTs) with at least one treatment arm that involved immediate IUC placement (i.e., within 10 minutes of placenta delivery). Comparison arms could have included early postpartum insertion (from 10 minutes postplacental to hospital discharge) or standard insertion (during a postpartum visit). Trials could also have compared different IUC methods or insertion techniques. Delivery may have been vaginal or cesarean. Primary outcomes were placement (insertion), subsequent expulsion, and method use at study assessment.
For dichotomous outcomes, we used the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). Earlier studies primarily reported results as life-table rates. We aggregated trials in a meta-analysis if they had similar interventions and outcome measures. A sensitivity analysis included studies with moderate or high quality evidence and sufficient outcome data.
We included 15 trials. Seven studies reported from 2010 to 2014 were added to eight from the original 2001 review. Newer trials compared immediate postplacental insertion versus early (10 minutes to 48 hours) or standard insertion (during the postpartum visit). Of four with full reports, three were small trials. The other three studies had conference abstracts. The eight early trials examined immediate insertion of different devices or insertion techniques. Most studies were published in the 1980s, some with limited reporting.Our sensitivity analysis included trials with sufficient outcome data and moderate or high quality evidence. Four newer trials comparing insertion times met the inclusion criteria. Two studies used the levonorgestrel-releasing intrauterine system (LNG-IUS) after vaginal delivery. The other two trials placed IUC after cesarean section; one used the CuT 380A intrauterine device (IUD) and the other used the LNG-IUS.A pilot trial compared immediate insertion versus early or standard insertion. In groups comparing immediate versus early insertion (N = 30), all women had the LNG-IUS inserted. By six months, the groups had the same expulsion rate and did not differ significantly in IUC use.For immediate versus standard insertion, we conducted meta-analyses of four trials. Insertion rates did not differ significantly between study arms. However, the trial from Uganda showed insertion was more likely for the immediate group, although the estimate was imprecise. In the meta-analysis, expulsion by six months was more likely for the immediate group, but the confidence interval was wide (OR 4.89, 95% CI 1.47 to 16.32; participants = 210; studies = 4). IUC use at six months was more likely with immediate insertion than with standard insertion (OR 2.04, 95% CI 1.01 to 4.09; participants = 243; studies = 4). Study arms did not differ in use at 3 or 12 months in individual small trials.
Recent trials compared different insertion times after vaginal or cesarean delivery. Evidence was limited because studies with full reports generally had small sample sizes. Overall, the quality of evidence was moderate; abstracts and older studies had limited reporting. Ongoing trials will add to the evidence, although some are small. Trials of adequate power are needed to estimate expulsion rates and side effects.The benefit of effective contraception immediately after delivery may outweigh the disadvantage of increased risk for expulsion. Frequent prenatal visits during the third trimester provide the opportunity to discuss effective contraceptive methods and desired timing for initiation. Clinical follow-up can help detect early expulsion, as can educating women about expulsion signs and symptoms.
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