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Table of Content - Volume 14 Issue 2 - May 2020 A prospective study to assess the safety and efficacy of postplacental intrauterine contraceptive device
Shetal Prajapati1, Bhavana Joshi2*
1Assistant Professor, 2IIIrd Year Resident, Department of Obstetrics & Gynaecology, PDU Medical College, Rajkot, Gujrat, INDIA. Email: bhavanajoshi24@yahoo.in
Abstract Background: Postpartum period is the ideal time of family planning. Studies show that spacing less than two years of child birth can lead to obstetric complication and maternal mortality. Hence practice of contraception is mandatory. Intrauterine Contraceptive Device (IUCD) is one of the most commonly used reversible methods of contraception among married women of reproductive age worldwide, and IUCDs provides very effective, safe and long-term protection against pregnancy. Method: This study was carried out in the Department of Obstetrics and Gynecology at PDU Medical College and Hospital Rajkot, Gujarat from 1st June 2018 to 30 October 2018, a period of One year. All cases who are delivered at PDU medical college were included in the study. Result: Out of 500 cases, majority of patients belongs to age group 20-24 years and that is 41.4%, majority 40% were following their second child accepted PPIUCD.405 women (81%) following cesarean section preferred PPIUCD usage.93 women (18.6%) perceived pain, 53 women (10.6%) having menstrual irregularities, 27(5.4%) women having complaint of white discharge.3(0.6%) women having expulsion of PPIUCD. Expulsion rate is only 0.6% in our study which is quite lower than other. In 1 patient IUCD removed which was kept after vaginal delivery and removed due to complaint of irregular bleeding per vagina. Conclusion: The PPIUCD is particularly safe with few complications as in this study. The patients should be counselled regarding the advantages even in the antenatal clinic itself as successful family planning measures help to avert 20-35% of maternal deaths and nearly 20% of neonatal deaths. Key Words: post placental intrauterine contraceptive device, postpartum contraception, family planning, IUCD
INTRODUCTION India is world’s second most populated country. India’s population which crossed one billion in 2000, is projected to reach 1.53 billion by 2050, making it the most populous country in the world. Women of reproductive age group (15-49) make up approximately 248 million. Nearly 20.7% of the Indian population have unmet needs for family planning with 65% of the need in the first year of postpartum period. A baby born after a short birth interval has increased chances of:
With the increased number of institutional deliveries due to provision of Janani Suraksha Yojana – a cash transfer scheme there is increased access to the pregnant women for promoting family planning services. Furthermore in the immediate postpartum period, the insertion of intrauterine devices is convenient and these women are highly motivated. The postplacental IUCD insertion is particularly suitable for our country where even para medical personnel can insert the cu – T and delivery is the only time when these patients come in contact with the hospital. Aim:
Methods: Study carried out in PDU medical college Rajkot. 500 women meeting the inclusion criteria were recruited, over a period of 1 year from 1st june 2018 to 30 october 2018. ELIGIBILITY CRITERIA Ages eligible for study: 18 years and older Accepts Healthy Volunteers: Yes INCLUSION CRITERIA: Pregnant at time of enrolment. Desire to use the CU T for contraception. Willing and able to sign an informed consent. Willing to comply with the study protocol. Age greater than or equal to 18 years EXCLUSION CRITERIA: Absent of consent. Outside delivery. PROM >18 HOURS. Severe anemia. P/H/O Discomfort Due to IUCD. P/H/O menorrhagia. Suspected uterine anomaly. Bleeding tendency/APH. Unresolved Traumatic / Atonic PPH. Patient admitted with fever. H/O recent ectopic pregnancy. VBAC
RESULTS our study compromised 500 women who delivered at our hospital.
Table 1: Distribution according to age
Out of 500 cases, majority of patients belongs to age group 20-24 years and that is 41.4%. 38% were in age group 25-29 years. 19% patients were aged more than 30 years. 1.6% patients were in age group less than 20 years. This shows that PPIUCD usage is more among young females rather than among teenage pregnancies. Teenage mothers having fear of complications more and are not willing to accept PPIUCD usage.
Table 2: Distribution of women according to parity
The group was then studied according to their parity and it was found that 33% were primiparous, 40% were following their second child, 16% had three living children and 11% users with more than 3 living children. Unlike primipara women who use PPIUCD to space out their pregnancy. PPIUCD is used in higher order births when the women or their family members are unwilling for permanent sterilization. PPIUCD acceptance is significantly affected by duration of last child birth. Women after their first delivery prefer a long acting, reliable, reversible method of contraception.
Table 3: Distribution according the mode of delivery
In this study, 95 women (19%) following normal vaginal delivery, 405 women (81%) following cesarean section preferred PPIUCD usage.
Table 4: REASONS FOR DECLINING PPIUCD AMONG PARTURITIENTS
Table 5: complaints at follow up
93 women (18.6%) perceived pain, 53 women (10.6%) having menstrual irregularities ,27(5.4%) women having complaint of white discharge.3(0.6%) women having expulsion of PPIUCD.
Table 6: Complication at 2 week in the view of mode of delivey
In our study complications at 2 weeks interval were higher in normal delivery patient. Pain occurred in 18.27% of patients and 3.7% have discharge p/v and menstrual irregularities in 10.61% in LSCS, while in normal delivery the rate of pain 20% and discharge occurred in 12.63% and menstrual irregularities in 1.05%. So chi-square test was applied to know association between complaint at 2 week and mode of delivery. The p value is 0.69 in case of pain and association is not significant, p value in case of vaginal discharge is 0.974 and association is significant. P value in case of menstrual irregularities is 0.974 and association is not significant.
DISCUSSION Postpartum period is the time when women are highly receptive and motivated to accept family planning method. Also, women are vulnerable to unintended pregnancy because contraceptive options are limited in breast feeding women. Since ovulation is highly unpredictable in non-breast feeding and partially breastfeeding women, couples often underestimate the likelihood of pregnancy. Postpartum women often want a method that provide long term temporary contraception, but doesn’t want permanent sterilization. This emphasizes the need to provide a contraceptive method in the immediate postpartum period, in order to avoid unplanned pregnancies and the morbidity associated with subsequent abortion. Postpartum insertion of IUCD provides long term and effective contraception immediately after delivery without significant additional complications and does not require constant supervision. Women who wish to use contraceptive method 6 weeks after delivery, often do not return and subsequently experience an unintended pregnancy. Thus, insertion of copper T immediately after delivery can help in preventing unplanned pregnancy and subsequent safe or unsafe abortions. In our study, majority of patients belongs to age group 20-24 years and 41.4%. 38% were in age group 25-29 years. 19% patients were aged more than 30 years. 1.6% patients were in age group less than 20 years and was found that 33% were primiparous, 40% were following their second child, 16% had three living children and 11% users with more than 3 living children as compared to S.SUBATHRA et al.(76) in which 322(64.4%) belong to age group 20-24 years, 161(32.1%) cases belong to 25-29 year age group, 16(16.5%) belong to age group 30-34 years, 1(0.2%) patient belong to age group more than 35 years and in S.SUBATHRA et al.(76) study majority of patients 384(76.8%) were primigravida, 111(22.1%) were following their second child 5(1.1%) had three living children. In our study, 95 women (19%) following normal vaginal delivery, 405 women (81%) following cesarean section preferred PPIUCD usage. On studying the reasons for women refusing to accept PPIUCD, varied reasons were identified. 1. women preferred to use another method of contraception, 2. women were not willing to use PPIUCD as their partners refused contraception,3. had fear of pain and heavy bleeding despite reasoning out, 4.women did not prefer contraception, 5. had fear of cancer, 6.refused on religious grounds and 7. had no specific reason. Out of 500 cases, in 405 cases Cu-T kept during intracesarean and accepted 100% and in 95 cases Cu-T inserted during vaginal delivery and accepted in 98.94% cases.93 women (18.6%) perceived pain, 53 women (10.6%) having menstrual irregularities ,27(5.4%) women having complaint of white discharge.3(0.6%) women having expulsion of PPIUCD and in S.SUBATHRA (76) et al. study 12 women (2.4%) having complaint of pain, in 23(4.6%) patients IUCD expulsed, in 24(4.8%) patients lost strings occurs and in 45(9%) patients menstrual irregularity occurs. In 1 patient IUCD removed which was kept after vaginal delivery and removed due complaint of irregular bleeding per vaginum. In our study the failure rate is 0% as none of the patients became pregnant in 6 month follow up period and none of the patients had perforation. The immediate post partum IUCD insertion is safe and effective in any of the mode of delivery, i.e. either in normal delivery or during cesarean section. The most complaints of the patients at 2 weeks follow up are pain and discharge. Pain is being a remote complaint in further follow up, which is predominant in subsequent follow up. The expulsion of the IUCD occurs in 0.6% of cases overall patients. There were 3 patient’s having complaint of expulsion one was primigravida and 2 were multiparous. IUCD expulsed in 3 patients from which 2 were kept in vaginal delivery and 1 in LSCS.
CONCLUSION Thus it was concluded from the present study that insertion of Cu T immediately following delivery i.e. postplacental is an effective, safe, convenient, low cost and long term method of postpartum contraception irrespective of the mode of delivery. Increased institutional deliveries in India provides an opportunity for offering family planning services to the women, who have just delivered at health facilities and want to prevent unintended pregnancies or delay having more children. Although, the rate of expulsion of copper T is high in postpartum period when compared to interval insertion but it can be reduced by ensuring correct technique of insertion and correct timing of insertion i.e. within 10 minutes of expulsion of placenta. The risk of other complications like bleeding, pain in lower abdomen and infection were relatively less in both the groups. The removal rate for bleeding and/or pain was found to be lower in either group. No case of perforation and pregnancy occurred in the entire study. The incidence of missing threads was higher in PPIUCD group which was probably due to coiling of long threads of copper T inside the uterine cavity. The 6 months’ continuation rate was quite good in PPIUCD group. As, there is an increased risk of expulsion, by which questions regarding its efficacy are made. But, its benefits outweigh the risks. So this method should be popularized across the country as an option to all women, undergoing institutional deliveries, in tertiary health centers irrespective of the mode of delivery. Acknowledgements Authors would like to thank Dr.Kamal goswami (Head of department) for his guidance and constant support. Funding: no funding source Ethical approval: The study was approved by the institutional ethical committee.
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