|Year : 2020 | Volume
| Issue : 2 | Page : 440-444
Predicting successful use of post-placental intrauterine contraceptive device by ultrasound
Mohamed A Emarah1, Emad E. A. Soliman1, Haitham A Aboali1, Sara E Hasan2
1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Obstetrics and Gynecology, Shebin El-Kom Teaching Hospital, Menoufia, Egypt
|Date of Submission||06-Mar-2019|
|Date of Decision||31-Mar-2019|
|Date of Acceptance||03-Apr-2019|
|Date of Web Publication||27-Jun-2020|
Sara E Hasan
Source of Support: None, Conflict of Interest: None
To assess the role of ultrasound in predicting the successful insertion of intrauterine contraceptive device (IUD) immediately after delivery.
Waiting until the 6-week postpartum visit to initiate a method of birth control puts women at risk for unintended pregnancy.
Patients and methods
A single experienced doctor measured the distance from each wall of the uterus to the body of the IUD and from the lower edge of the IUD to the internal cervical OS following delivery and again at 6 weeks following delivery in women who received a postpartum IUD and then compared in unsuccessful and successful cases of postvaginal delivery (PVD) and postcesarean section (PCS) IUD insertion. The difference in success between the two modes of delivery and the optimal cutoff distance for successful retention were assessed using logistic regression and receiver-operating characteristics curve analysis, respectively.
One hundred women, comprising 63 PVD and 37 PCS IUD insertions, were recruited. Eleven PVD and eight PCS IUDs were either expelled or extracted due to improper placement at the 6-week visit. The mean difference between the distance from the internal OS to the lower end of the IUD in successful versus unsuccessful cases was 8.91 ± 5.64 and 11.77 ± 5.25 mm (P < 0.001) in PVD and PCS insertions, respectively. This distance at the discharge scan was moderately accurate in predicting retention of the IUD, with an area under the curve of 0.72 (sensitivity, 73%; specificity, 83%).
Ultrasound could be considered for predicting the success of IUD retention after delivery.
Keywords: contraception, intrauterine devices, postpartum period, pregnancy, unplanned
|How to cite this article:|
Emarah MA, Soliman EE, Aboali HA, Hasan SE. Predicting successful use of post-placental intrauterine contraceptive device by ultrasound. Menoufia Med J 2020;33:440-4
|How to cite this URL:|
Emarah MA, Soliman EE, Aboali HA, Hasan SE. Predicting successful use of post-placental intrauterine contraceptive device by ultrasound. Menoufia Med J [serial online] 2020 [cited 2020 Jul 14];33:440-4. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/440/287810
| Introduction|| |
Use of contraception is one of the global reproductive health indicators that determine the total fertility rate. In 2007, there were an estimated 162 680 000 women using intrauterine contraceptive devices (IUDs) worldwide. This represented 23% of all contraceptive users and 14% of all women aged 15–49 years.
Insertion of an IUD immediately after delivery (within 10 min of placental delivery) has been described recently in the context of optimizing the use of reliable, effective, and long-lasting contraceptive methods. Available literature shows that the expulsion rate of IUDs varies between 7 and 15%, indicating a higher rate of unsuccessful retention when an IUD is inserted at the time of delivery compared with insertion 6 weeks after delivery.
Most of these studies used visualization of the IUD thread after 6 weeks as the outcome measure of success. Displacement of an IUD within the uterus (dislodgement into the cervical canal) cannot be assessed clinically; however, such displacement reduces the optimum contraceptive efficacy of an IUD. Anteby et al. reported a 14 times higher incidence of pregnancy in women with an intracervical IUD than in women with an IUD positioned in the uterine fundus [odds ratio: 13.93; 95% confidence interval (CI): 4.13–48.96)]. The authors suggested that cases of failed contraceptive action of the IUD may be secondary to a malpositioned device and recommended an ultrasound examination to identify the displaced devices. Predicting the rate of IUD retention is important because it can enable determination of the risk of, and thus avoidance of, an unplanned pregnancy. In this study, we aim to assess whether ultrasound can be used to predict the success of postvaginal delivery (PVD) and postcesarean section (PCS) IUD insertion.
| Patients and Methods|| |
This prospective, observational study was conducted at the Menoufia University Hospital, Shebin El-Kom Teaching Hospital, after approval of the study by institute ethics committee on 100 pregnant women; of them 63 underwent normal vaginal delivery and 37 underwent CS. We included women who were delivered in the hospital and looking for contraception without contraindications for IUD insertion. Exclusion criteria were: anemia (hemoglobin < 10 g/dl), postpartum hemorrhage, and prolonged pre-labor rupture of membranes and obstructed labor. A written consent was taken from every patient before participation in the study.
The used IUD in our study was Copper T 380 Ag, DKT International (Washington, DC, USA). Women with normal vaginal delivery remained in the dorsal position after vaginal delivery and underwent immediate insertion of the IUD after delivery of the placenta. The IUD was introduced into the uterine cavity with guidance from the index and middle fingers. To facilitate smooth insertion, suprapubic pressure can be applied to move the uterus into a more axial plane and minimize retroversion. The IUD is then placed in the highest possible position in the uterine cavity. In women with cesarean section, the IUD is placed at the fundus of the uterus, through the incision made during the cesarean section, as soon as the placenta and membranes are delivered. Routine closure of the uterine incision is performed subsequently.
All patients were told to check the position of their IUD if they experienced any bleeding. Two ultrasound examinations were performed: first, before discharge from the hospital and second, 6 weeks following delivery. On each occasion, both transabdominal and transvaginal ultrasound examinations were performed. A single experienced doctor measured the distance from each wall of the uterus to the body of the IUD and from the lower edge of the IUD to the internal cervical OS in both examinations. The IUD is defined as being 'in place' when visualized in close proximity to the uterine fundus and when both distances, one from each uterine wall to the body of the IUD, are similar. The choice of using the distance between the lower pole of the IUD and the internal cervical OS to predict successful IUD insertion is based on the assumption that when the device is displaced from its normal position the distance between its lower end and the cervix should be reduced; on the other hand, this distance should remain relatively constant when the IUD remains in its normal position, close to the uterine fundus.
Presence of the IUD thread is documented in each examination. At a review at 6 weeks postpartum, mothers were asked about history of fever, abnormal vaginal discharge, or expulsion of the IUD. In the absence of history of expulsion of the IUD and if it is not visualized by an ultrasound, a radiograph of the pelvis is offered to exclude intra-abdominal dislodgement of the IUD. Since the IUD should be placed completely inside the uterus in order to achieve optimum efficacy, complete expulsion and displacement of the IUD into the uterine cervix is considered as unsuccessful IUD retention.
Mean distance from the lower end of the IUD to the internal OS in both immediate PVD and PCS insertions was compared in successful and unsuccessful IUD retention groups at the 6-week scan. The Mann–Whitney U-test was used to compare continuous non-normally distributed data. All P values are reported as two-tailed and P value less than 0.05 was considered statistically significant. Logistic regression analysis was performed to determine the difference in success between PVD and PCS IUD insertions. Receiver-operating characteristics curve analysis was used to determine the accuracy of the distance (mm) from the lower end of the IUD to the internal OS, measured at the scan prior to discharge, in predicting IUD retention or expulsion. Statistical analysis was performed using R statistical software version 3.4.3 (Texas, USA).
| Results|| |
One hundred women were recruited with IUD inserted immediately after delivery. Among these, 63 women underwent vaginal delivery including 31 primigravida cases, and 37 women underwent cesarean section including 15 primigravida cases.
Two PVD IUDs were expelled before hospital discharge. Eleven (18.1%) PVD and eight (21.6%) PCS IUDs were either subsequently expelled spontaneously or removed at the 6-week scan because of displacement [Figure 1]. A summary of ultrasound measurements at each examination is given in [Table 1]. The mean distance from the internal OS to the lower end of the IUD, measured at the ultrasound scan prior to hospital discharge, was almost one time and half of the length in successful cases as compared with unsuccessful cases, for both PVD and PCS IUD insertions; the mean difference between the distance in successful versus unsuccessful cases was 8.91 ± 5.64 and 11.77 ± 5.25 mm (P < 0.001) in PVD and PCS insertions, respectively [Table 2].
|Figure 1: Flowchart of the study population of 100 women who received an intrauterine contraceptive device (IUD) immediately after vaginal delivery or a cesarean section.|
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|Table 1: Ultrasound findings prior to hospital discharge and at 6 weeks following delivery in women receiving an intrauterine contraceptive device immediately postvaginal delivery or postcesarean section|
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|Table 2: Logistic regression table showing association between successful retention of intrauterine contraceptive device, mode of delivery, and the mean distance from the lower end of internal OS|
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Logistic regression analysis demonstrated that the mode of delivery was not independently associated with successful retention of the IUD (P = 0.44; odds ratio: 1.67; 95% CI: 0.47–6.83); therefore, a common cutoff value was considered for both PVD and PCS groups. The distance from the lower end of the IUD to the internal OS at the discharge scan was moderately accurate in predicting retention of the IUD, with an area under the curve of 0.74 (sensitivity, 74%; specificity, 84% positive predictive value, 52%; negative predictive value, 93%) [Figure 2] and [Figure 3].
|Figure 2: Receiver-operating characteristics curve analysis of distance from internal OS to lower edge of intrauterine contraceptive device (IUD) for the prediction of successful retention in women receiving postvaginal or postcesarean IUD. Area under the curve (AUC): 0.74, sensitivity: 0.74, specificity: 0.84, positive predictive value (PPV): 0.52, and negative predictive value (NPV): 0.93.|
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|Figure 3: Transabdominal ultrasound images in a woman with an intrauterine contraceptive device (IUD) inserted immediately after vaginal birth, showing: (a) distance from the lower end of the IUD to internal OS, (b) cervical length, and (c) distances from the IUD to anterior and posterior walls of the uterus.|
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| Discussion|| |
In this study, 100 women who had an IUD inserted immediately after delivery and 63 after a cesarean section delivery were included in this study. Two (3.2%) PVD IUDs were expelled before hospital discharge. Thirteen (20.6%) PVD and eight (21.6%) PCS IUDs were either subsequently expelled spontaneously or removed at the 6-week scan because of displacement. Chi et al. examined the performance of IUDs inserted immediately after cesarean deliveries. Among the 52 women who delivered by a cesarean section in a medical center in Beijing, China, had either a Delta Loop or Delta-T IUD inserted manually through the incision wound. The expulsion rates were significantly lower than among a comparable group of 147 women who both delivered and had the IUD inserted vaginally (4.1 vs. 20.5/100 women at 6 months postinsertion). Grimes et al. assessed the efficacy and feasibility of IUD insertion immediately after expulsion of the placenta and hypothesized that this practice is safe but is associated with higher expulsion rates than interval IUD insertion.
Although there are no randomized, controlled trials that evaluated IUD insertion at the time of cesarean section delivery, one cohort study found a significantly lower expulsion rate with IUD insertion at the time of cesarean delivery than with insertion immediately after birth. A more recent study reported that the expulsion rate for IUDs placed immediately after vaginal delivery was 38%, while only 12% of IUDs placed after caesarean delivery were expelled. Although individual risk estimates of expulsion vary between studies, this body of evidence is consistent in the relationship between IUD insertion timing and respective expulsion rates. Many studies have identified other factors associated with expulsion risk, such as age, parity, type of provider, and provider experience; however, only one study successfully adjusted for age and parity and only one study demonstrated lower expulsion rates for primiparous when compared with grand multiparous women.
In this study, the mean distance from the internal OS to the lower end of the IUD, measured at the ultrasound scan prior to hospital discharge, was almost one time and half of the length in successful cases as compared with unsuccessful cases, for both PVD and PCS IUD insertions. The distance from the lower end of the IUD to the internal OS at the discharge scan was moderately accurate in predicting retention of the IUD, with an area under the curve of 0.74 (sensitivity, 74%; specificity, 84% positive predictive value, 52%; negative predictive value, 93%). This result is going with the study done by Dias et al. where 91 women were included in the study, comprising 60 PVD and 31 PCS IUD insertions and an optimal cutoff of at least 30 mm [sensitivity, 64.71% (95% CI: 52.17–75.92%) and specificity, 80.95% (95% CI: 58.09–94.55%)]. Moreover, we did not find any independent influence of the mode of delivery on retention success rate of the IUD. It is recognized that the entire IUD should be in place inside the uterine cavity to achieve optimum contraceptive efficacy. This result goes with the study done by Johnson.
| Conclusion|| |
Immediate postpartum IUD insertion is feasible but carries a substantial risk of unsuccessful retention. Ultrasound examination after IUD insertion could be used effectively to predict the success of IUD retention. Visibility of the IUD thread at 6 weeks alone is not sufficient to reassure women regarding proper IUD placement since the IUD could still be displaced into the cervix despite the presence of the IUD thread. Large prospective studies are required to assess whether ultrasound may be a feasible tool providing reproducible results for counseling women regarding the success of an IUD insertion.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]