Efficacy of Immediate Insertion of an Intrauterine Contraceptive Device during Cesarean Section in Comparison with Late Insertion after the Puerperium

INTRODUCTION

Because breast-feeding women have limited contraception choices, the postpartum period is particularly prone to unwanted pregnancy. At the same time, ovulation in non-breastfeeding or non-exclusive breast-feeding women is very unpredictable. This is a great time to start contraceptive essince women are very encouraged to do so at this time, and it is also efficient for both women and health care professionals.¹

If used properly, family planning may avoid approximately one-third of maternal fatalities and 10% of infant fatality, particularly if the deliveries are spaced more than two years apart.²

Cu-T is a kind of long-acting reversible contraception that is used all over the globe and is one of the most efficient methods of birth control.³

Post-placental intrauterine device (IUD) placement, defined as IUD placement within 10 minutes after delivery of the placenta, is an attractive strategy for increasing availability to postpartum IUDs since it does not need a separate postpartum visit.⁴

The immediate post insertion of intrauterine devices (IUDs) following caesarean birth is safe and accepted, and it might help to overcome a significant obstacle to long-term effective contraception.⁵

During caesarean delivery (CD), both immediately insertion of an intrauterine contraceptive device (IUCD) and tubal ligation may be done, however IUCDs offer some potential benefits.⁶

Copper T-380A IUDs may be successfully inserted intraoperatively by incision at the moment of cesarean delivery.⁷

Although full expulsions are less likely to be misclassified, partial expulsion may or may not involve malposition IUDs with uncertain clinical relevance.⁷

Immediate intra-caesarean IUD insertion after placental delivery provides changeable and efficient long-term contraceptive that does not interfere with lactating.⁸ It may also eliminate the pain associated with normal insertion, and lochia will hide any insertion blood. The lady is known to be not pregnant, thus contraception will be a key priority for her.⁹

The goal of this research was to evaluate and compare the expulsion rate, discomfort, and quantity of haemorrhage after IUD (pregnant T Cu 380A) insertion at the caesarean section vs. after puerperium, in order to suggest or not recommend IUD insertion at the caesarean section instead of after puerperium.

PATIENTS AND METHODS

This was a prospective trial including 200 women who were planned for an optional caesarean section and were separated into two groups at the Department of Obstetrics and Gynecology of El Hussein University Hospital and El Sayed Galal Hospital: (Group I): 100 women consented to have an immediate post-placental IUD inserted during a C/S birth; (Group II): 100 women decided to have an IUD inserted after puerperium as a control group.

Inclusion Criteria: Pregnant women between the ages of 18 and 40 who are planning an elective cesarean delivery at a gestational age of 37 to 40 weeks and are looking for contraception after birth.

Exclusion Criteria: History of menorrhagia or extreme dysmenorrheal, history or existing of pelvic inflammatory disorder (ex: puerperal sepsis, purulent cervicitis), ruptured membranes for more than 24 hours prior to delivery, patients with bleeding abnormalities, structural uterine abnormality or large uterine fibroids distorting anatomy, history of past IUD expelling or removal for problems, history of ectopic pregnancy, and ante- or intrapartum hemorrhage.

Every patient was exposed to:

full history taking:

Personal history.

Menstrual (Gynecological) history.

Obstetric History.

Present history of chronic diseases and medication.

Past history of HTN, DM, Bleeding disorders.

History of allergy to any medication.     

Surgical history of operation, laparoscopic interference, treatment of hirsutism by Laser.

Post placental IUD Insertion: Immediately after the recommendation of a cesarean delivery, all women were given the option of IUD insertion at surgery, and their questions regarding this type of contraceptives were explained. Women who signed a written informed consent form and consented to participate in Group 1 were included.

After Puerperium IUD Insertion: Women who decided to put an IUD 6 weeks following a caesarean section had been involved in group 2 after sign a written informed consent. The insertion process generally took between five minutes and fifteen minutes. The procedure was difficult for some women.

Follow up: After 6 weeks of IUD insertion, the two groups were followed up to ensure the normal IUD position and to exclude any complications.

Those women were undergo:

Gynecological examination: Vulvar examination, vaginal examination, and bimanual examination.

Transvaginal sonography at the hospital: Transvaginal ultrasonography at 6 weeks after IUD insertion. If a patient had pelvic discomfort, fever, severe hemorrhage, or an abnormal vaginal discharge; they were encouraged to call a physician immediately. Sonography was performed transvaginally using a real-time sector scanner and a high-frequency (5/7.5 MHz) endovaginal probe.

Primary outcome: Successful placement, subsequent expulsion.

Secondary outcome: Bleeding, pain and other adverse events.

Statistical Analysis:

Using SPSS 22.0 for Windows, all data were gathered, tabulated, and statistically evaluated (SPSS Inc., Chicago, IL, USA). Utilizing the Shapiro Walk test, the normal distribution of the data was examined. Frequencies and relative percentages were utilized to depict qualitative data. As shown, the Chi square test (χ2) and Fisher exact were employed to quantify the variance between qualitative data. For parametric data, quantitative data were represented as mean±   SD (Standard deviation), and for non-parametric data, as median and range. For parametric and non-parametric measures, respectively, the Independent T test and the Mann Whitney test were employed to compute the variance between quantitative variables in two groups. P value was chosen to< 0.05 for statistically substantial findings and

RESULTS

At the Department of Obstetrics and Gynecology at El Hussein University Hospital and El Sayed Galal Hospital, prospective research of 200 women who were scheduled for an optional cesarean delivery was conducted. The 200 women were randomly divided into two groups: Group I: included 100women who agreed to insert immediate post placental IUD at the C/S delivery. The mean age was 30.58, the mean BMI was 27.64, the mean gravidity was 2.86, and Group II included 100 women who chose to insert IUD after puerperium as a control group. The mean age was 31.02, the mean BMI was 28.31, the mean gravidity was 2.97.

Table 1: Socio demographic characteristics among the investigated groups

There was no statistically substantial variance in the groups according socio demographic data (Table 1).

Table 2: Abnormal bleeding and pain distribution of the two investigated groups.

There was no substantial variation in the groups according abnormal bleeding. Regarding group I 24% of the patients presented with abnormal bleeding while only 19% in group II. Also, there was no substantial variation in the groups according pain. Regarding group I 24% of the patients suffered from pain while only 17% in group II suffered from pain (Table 2).

Table 3: Pelvic inflammatory disease (PID) and endometritis distribution of the two investigated groups.

There was no substantial variation in the groups according PID. Regarding group I, 6% of the patients presented with PID while only 3% in group II presented with PID. Also, there was no substantial variation in the groups according endometritis. Regarding group I, 2% of the patients presented with endometritis while only 1% in group II presented with endometritis (Table 3).

Table 4: IUD status distribution of the two investigated groups.

There was no substantial variation in the groups. Regarding IUDs in group I, 85% patients were retained, 15% were Expulsed. Regarding IUDs in group II, 92% patients were retained, 8% were expulsed (Table 4).

Table 5: Types of expulsion of the two investigated groups

There was no substantial variation in the groups. Regarding IUDs in group I, 11% of IUDs were partially expulsed while 4% were completely expulsed. Regarding IUDs in group II, 6% of IUDs were partially expulsed while 2% were completely expulsed (Table 5).

Fig. 1: IUD status distribution of the two investigated groups.

Thus, the only substantial variation in the two groups is difficulty during IUD insertion, otherwise there are no significant difference regarding expulsion, abnormal bleeding, pain and other adverse events (Figure 1).