IUCD Insertion and Fixation versus Insertion Only During Cesarean Section

INTRODUCTION

Just after the baby is delivered is the optimal time to begin utilising postnatal control, either as a preventative precaution or as a family tool for planning. Instant contraception is both practical and timely when a woman is actively considering her present and future health choices. The return of a female's fertility after childbirth is unpredictable, as it could happen in as little as three weeks in women who are not breast-feeding and is not always followed by menstruation. The prenatal period is a near-ideal time for discussing contraception with women, in terms of requirements, the nature of the products accessible, and other topics, as well as the advantages and disadvantages of each. The willingness of the patient to pick a certain type of contraceptive is an important aspect in assisting a woman in appropriately managing her contraceptive requirements. ¹ Females who have caesarean sections with less than 18 months between deliveries have a higher risk of uterine rupture ². Using contraceptives as soon as feasible after delivery to prevent uterine rupture following a caesarean section would allow the wound to heal and the woman to recover completely from her gestation. Efficient contraception will help such women avoid undesired pregnancies, and it may even allow them to have natural births instead of caesareans.

Intrauterine devices (IUDs) are largely regarded as the near-ideal contraception type, with advocacy organizations, clinicians, as well as gynaecological organisations all advocating for them. IUDs have high effectiveness and a low rate of failure, owing in part to the female's lack of participation. Rapid postpartum IUD insertion is worth considering since it could offer rapid contraceptive methods, prevent unintended pregnancies, as well as decrease the requirement for a second caesarean birth ³. Unfortunately, the high expulsion and displacement rates of traditional T-shape IUDs limit their usage right after placental delivery ^{4, 5}.

With T-shape devices, the timing of implantation after placenta delivery is crucial. According to studies, when the catheter was put in more than 10 minutes after delivery, rates of expulsion have been greater than in usual women

PATIENTS AND METHODS

This was a randomized controlled clinical trial performed at Sohag General Hospital's Department of Obstetrics and Gynecology (Sohag, Egypt) for twelve months (December 1^st, 2019 – November 30th , 2020).

Patients: The study included 200 pregnant women scheduled for elective CS and desired immediate postpartum IUCD insertion during CS at Sohag General Hospital during the period of the study.

Inclusion criteria: Gestational age between 36 – 40 weeks, singleton pregnancy, elective CS, normal findings on ultrasound scanning, and request of the Cu T380A IUD for immediate postpartum contraception.

Exclusion criteria: Gestational age < 36 weeks or > 40 weeks, distorted uterine cavity, multiple gestations, abnormal placenta (e.g., previa, accreta), ruptured membranes for more than 12 hours or evidence of chorioamnionitis, emergent CS, uterine fibroid, history of ectopic pregnancy, bleeding tendency, repeated PID, allergy to copper and wilson disease.

Methods: All participating pregnant women were subjected to the following:

Complete history taking: including the following data: Sociodemographic data: including age, residence, and socioeconomic status. Menstrual history: including age at menarche, and details of menstrual cycles. Obstetric history: including number of pregnancies and deliveries, mode of delivery, and previous obstetric complications. Medical history: including diabetes mellitus, hypertension, and other medical conditions.

Antenatal counselling and consent: All women have been counselled about contraception throughout prenatal care with a full description of different methods of contraception, different types of IUCDs, and the advantages and disadvantages of each of them.

Examination: All study participants underwent complete general examination, abdominal examination, and pelvic examination.

Investigations: All study participants underwent pelvic Ultrasound for thorough assessment of uterus and ovaries. Moreover, blood samples were obtained for complete blood counts and hemoglobin levels, kidney functions, liver enzymes, and coagulation profiles.

Insertion of TCu-380A: The TCu-380A (Pregna International Ltd, Mumbai, India) is a T-shaped device with a vertical measurement of 32 mm and a horizontal measurement of 36 mm. The monofilament polyethylene tail strings are threaded into a 3 mm bulb at the vertical stem base, allowing the patient to check for the device's continued presence and facilitating the IUCD's later removal. All IUCDs were put by physicians who had undergone adequate training. The TCu-380A IUCD was placed via the lower uterine segment incision after delivery of the baby, placenta, and membranes through caesarean section. The IUD was manually inserted into the most proximate portion of the uterine fundus after being detached from its applicator. In the fixation group, A single absorbable stitch was used to anchor the TCu-380A to the fundal wall. At the connecting arm of the TCu-380A, the anchor ring was tied. Both IUCD strings were lengthened before being placed in the uterine cavity by threading 10 cm of Vicryl threads number 0 through the cylinder and out the other end. The cylinder is progressively pushed downwards through the threads after being inserted near to the fundus, passing through the cervix and being withdrawn vaginally after delivery.

Assessment & follow-up: Follow-up appointments were scheduled for 3, 6, 9, and 12 months after birth for the women who took part. They were shown how to check for IUCD threads and told that if they couldn't feel them, they should seek medical help right once. The Vicryl suture knot emerged beneath the cervix during the puerperium, and the threads were reduced to 2 cm from the cervix. The IUCD was detected via ultrasonography.

Measured outcomes: The rate of IUCD expulsion at 3, 6, 9, and 12 months following CS was the primary endpoint in this study. This was determined by collecting a medical history, performing a pelvic examination, and using an ultrasound. When the IUCD's longitudinal arm is partly or completely within the cervix or vagina, it was considered complete ejection. When the IUCD was more than 10 millimetres away from the fundus but remained completely contained inside the uterine cavity, it was considered partial ejection or displacement ^{5; 6}. The incidences of intrauterine pregnancy on top of an IUD, ectopic pregnancy, menstrual disturbances, and PID were among the secondary outcomes. Pregnancy was determined by taking a medical history (e.g., missed periods), a pregnancy test, hCG titration, and an ultrasound. PID was defined as chills, fever (temperature N38°C), foul-smelling lochia, spontaneous uterine discomfort or tenderness, and/or delayed uterine involution.

Ethical Considerations: The study was accepted by Al-Azhar University's Faculty of Medicine's Ethical Research Committee (Assiut). Pregnant women gave their informed consent to participate in the study. All data were kept confidential and used for only scientific purposes.

Statistical Analysis: The collected data has been coded, reviewed, and entered into IBM SPSS version 20 (Statistical Package for Social Science). The Chi-square test was used to compare two groups with qualitative results, but the Fisher exact test has been employed rather when the predicted count in any cell was < 5. The independent t-test was employed to compare two groups having quantitative data as well as a parametric distribution, whereas the Mann-Whitney test has been employed to compare two groups having quantitative data as well as a non-parametric distribution. The acceptable margin of error has been established at 5%, with a 95% confidence interval.

RESULTS

Address of 28.5 of patients (57) elbaliana, of 20.5% (41) was sohag, of 36% (72) was almonshaa.  Mean of age was 29.01 with range from 20 to 42 years. (Table 1)

95 patients (47.5%) were have previous use of IUD,25% of patients (50) had Prev use of another method of contraception, Insertion of IUD of 100 patients (50%) was with stitch, of 100 patients (50%) was without stitch. (Table 2)

5 patients (2.5%) had pelvic infection and 71 patients (35.5%) had menstrual complications.( Table 3)

In the case of IUD insertion without stitching, there was a statistically significant increase in expulsion.

(Table 4)

In regards to occurrence, there were no statistically significant differences between IUD insertion with stitch versus IUD insertion without stitch. In regards to pelvic infection and menstrual complaints, there were no statistically significant differences between IUD insertion with stitch versus IUD insertion without stitch.( Table 5)

Table 1: Demographic data

Table 2: Prev use of IUD, Prev use of another method of contraception and Insertion of IUD with or without stitch

Table 3: Pelvic infection and menstrual complaints

Table 4: Comparison between Insertion of IUD with or without stitch as regards expulsion

Table 5: Comparison between Insertion of IUD with or without stitch as regards occurrence and Pelvic infection and menstrual complaints