International Journal of Current Research and Review
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IJCRR - 8(11), June, 2016

Pages: 28-33

Date of Publication: 11-Jun-2016


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LONG TERM CLINICAL OUTCOME OF POST PARTUM INTRA UTERINE CONTRACEPTIVE DEVICE (PPIUCD) INSERTION

Author: Vilvapriya S., Veeraragavan K.

Category: Healthcare

Abstract:Background: Majority of women are in need of effective contraceptive method for spacing. The unmet need for contraception results in unintended pregnancies, with increased maternal and neonatal complications. PPIUCD insertion is an effective contraceptive method, reduces unintended pregnancy and decreases health care cost expenditure.
Objective: This study aims to evaluate long term complications like bleeding, pain, expulsion rate, perforation, infection, missing strings and continuation rate.
Method: This prospective observational study was carried out in a tertiary care hospital in Chennai, between Jan 2012 - June 2012. CuT 380A was inserted immediately following placental delivery in caesarean section or in normal delivery or within 48 hours of normal delivery. They were followed up at the time of discharge, at 6 weeks, then at 6 monthly intervals till 30 weeks.
Results: A total of 300 PPIUCD acceptors were followed up for 30 months. Most of our acceptors are primipara group (n=199, 66.4%). Most of the insertions are in caesarean deliveries. (n=235, 78.3%), followed by post placental insertions (n=42, 13%) and immediate post partum (n=23, 7.7%). Continuation rate is high 90.7 %( n=272) at the end of 1 year and 84.3% at the end of 30 months. Expulsion rate was 4.7%, bleeding in 8.7%, pain in 8.4% and infection in 1% of acceptors. Removal rate at 30 months was 11%, majority of the removal was for opting to go for permanent method of sterilization (n=19, 6.33%), followed by planning for 2nd child (n=7, 2.3%). Pain was the cause for removal in only 0.67%, bleeding in 1.67%.
Conclusion: PPIUCD is safe and effective method of contraception with high continuation rate, low expulsion and complication rates.

Keywords: Post partum, Contraception, PPIUCD

Full Text:

INTRODUCTION
Post partum contraception can reduce one third of maternal deaths and 10% of neonatal mortality when pregnancies are spaced two years apart (1). Studies show that pregnancies within 24 months of previous birth have high risk of abortions, preterm births, low birth weight babies, post partum haemorrhage, maternal mortality and neonatal mortality. In India 61% of births were spaced less than three years. Unmet need is greater in first year of post partum (2). Only 3-5% of post partum women want another child within 2 years. So provision of IUCD in the immediate post partum period offers effective and safe method of contraception (3). The copper T 380 A is approved for 10 years. It is a cost effective, non-hormonal method. According to WHO Medical Eligibility Criteria IUCD be inserted within 48 hours of postpartum which is here referred as postpartum IUCD (PPIUCD). Insertion of copper T380A in postpartum period (PPIUCD) saves time and additional visits. There is reduced risk of perforation due to thick walled post partum uterus, reduced perception of bleeding and pain. Breast feeding does not get affected by PPIUCD. Women have been provided an effective method of contraception before discharge from the hospital. Women are highly motivated and more receptive to accept family planning in the immediate post partum period (4). By 2013, 19 states in India have started implementing PPIUCD insertion under National post partum family planning programme. Govt. of India is promoting institutional deliveries through programmes like Janani Suraksha Yojna (JSY). This conditional cash transfer scheme has expanded the accessibility of women to seek facility delivery and post partum care. The increased institutional deliveries give the health care providers an opportunity to effectively counsel and motivate for PPIUCD insertion (2). While follow up data on complications with PPIUCD insertion are available from international sources, given the scale of PPIUCD insertion in India, it is important to generate data on long term complications and continuation rate. Objective: This study aims to evaluate long term complications and continuation rate in women, who accepted PPIUCD insertion in a tertiary care centre. METHODS AND MATERIALS It is a prospective observational study carried out in a tertiary care center for a total number of 300 willing patients who accepted this contraceptive (PPIUCD) under national post partum family planning programme between Jan 2012 – June 2012 and these patients were followed up to two and a half years. Women were enrolled in the study after standardized written consent in the local language. Participants were interviewed prior to discharge after receiving a PPIUCD, at six weeks and then at 6 monthly intervals till two and a half years post insertion. Inclusion criteria: 1. Age >18 years, < 40 years 2. Delivery at term( both labour natural and caesarean deliveries) 3. Within 48 hours of delivery( immediate post placental, immediate post partum) Exclusion criteria: 1. PROM> 18 hours 2. Preterm labour 3. Uterine anomalies, fibroid uterus 4. Ante partum haemorrhage 5. Post partum haemorrhage 6. Immediate ante partum, intrapartum and post partum fever

RESULTS
(i) Age group: In our study most (n=176,58.6%) of the PPIUCD acceptors are in the age group of 20-24 years, followed by 25-29 years age group(n=80,26.6%), who are the active reproductive age women. 7.3% of women in the age group of 20-24 years and 6.3% in the age group of 25-29 years discontinued PPIUCD during our follow up period.

DISCUSSION
PPIUCD are the only post partum family planning method for couples requesting a highly effective, reversible, yet long term contraceptive method that can be initiated during immediate post partum period in lactating women. WHO medical eligibility criteria states that it is generally safe for postpartum lactating women to use PPIUCD with the advantages overweighing disadvantages. We can reduce the unmet need of family planning with this contraceptive. PPIUCD is more convenient for health care providers and for acceptors- using opportunity of child birth when both the mother and provider are at hospital. Another family planning visit and hospitalization is not necessary which is advantageous for socio-economically weaker section of women, who depend on Government hospitals for health care. Fewer instruments and staff are necessary for PPIUCD than for interval IUCD. Govt. of India promotes institutional deliveries and it provides increased opportunity for immediate post partum insertion of CuT. Advantages of immediate post partum insertion are high motivation, assurance that she is not pregnant and convenience. Most of the willing acceptors in our study were primipara (n=199, 66.4%), who are the ideal candidates for this non hormonal reversible spacing method of contraception. Most of our PPIUCD insertion is in intra-caesarean category (n=235, 78.3%), followed by post placental insertions (n=42, 13%) and immediate post partum (n=23, 7.7%). Comparison of our study with similar PPIUCD studies:

In our follow up study, continuation rate is high 90.7 %( n=272) at the end of 1 year and 84.3% at the end of 30 months comparable to other studies by MCHIP, Anjumafshan et al, Rajani Gowtham et al and Sahejakuttur et al. Spontaneous expulsion rate at 30 months was 4.7%, 13 out of 14 expulsion (4.3%) following first year of insertion. Expulsion rate in our study (4.3%) is less than in interval IUCD (5%) at the end of first year of insertion (9). Missing string were observed in 12.4 %( n=37), of whom nearly 2/3rd i.e. 7.7% (n=23) it was in the uterine cavity confirmed by sonography. 8.7 %( n=26) of the acceptors had excessive menstrual bleeding, in which only 5(1.67%) acceptors needed removal of IUCD. In none of the PPIUCD insertions, perforation of uterus occurred because of thick myometrium in the immediate post partum period (10, 11). Infection rate was 1% in our study (n=3) and no one needed removal of IUCD for that complication. They continued IUCD with medical management. This less incidence of infection could be due to antibiotic use in all our caesarean deliveries and careful selection of cases for PPIUCD insertion. Dysmenorrhea in our acceptor were noted in 8.3 %( mild n= 22, moderate n=3), among whom only 0.67% (n=2) needed removal of IUCD. Removal of IUCD for pain (0.67%) and excessive bleeding (1.67%) is less in our PPIUCD users (2.34%) compared to 5-15% in interval IUCD users. Most of the CuT removal in our users were for opting to go for either permanent sterilization 6.33 %( n=19) or for planning for second child 2.3 %( n=2.3%). 10 users (3.3%) needed intravenous sedation in OT for CuT removal. CONCLUSION PPIUCD is safe and effective method of contraception with low expulsion rate and high continuation rate. Women who received PPIUCD showed high level of satisfaction with their choice of contraception. It is not associated with increased risk of infection, perforation, post partum bleeding, sub involution, excessive menstrual bleeding and pain. Hence it can be highly recommended as an effective method of postpartum contraception in developing countries.

ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Conflict of interest: The authors declare that they have no conflicts of interest. Source of funding: No funding received from any source for this study.

References:

1. Somesh Kumar, Reena Sethi, Sudharsanam Balasubramaniam, Elaine Charurat, Kamlesh Lalchandani, Richard Semba, and Bulbul Sood Women’s experience with postpartum intrauterine contraceptive device use in India, Reprod Health. 2014; 11: 32.

2. Postpartum IUCD reference manual: family planning division, ministry of health and family welfare, Govt. of India, Nov 2010.

3. Lakshmi Garuda, Suhasini Kambham: Clinical outcome of PPIUCD (copper T-380A) - intra caesarean insertion. Indian Journal of Obstetrics and Gynaecology research 2015; 2(4): 218-226.

4. WHO medical eligibility criteria for contraception.4.Geneva. WHO: 2010.

5. Holly Blanchard, Maternal and child health integrated program guidance for PPIUCD: United States agency for international development, May 2012. Available at http:/www.mchip.net/pdf, accessed on 16/10/2015

6. Anjum Afshan,Shabnam Shamim Asim, Immediate Postpartum IUCD (PPIUCD) Insertion: An Opportunity Not to be Missed, Annals Abbasi Shaheed Hospital and Karachi Medical and Dental College Volume No. 19 (1), June 2014.

7. Rajni Gautam, K. N. Arya, S. Kharakwal, Sudhir Singh, Monika Trivedi. “Overview of Immediate PPIUCD application in Bundelkhand Region”. Journal of Evolution of Medical and Dental Sciences 2014; Vol. 3, Issue 36, August 18; Page: 9518-9526

8. Sahaja Kittur, Y. M. Kabadi. Enhancing contraceptive usage by post-placental intrauterine contraceptive devices (PPIUCD) insertion with evaluation of safety, efficacy, and expulsion: Int J Reprod Contracept Obstet Gynecol. 2012; 1(1): 26-32.

9. Mark Fritz, Leon Speroff. Clinical gynaecological endocrinology and infertility, 8th edn, 2011, 1104-1113.

10. Celen, S., Moroy, P., Sucak, A., Aktulay, A., and Danisman, N., (2004). Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices.Contraception,69(4),279-82.

11. Dr. Satyavati Maluchuru, Dr. V. Aruna, Dr. N. Prabhavathi., Postpartum intrauterine device insertion-2 year experience at a tertiarycare center, IOSR Journal of Dental and Medical Sciences, vol. 14, issue 3 ver. IV (Mar-2015).

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A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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