Post-puerperal Cu-T insertion : a prospective study.AR Bhalerao, MC Purandare
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 0002621664
Source of Support: None, Conflict of Interest: None
One hundred and sixty eight consecutive women accepting copper T (CuT) intrauterine contraceptive device in the post-puerperal period were studied. Out of them, 63 could be followed after 6 weeks of insertion and 65 after 6 months of insertion. The risk of heavy bleeding, pain in abdomen etc. were no greater than those usually found when interval CuT insertion is carried out. There was no case of uterine perforation leading to migration of CuT. But the expulsion rate was found to be high i.e. 16.4%. CuT is a very useful post-puerperal contraceptive method and should be given more importance in MCH programme.
Keywords: Female, Human, Intrauterine Devices, Copper, Pregnancy, Prospective Studies, Puerperium, Risk Factors, Time Factors,
It is accepted that intra-uterine device (IUD) is an ideal contraceptive method for lactating women because it has no effect on the quality or composition of breast milk. A convenient time for IUD insertion is 6-8 weeks after delivery (post-puerperal insertion). Post-puerperal insertion of an IUD has several advantages. Women are vulnerable to accept IUD in this period. IUD insertion can be combined with the follow-up examination of the woman and her child. There is concern, however, based on a few case reports and a case control study involving 32 women, that insertion during lactation may involve a higher risk of uterine perforation., Another small study found that breast feeding made no difference to the risk of perforation. In view of this controversy a prospective study was undertaken by us on post puerperal copper T (CuT) insertion.
One hundred and sixty eight consecutive women accepting CuT in the post-puerperal period were studied. After taking complete history, women were examined clinically. CuT was inserted in all the women during 6 weeks to 3 months of delivery. These women were asked to come for follow-up after 6 weeks and again after 6 months of insertion whether they had any complaints or not. At the follow-up visits, they were interogated about any complaints due to IUCD, were examined and necessary treatment was given when required.
[Table - 1]shows parity-wise distribution of 168 women accepting CuT. Equal number of women i.e. 77 (45.8%) with parity I and II accepted this method of contraception. But it is seen that the presence of at least 1 male living child was found to be the determining factor in 116 women i.e. 69%.
The incidence of various complaints and examination findings at 6 weeks and 6 months follow-up visits is shown in [Table - 2]Sixty three women came after 6 weeks and 65 after 6 months for follow-up visit. No one had uterine perforation, leading to migration of CuT; 1.5% reported with intrauterine pregnancy. Partial expulsion was diagnosed on speculum examination by observing the stem of the IUD protruding through the external os.
[Table - 3]shows the incidence and reasons for CuT removal after 6 weeks and 6 months of insertion.
In[Table - 4]one year event rates and continuation rates in multicentre studies (1970-1979) per 100 woman users are compared with those found in our study. It is evident that failure rate and removal due to bleeding and pain is almost same in both the groups, whereas the expulsion rate is definitely high in the study group (postpuerperal insertion).
In our study (post-puerperal insertion), the risks of heavy bleeding, pain in abdomen etc. were no greater than those usually found when interval CuT insertion is carried out. Studies in the US and Sweden find that IUD users are about 1.5 times more likely to develop PID than sexually active women using no contraception at all. Out of total IUD users 2 to 4% may develop infection. In our series mild PID in the form of leucorrhoea, erosion and tenderness in fornix was found in 10% after 6 weeks of insertion and in 18% after 6 months of insertion. In many large series, pregnancy occurred in 1 to 4 cases per 100 IUD users in the first year. In our series, after 6 months of insertion only one woman came with pregnancy giving an incidence of 1.5%.
Spontaneous expulsion rate varies from 5 to 20 per 100 women at 1 year. Highest incidence occurs in first 3 months of use, mostly during menstruation, especially the first menstrual period after insertion. Timing of insertion and the age-parity of the user influence the likelihood of expulsion. Some IUDS are expelled due to faulty technique of insertion (low insertion). In our series, rate of partial expulsion was high 23.8% had partial expulsion after 6 weeks of insertion and 9.2% after 6 months of insertion. The causes may be atrophic or bulky uteri found in these women. To reduce expulsion rate, following precautions are necessary.
(1) Avoid insertion in small or bigger uteri.
(2) Strict follow-up should be done to rule out expulsion or partial expulsion.
(3) There is a great need of tailor-made IUD for atrophic or subinvoluted uteri.
According to Hutchings et al, bleeding accounts for 10-20% of all IUD removals. In our series, after 6 months of insertion till 1 year, CuT was removed in 3.1 % women due to menstrual problems and in 3.1 % due to pain in abdomen, WHO estimates that 15-401/ of IUD removals appear to be for pain only (low backache, cramps in lower abdomen and pain down thighs).
Failure rate and removal rate due to bleeding and pain was found to be almost same in study group and other multicentre studies on interval CuT insertion. There was no case of uterine perforation leading to migration of CuT. But the expulsion rate in our study was high. These findings indicate that if precautions are undertaken to decrease expulsion rate, post-puerperal CuT insertion will turn out to be as good as interval insertion with respect to side effects, complications and failure rate with added advantages of high acceptibility of contraceptive method by these women and no adverse effect on lactation. Post-puerperal CuT insertion should be considered on important part of maternal and child health care.
[Table - 1], [Table - 2], [Table - 3], [Table - 4]