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COMMENTARY
Year : 2012  |  Volume : 136  |  Issue : 3  |  Page : 370-371

Post placental insertion of intrauterine contraceptive device


Department of Obstetrics & Gynaecology, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India

Date of Web Publication4-Oct-2012

Correspondence Address:
Vanita Suri
Department of Obstetrics & Gynaecology, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012
India
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Source of Support: None, Conflict of Interest: None


PMID: 23041730

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How to cite this article:
Suri V. Post placental insertion of intrauterine contraceptive device. Indian J Med Res 2012;136:370-1

How to cite this URL:
Suri V. Post placental insertion of intrauterine contraceptive device. Indian J Med Res [serial online] 2012 [cited 2019 Oct 21];136:370-1. Available from: http://www.ijmr.org.in/text.asp?2012/136/3/370/101975

Insertion of an intrauterine contraceptive device (IUD) immediately after delivery has been recommended by the WHO, as one of the safe and effective methods of temporary contraception. In the immediate post delivery period the women are highly motivated and need an effective method for contraception so that the child can be brought up with a relaxed mind without the worry of unintended pregnancy. On the other hand, if they are made to wait for 6 wk for initiating an effective contraception, they may conceive accidentally or may not come for contraception. This approach is more applicable to our country where delivery may be the only time when a healthy woman comes in contact with health care personnel. Compared with sterilization, however, use of an intrauterine device (IUD) is simpler, less expensive, and immediately reversible. Insertion of an IUD after delivery may avoid the discomfort related to interval insertion, and any bleeding from insertion will be disguised by lochia. However, immediate post-partum IUD insertion may have disadvantages as well. The risk of spontaneous expulsion may be unacceptably high.

In a systematic review by Kapp and Curtis [1] , the outcomes of post-partum insertion of IUD at different time interval were compared. The evidence demonstrated no increase in risk of complications among women who had an IUD inserted during the post-partum period; however, some increase in expulsion rates occurred with delayed post-partum insertion when compared to immediate insertion. Expulsion rates were more when compared to interval insertion. Post-placental insertions during caesarean section were associated with lower expulsion rates than post-placental vaginal insertions without any increase in other complications.

In another systematic review [2] , nine trials were reviewed. One of these compared insertion right after child birth with a later time. The results were compared with studies of IUDs inserted at other times. The authors' conclusion was: immediate post-partum insertion of IUDs appeared safe and effective, though direct comparisons with other insertion times were limited. Expulsion rates appeared to be higher than with interval insertion. Advantages of immediate post-partum insertion include high motivation, assurance that the woman is not pregnant, and convenience. The popularity of immediate post-partum IUD insertion in countries as diverse as China, Mexico, and Egypt supports the feasibility of this approach [2] . Early follow up may be important in identifying spontaneous IUD expulsions.

According to medical eligibility criteria 2009, 4 th edition [3] , immediate post-placental insertion of Copper (Cu T) is recommended in breast feeding as well as non breast feeding mothers. It is safe and effective. Insertion after delivery of the placenta is associated with lower expulsion rates than delayed post-partum insertion. Additionally, post-placental placement at the time of caesarean section has lower expulsion rates than post-placental vaginal insertions. Insertion complications of perforation and infection are not increased by IUD placement at any time during the post-partum period [1],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] .

In the study by Shukla et al[16] , the authors inserted Cu T 200B in 1317 women in the immediate post-partum period. The complicated cases were excluded. There was no immediate complication and expulsion rate at the end of follow up was 10.68 per cent. Only 11.3 per cent came for follow up at 6 months and 78 per cent came for follow up at 6 wk. So the rate of expulsion at 6 month period was apparently not true as only 11 per cent women came for checkup. Cu T 200B has been used because this study was conducted in 1995-2000. There is a need for randomized controlled trials to compare the safety and efficacy of IUD (Copper T 380A) when inserted at different times.

There was no case of pelvic inflammatory disease (PID) in the present study but the follow up rate was very low [16] . Therefore, it cannot be concluded nil infection. There are reports of high incidence of infections in developing countries [17],[18] which may affect the risk of pelvic infection. Use of prophylactic antibiotics may be considered in our setting where the incidence of post-delivery sepsis is high as compared to developed countries.

It has been observed that expulsion rates vary according to clinician's skill in post-placental insertion of IUD [19] . Thus additional training for post-partum insertion of IUD should be provided to the clinicians and the special kit for the same should be provided to the health centers where deliveries are conducted [20] .

There is a need for large randomized studies to compare the risks and complications of post-placental IUD insertion in special risk groups where there is increased risk of infection such as women with heart disease, diabetes, HIV positive women and patients who are on immunosuppressants for autoimmune diseases. There are not much data from our country. We need to have more studies in different settings before we declare the post-placental IUD insertion completely safe.

 
   References Top

1.Kapp N, Curtis KM. Intrauterine device insertion during the postpartum period: a systematic review. Contraception 2009; 80 : 327-36.  Back to cited text no. 1
    
2.Grimes DA, Lopez LM, Schulz KF, Van Vliet HAAM, Stanwood NL. Immediate post-partum insertion of intrauterine devices. Cochrane Database Syst Rev 2010; Issue 5. Art. No.: CD003036.   Back to cited text no. 2
    
3.Department of Reproductive Health, WHO. Medical eligibility criteria for contraceptive use, 4 th ed.; 2009.  Back to cited text no. 3
    
4.Bonilla Rosales F, Aguilar Zamudio ME, Cazares Montero Mde L, Hernandez Ortiz ME, Luna Ruiz MA. Factors for expulsion of intrauterine device Tcu380A applied immediately postpartum and after a delayed period. Rev Méd Inst Mex del Seguro Soc 2005; 43 : 5-10.  Back to cited text no. 4
    
5.Brenner PF. A clinical-trial of the delta-T intrauterine-device - immediate postpartum insertion. Contraception 1983; 28 : 135-47.  Back to cited text no. 5
[PUBMED]    
6.Celen S, Moroy P, Sucak A, Aktulay A, Danisman N. Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices. Contraception 2004; 69 : 279-82.  Back to cited text no. 6
    
7.Chi IC, Wilkens L, Rogers S. Expulsions in immediate postpartum insertions of Lippes Loop D and Copper T IUDs and their counterpart Delta devices - an epidemiological analysis. Contraception 1985; 32 : 119-34.  Back to cited text no. 7
[PUBMED]    
8.El-Shafei MM, Mashali A, Hassan EO, El-Boghdadi, El-Lakkany 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.  Back to cited text no. 8
    
9.Eroglu K, Akkuzu G, Vural G, Dilbaz B, Akin A, Taskin L, et al. Comparison of efficacy and complications of IUD insertion in immediate postplacental/ early postpartum period with interval period: 1 year followup. Contraception 2006; 74 : 376-81.  Back to cited text no. 9
    
10.Lara R, Sanchez RA, Aznar R. Application of intrauterine device through the incision of the cesarean section. Ginecol Obstet Mex 1989; 57 : 23-7.  Back to cited text no. 10
    
11.Mishell DR, Jr, Roy S. Copper intrauterine contraceptive device event rates following insertion 4 to 8 weeks post partum. Am J Obstet Gynecol 1982; 143 : 29-35.  Back to cited text no. 11
    
12.Morrison C, Waszak C, Katz K, Diabate F, Mate EM. Clinical outcomes of two early postpartum IUD insertion programs in Africa. Contraception 1996; 53 : 17-21.  Back to cited text no. 12
    
13.Muller ALL, Ramos JGL, Martins-Costa SH, Dias RSP, Valerio EG. Transvaginal ultrasonographic assessment of the expulsion rate of intrauterine devices inserted in the immediate postpartum period: a pilot study. Contraception 2005; 72 : 192-95.  Back to cited text no. 13
    
14.Welkovic S, Costa LO, Faundes A, de Alentar Ximenes R, Costa CF. Post-partum bleeding and infection after post-placental IUD insertion. Contraception 2001; 63 : 155-8.  Back to cited text no. 14
    
15.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. 15
[PUBMED]    
16.Shukla M, Qureshi S, Chandravati. Post-plecental intrauterine device insertion - A five year experience at a tertiary care centre in north India. Indian J Med Res 2012; 136 : 432-5.   Back to cited text no. 16
    
17.Marai W. Lower genital tract infections among pregnant women: a review. East Africa Med J 2001; 78 : 581-5.  Back to cited text no. 17
[PUBMED]    
18.Kurewa NE, Mapingure MP, Munjoma MW, Chirenje MZ, Rusakaniko S, Stray-Pederson B. The burden and risk factors of sexually transmitted infections and reproductive tract infections among pregnant women in Zimbabwe. BMC Infect Dis 2010; 10 : 127.  Back to cited text no. 18
    
19.Thiery M, Van Kets H, Van Der Pas H. Immediate postplacental IUD insertion: the expulsion problems. Contraception 1985; 31 : 331-49.  Back to cited text no. 19
[PUBMED]    
20.Muthal-Rathore A. Immediate postpartum insertion for intrauterine devices: RHL commentary. The WHO Reproductive Health Library; Geneva: World Health Organization; 2010.  Back to cited text no. 20
    




 

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