IUCD

Role of antibiotics in immediate postpartum period:

        There is still debate about routine use of antibiotics after fitting an IUD. The present consensus is not to use prophylactic antibiotics routinely in all cases. However, in settings of both high prevalence of STIs and limited STI screening, facility such prophylaxis may be considered or else HCP may counsel the IUD user to watch for symptoms of PID, especially during the first month. If symptoms appear (pain, fever, white discharge) then one can prescribe antibiotics.

i.      During lactation period without having restoration of menstrual period: IUD can be fitted if urine for pregnancy test is negative but this should be fitted at least six weeks after childbirth. Earlier, there was some concern that insertion during lactation might involve a higher risk of uterine perforation as the womb is still small and soft.

                             i.            IUD insertion after abortion –

IUD can be introduced after surgical evacuation of uterus (abortion) if there is no sepsis.

Insertion during postabortal period

a)  When abortion occurs/contemplated before 14 weeks of gestation -

IUDs can be safely inserted during evacuation of the uterus (surgical abortion). Provided the pregnancy is less than 14 weeks. The couple should be made aware that conception can occur as early as 10 days after abortion. Therefore effective contraception is needed soon after abortion. IUDs can safely be inserted after spontaneous or induced abortion except in women with evidence of pelvic infections or septic abortion.

    WHO studies show moderate expulsion rates associated with IUD insertion following first trimester abortions – ranging at two years from 5 to 9 per 100 women after induced abortion and from 10 to 14 after spontaneous abortions.

ii) When spontaneous abortion occurs or Medical Termination is contemplated between the period 14 weeks to 20 weeks pregnancy. It is not customary to fit IUD after second trimester abortion (14-20 weeks of pregnancy). Because there is 5-10 times more chance of expulsion of the IUD is being inserted immediately after second trimester abortion (WHO Task Force Study, 1985). So it is better to wait for 4 weeks or till the next period ensue whichever is earlier.

Safety Concerns: It is a safe contraceptive though misperceptions about the risks associated with IUD use are well documented. Although every contraceptive intervention has its risks, including failure and the much greater medical risks associated with pregnancy and childbirth, the overall safety profile of modern IUC is among the best in the contraceptive armamentarium.

Poor candidates for IUDs: Contraindication of IUD as a contraceptive:

b) Recurrent or current pelvic infection (PID). This is the most important contraindication for IUD use. But IUD can be used if there is one pregnancy after an attack  of PID and there is no risk of acquiring S.T.I.

c)   behavior of the acceptor or her husband is so that there is a fair chance for acquiring sexually transmitted disease. It any of the spouse has multiple sex partners then ideally sexual copper bearing IUD should not be fitted. Hormone containing IUDs may however will be a better option.

d) Those who are already suffering from menstrual cramps and/or heavy periods. Hormone containing IUC (Mirena) may be beneficial in such women. Such IUD will serve the dual purpose of contraception and disease transmission.

e)  Similarly those who are suffering from abnormal bleeding or anemia are also not good candidates for IUD.

f)    Part history of ectopic pregnancy: It is better to avoid IUD for those group of women though opinion differs. Now only a few gynecologists believe that IUD should not be fitted in such women.

g)  Uterine Fibroids hormone containing IUDs may however be used. According to WHO if Myomas do not distort the uterine cavity then copper IUD may be used if no other suitable contraceptive is available?

h) A very large/small uterus and other anatomical abnormalities of womb.

i)     Obvious cervical or uterine cancer.

The assessment of suitability of IUD is done in stepwise manner. e.g. -

1) Replies by the client in response to some question.

2) Clinical examination by the HCP.

3) Laboratory lists to desires exclude STI.

Checklist (question) for screening clients who to initiate Use of the copper IUDs:

  Intrauterine devices (IUDs) are generally safe and effective for use by many women, including those who have not given birth, who want to space births, and those who are at risk of HIV infection or living with HIV infection. But some women are unsuitable for IUD due to the presence of certain female diseases, such as current cervical infections (infections of the mouth of the womb), PID or other diseases of womb (uterus). For these reasons, women who desire to use an IUD must be screened for associated gynecological conditions to determine whether if they are appropriate candidates for the IUD. It no such screening is done prior to IUD insertion then post insertion complications will increase considerably which must be avoided by all means.

        The checklist consists of a series of questions planned to identify any medical condition or behavior that would either prevent safe IUD use or require further screening in the form of investigation. As well as provide further guidance and directions based on client responses. A health care provider should analyze her response to all questions before inserting an IUD and thus assess eligibility of IUD use.

Answers to be replied by prospective acceptor:

1) Have you given birth within the last 4 weeks? IUD should be fitted after 4 weeks of childbirth and not before.

2) Have you been told that you have pelvic tuberculosis or any type of cancer in your genital organs?

3) Do you have bleeding between menstrual periods that is unusual for you or bleeding after sex?

4) Within the last 3 months, have you had more than one sexual partner?

5) Within the last 3 months, do you think your partner has had another sexual partner?

6) Within the last 3 months, have you been told you have an STI?

7) Within the last 3 months, has your partner been told that he has an STI or has he had any symptoms for example, penile discharge?

8) Are you HIV positive?

9) Have you developed AIDS?

a)  If answers to Q No. 3 are yes then it implies that she has probably some female (gynecological) disease then she should be treated for that specific disease and IUD fitted at a later data with the approval of gynecologist.

b) If answer to any of the questions 4 to 7 is affirmative then also IUD should be avoided. IUD can be fitted after cure of suspected gonorrhea or Chlamydia infection (STI)

c)   If answer to Q 8 is yes and there is no evidence of AIDS disease then she can use IUD.

d) If answer to Q. 9 is yes then IUD may be used if she is doing clinically well on ARV drugs (antiretroviral agents). But if she is not on ARV then IUD should not fitted.

Additionally, no pregnant women should be fitted with IUD. Pregnancy can be excluded by home monitoring of urine for pregnancy test after the expected date of period in over. But occasionally such kit may not be available in remote areas of India. Then putting the following questions to the acceptor can reasonably assess whether she is pregnant or not. These questions will also give a possibility of having pregnancy in the running cycle before the expected date. Pregnancy is almost always impossible under the following situations.

1) She has abstained from sex since last period.

2) She has given birth in the last four weeks or she had an abortion in last two weeks.

3) The baby is less than six months age, and she is fully or nearly fully breastfeeding and has not resumed menstruation as yet (Lactation Amenorrhea Method).

4) Pregnancy is also unlikely in the current cycle if she was using a reliable contraceptive ‘consistently and correctly'.

B)      Pre-insertion clinical examination by the HCP:-

1) Is there any ulcer on the vulva vagina or cervix?

2) Is   there purulent cervical discharge?

3) Does the cervix bleed easily when touched?

4) Were you unable to determine the size and/or position of the uterus?

5) Is there any ‘motion tenderness’ i.e. movement of cervix does the client feel pain in her lower abdomen when one move the cervix sideways?

“Stop-Look—Then insert the device:-- :!!!  Laboratory investigation to exclude STI:

Is it essential to screen all women for STI if she desires for IUC? Gonorrhea and Chlamydia are the too common STIs which cause immense local damage in genital organs. There are many other fatal and nonfatal STIs which do not primarily affect the genital tract but cause damage of other parts of body e.g. syphilis, hepatitis B, HIV etc. etc. So far as screening for fitness of IUD is concerned on should ?????? on gonorrhea and/or Chlamydia only but screening for STIs should be individualized to the patient population. For instance evidence does not support routine screening for gonorrhea and Chlamydia in populations at low risk of STIs. Factors that indicate high risk include history of a new sexual partner, age under 25, or recent history of STIs. If  screening in indicated, it can be done at the time of the insertion, and the patient can be called for treatment and encouraged to employ dual form of protection IUC for pregnancy protection and consistent condom use for STI prevention.

        Side effects and/or complications of IUD are minimal if the acceptors are properly selected. Properly fitted IUD in eligible women rarely cause any annoying side effects. Occasionally there can be missing of threads and irregular vaginal bleeding with or without pelvic pain and only on rare occasion there can be accidental pregnancy (uterine or extra uterine). Pelvic infection is also a possibility which has been long debated. This is particularly time if the couple dies not maintain a monogamous relationship. All these complicates are discussed at length.