THE INCIDENCE OF INTRAUTERINE DEVICE EXPULSION

SIX WEEKS POSTPARTUM IN WOMEN

WHO UNDERWENT IMMEDIATE POST-PLACENTAL
INSERTION
OF COPPER T (Cu- T380) INTRAUTERINE DEVICE DURING
NORMAL SPONTANEOUS DELIVERY IN A TERTIARY
HOSPITAL (OSPITAL NG MAYNILA MEDICAL CENTER)
Investigator: Ethel Grace F. Tamaray, M.D.
Co-Author: Teresita Cadiz-Brion, M.D.
INTRODUCTIO
N
INTRAUTERIN
E DEVICES
(IUDs)
Small contraceptive devices
inserted through the cervix or
into the uterus postpartum and
position into the uterine cavity
14.3% OF WOMEN OF
100 MILLION ESTIMATED
REPRODUCTIVE
USERS AGE
 COPPER IUD
TCu-380A
T-shaped plastic device with a string of copper
wrapped around its stem and copper bands on its
arm
Highly effective method without requirement
of frequent visits or additional funding
Advantages
Rapid return to fertility after removal
is almost always ensured (ACOG, 2015)
Immediate postpartum IUD insertion at normal spontaneous
delivery provides a good opportunity to achieve long-term
contraception with minimal discomfort to the patients.
SIGNIFICANC
E OF THE
STUDY
 THIS STUDY AIMS TO
DETERMINE
INCIDENCE OF
IUD EXPULSION
SIX WEEKS
INPOSTPARTUM
PATIENTS WHO
IUDINSERTION
UNDERWENT
POSTPARTUM
IMMEDIATELY
NSD
DURING
 SIGNIFICANCE

This can help supplement the government’s efforts for a strong

population program by providing evidence that IUD insertion
immediately postpartum is a viable and practical option for family
planning and contraception with effectivity of ten (10) years.

This can aid in promoting responsible parenthood with the

achievement of the desired family size, which in the long-run will
impact on poverty alleviation and economic gain.
REVIEW OF
RELATED
LITERATURE
 POSTPARTU
M
PERIOD
PERIOD BEGINNING
IMMEDIATELY AFTER THE
BIRTH OF A CHILD
AND DELIVERY OF PLACENTA
CONTINUING UNTIL 6 WEEKS
POSTPARTU PERIOD
M
Sonographically, the uterus and
endometrium return to prepregnant size by
six to eight weeks postpartum and
complete extrusion of placental site occurs
up to six weeks postpartum.
POSTPARTU PERIOD
M
Represents an opportunity to
introduce family planning methods
that will improve the health of our
women and families.
AMONG THE 33, 900 WOMEN COUNSELED
ON POSTPARTUM FAMILY PLANNING IN
THE PH
ONLY 1,957 (5.8%)
ACCEPTED POSTPARTUM FAMILY
PLANNING
All these women accepted only
postpartum intrauterine device as method
of postpartum family planning.

Pfitzer et al., 2015

AMONG 2001 WOMEN 0-23 MONTHS POSTPARTUM
DID NOT USE ANY POSTPARTUM
53% FAMILY PLANNING METHOD

31% USED MODERN FAMILY PLANNING

METHODS
17% USED TRADITIONAL FAMILY PLANNING
METHODS

Moore et al., 2015

 OBJECTIVE OF FAMILY
PLANNING
To help couples and individuals achieve
their desired family size within the context
of responsible parenthood
and improved reproductive health
 UNMET NEED FOR
 About CONTRACEPTION
24% percent of unmarried sexually active
women aged 15–29 years old
 22% of married women aged 20-24 years old
 Highest among the poorest of married women
(28%)
 Accounts for most unintended pregnancies
 HIGH POPULATION
GROWTH RATES
EXACERBATE POVERTY
105.34 MILLION
FILIPINOS
12.18 MILLION
AS OF OCTOBER 2017

LIVE IN EXTREME
POVERTY
 ONE IN THREE BIRTHS (36%)
IN THE PHILIPPINES IS EITHER
UNWANTED (16%) OR MISTIMED
(20%)
AGGRAVATES NEGATIVE EFFECTS OF
POVERTY
 Increasing trend in the number of
unintended pregnancies of up to
2.4 million for the past year

National Family Planning Program

 Emphasizes immediate
postpartum contraception

A woman can have a copper-bearing IUD

inserted up to 48 hours after delivery, including
immediately after delivery of the placenta.
 INTRAUTERINE DEVICES
(IUDs)
LONG-ACTING REVERSIBLE CONTRACEPTION
(LARC)
 Highly effective method independent from coitus,
user motivation, and adherence
 Offers the highest continuation rates and user
satisfaction of all reversible methods
 Inexpensive – frequent visits not required for resupply
since its effectivity lasts for 10 years
 Rapid return to fertility after removal is almost always
ensured
 COPPER IUD (TCu-380A)
 Nomenclature: from the measurement of the copper
wire wrapped around the horizontal arms and vertical
stem giving it a total surface area of 380 mm2
 Small contraceptive device inserted through the cervix
or into the uterus during vaginal or cesarean deliveries
and positioning into the uterine cavity
 It has two-stranded monofilament tails that would
protrude through the vaginal canal into the upper part
of the vagina allowing easy identification and removal
 COPPER IUD (TCu-380A)
 32 mm wide with copper collar on each of its
horizontal arms
 36 mm long
 A plastic ball at the bottom of the vertical stem to
guard against cervical penetration
 A pigmented polyethylene filament is tied in a knot
through a small hole in the plastic ball to provide
two equal-length threads to locate and remove the
device
COPPER IUD (TCu-380A)
MECHANISM

TCu-380A
 COPPER IUD (TCu-380A)
MECHANISM

PREVENTS
TCu-380A FERTILIZATION OF
THE OVUM BY THE
SPERM
EFFECTIVITY OF INTRAUTERINE
DEVICES
99.4% WITH PERFECT
USE
99.2% WITH TYPICAL
USE
992 TO 994 OF EVERY 1,000 WOMEN
WHO USE IUDs OVER THE FIRST
YEAR WILL NOT BECOME
PREGNANT
OTHER COMPLICATIONS THAT MAY NECESSITATE EARLY
REMOVAL
VAGINAL
BLEEDING

Twice as long or twice

as much as the usual
menses
Lopez et al., 2015
 OTHER COMPLICATIONS THAT MAY NECESSITATE EARLY
REMOVAL
ABDOMINAL
CRAMPING
 Experienced during the first three to six
months of IUD insertion
 If severe or continuous for more than
three months, problems such as infection
or partial expulsion of IUD should be
examined
 If intolerable, the patient may choose to
remove the IUD.
UNNOTICED EXPULSION OF INTRAUTERINE DEVICE

17.6% of 245 had experienced

spontaneous IUD expulsion
Celen et al., 2011

20% out of 42 women experienced

IUD expulsion six months after
post-placental IUD insertion
Whitaker, 2013
 SUSPICION OF INTRAUTERINE DEVICE EXPULSION

A detailed history and pelvic examination is warranted.

It is prudent to ask when she last felt the string.
A pelvic exam is needed to be performed to
determine if the string is high in the cervix or
hidden by a fold of the vagina.

If the string is still not visible or even felt on

internal examination, a transvaginal
ultrasound is necessary to locate the IUD.
 UTERINE PERFORATION
Most serious complication associated with an intrauterine
contraceptive device and requires an emergency surgical procedure.
According to the WHO, the probability of perforation
at the time of insertion is 1 in 1,000 cases.
Occurs when the IUD is not inserted in the correct
direction of the uterine cavity or when the length of the
uterine cavity is not correctly determined.
Risk is increased by forceful insertion.
Signs & Symptoms: sharp pain during insertion, loss of
resistance to upward pressure of inserter, signs of hemorrhage
 PELVIC INFECTION
May occur when the insertion is performed under unsanitary
conditions or when the IUD is inserted in the presence of an
undiagnosed sexually transmitted infection.
Immediate removal of the IUD is unnecessary.
However, should the patient decide to remove the IUD, diagnosis of
PID should first be established and proper antibiotics should be given.
FOLLOW-UP CONSULTATIONS

3 TO 6
AFTER POST-PLACENTAL
WEEKS
IUD (PPIUD) INSERTION
REASEARC
H
OBJECTIVE
REASEARCH
OBJECTIVES
1
To determine the incidence of IUD expulsion six weeks postpartum
of patient who underwent Intrauterine Devices Insertion immediately
after placental expulsion during Normal Spontaneous Delivery; and
To describe complications which resulted to medically related
2 removals six weeks postpartum of Immediate Placental Insertion of
IUD during Normal Spontaneous Delivery
HYPOTHES
IS
HYPOTHESIS

The incidence of IUD expulsion inserted immediately

postpartum observed during that period is less than the
incidence of IUD expulsion inserted immediately
postpartum observed after six weeks.
METHODOLO
GY
PROSPECTIVE COHORT

OSPITAL NG MAYNILA
MEDICAL CENTER

SEPTEMBER 2019
TO DECEMBER 2019
 January, March, April,
  August September October November December
February May, June, July
             
Research Problem
Identification and Writing              
of Research Proposal

Revisions              
Obtaining sampling              
frames from population of
interest
             
Randomization of
Participants

             
   
 
Collection of pre-test Data  
and Conduct of IUD
placement

             
Post-IUD insertion follow-
up and collection of Post-
Test Data

Data Encoding              
Data Analysis              
Results and Discussion              
Final Paper              
SAMPLE SIZE
Ahuja (2014)
SAMPLE SIZE

ESTIMATE 10%
LOSS D
TO FOLLOW-
UP FINAL SAMPLE
SIZE 168
 INCLUSION
CRITERIA
All postpartum patients who
delivered via normal spontaneous
vaginal delivery without any co-
morbidities regardless of gravidity
and parity
 EXCLUSION
 AllCRITERIA
patients delivered vaginally with co-morbidities such as hypertension,
gestational diabetes mellitus, bronchial asthma, cardiac disease and thyroid
disease
 All patients delivered vaginally after caesarean section even if without co-
morbidities.
 Pre-labor rupture of membranes for 18 hours or more (with positive
Ferning’s test)
 Prolonged labor of- approximately 20 hours or more
 History of fever or clinical symptoms of infection
 History of pelvic inflammatory disease
 Structural abnormality of the uterus such as fibroids growth and Mullerian
anomalies
WITHIN 10 MINUTES AFTER REMOVAL OF
PLACENTA

TCu-
380A
All who went normal vaginal
delivery were given
oral antibiotics.
 IUD RECIPIENTS
Examined 2 days after IUD insertion
before hospital discharge through pelvic examination
to assess if the IUD monofilament tail protrudes
through (in) the cervical OS.
 FOLLOW-UP VISITS
A follow-up visit was scheduled after 1 week and 6 weeks.
The subjects were interviewed and had physical
and pelvic examinations to verify the presence of the IUD
and to check for signs of infection and excessive bleeding.
 IUD EXPULSIONS
Verified by transvaginal ultrasound six weeks postpartum
Subjects were directed to return at anytime if they experienced pelvic
pain, fever, excessive bleeding or an unusual vaginal discharge.
The IUD will be removed in case of bleeding, pain,
expulsion or pregnancy or upon the subject’s request.
DESCRIPTIVE
ANALYSIS
Tables and graphical presentations used to describe and
compare population distribution and sociodemographic
characteristics were generated using Microsoft Excel 2007.

Mean, standard deviation and range were

calculated for continuous variables.
Qualitative variables were analyzed and
presented using distributions.
INFERENTIAL
ANALYSIS
MULTIVARIATE MULTILEVEL
LOGISTICS REGRESSION HIERARCHICAL
ANALYSIS ANALYSIS
Used to analyze the relationship between the
exposure variables and the outcome variable to build
the statistical model to be tested

Potential confounders were identified through

a series of crude (univariate) analyses.
INFERENTIAL
ANALYSIS
MULTIVARIATE MULTILEVEL
LOGISTICS REGRESSION HIERARCHICAL
ANALYSIS ANALYSIS
Done to simultaneously Performed to address the
control for the many issue of having different units
confounders whose effects of observation for the
can get mixed-up with the exposure and outcome
major exposure variable of variables
interest
ETHICAL
CONSIDERATIO
NS
 CONSENT REQUESTED FOR
The identity ofPARTICIPATION
the patient with IUD remained confidential.

For ages below 18 years old, signature of legal guardian

was obtained to perform the said procedure.

Subjects given copies of the repeat transvaginal

ultrasound six weeks postpartum.
BUDGE
T
BUDGET
The transvaginal
ultrasound 6 weeks
postpartum was freely
The Copper T (Cu-380) IUD done at the tertiary
was freely provided by the hospital.
tertiary hospital as part of the
family planning program of
The consent forms was provided by
the local government.
the researcher, which was estimated to
be Php3,000.00 for the reproduction
of the consent forms.
 Baseline Characteristics of Women Intrauterine Device
Placement Immediately During Normal Spontaneous Delivery
DEMOGRAPHIC NORMAL SPONTANEOUS IUD
CHARACTERISTICS PLACEMENT
N = 168 (N%)
Age 21 ± 4 years
Parity
0 38 (22.6)
1 39 (23.2)
2 32 (19.04)
3 29 (17.2)
>4 30 (17.85)
 Baseline Characteristics of Women Intrauterine Device
Placement Immediately During Normal Spontaneous Delivery
DEMOGRAPHIC NORMAL SPONTANEOUS IUD
CHARACTERISTICS PLACEMENT
N = 168 (N%)
Educational Status
HS or Less 64 (38)
High School Graduate 73 (43.2)
Monthly Household Income
<P10,000 97 (57.73)
P10,000 – P20,000 38 (22.6)
P20,000 – P30,000 19 (11.3)
>P30,000 14 (8.3)
Marital Status
Married 90 (53.5)
Single 78 (46.4)
RESUL
TS
 7.8 MINUTES
168 WOMEN Mean time from placental
Inserted with an IUD delivery to IUD insertion
immediately after placental
expulsion during NSD.
All were successfully placed.
Data was collected
one to six weeks postpartum
placental IUD insertion.
Complications Related to Intrauterine Device Use at 1 Week Postpartum for Women who were
Allocated to Post Placental IUD Placement in Normal Spontaneous Delivery
COMPLICATIONS N = 168 (N%)
IUD expulsion within 1 (one) week 26 (15.47)
IUD discontinuation 11 (6.55)
Fever 0
Discomfort 3 (1.79)
Cramping 2 (1.19)
Displaced threads 0
Pelvic infections 0
Uterine perforation 0
Vaginal bleeding 0
Total 42
Six weeks from IUD placement,
155 out of168 (92.26%)
went back for follow-up.
7.74% LOSS TO FOLLOW-UP
RATE
 Complications Related to Intrauterine Device Use Beyond 1 Week to 6 Weeks Postpartum for
Women who were Allocated to Post Placental IUD Placement in Normal Spontaneous Delivery
COMPLICATIONS N = 168 (N%)
IUD expulsion without beyond 1 week within 6 weeks 14 (8.30)
IUD discontinuation 8 (4.76)
Fever 0
Discomfort 1 (0.06)
Cramping 0
Displaced threads 0
Pelvic infections 0
Uterine perforation 0
Vaginal bleeding 0
Lost to Follow-Up 13 (7.74)
Total 36
 Comparison of Complication Rates
N = 168 (N%)
COMPLICATIONS
Within 1 week Beyond 1 week to 6 weeks
IUD expulsion 26 (15.47) 14 (8.30)
IUD discontinuation 11 (6.55) 8 (4.76)
Fever 0 0
Discomfort 3 (1.79) 1 (0.06)
Cramping 2 (1.19) 0
Displaced threads 0 0
Pelvic infections 0 0
Uterine perforation 0 0
Vaginal bleeding 0 0
Lost to Follow-Up 0 13 (7.74)
Total 42 36
 Incidence Rate of IUD Expulsion by Increasing Parity

INCIDENCE RATE OF IUD EXPULSION

PARITY
N = 40 (24%)
0 5 (2.97)
1 6 (3.57)
2 6 (3.57)
3 9 (5.35)
>4 14 (8.33)
 Nineteen (19) participants
All expelled IUDs were chose to discontinue IUD use
complete expulsions. before the end of 6 weeks
postpartum.

There were no displaced threads, pelvic infections,

uterine perforations, nor vaginal bleeding noted
during the 6-week duration of this study.
DISCUSSIO
N
POSTPARTUM
IUD
Insertion
 INTRAUTERINE DEVICE
Most preferred long-term reversible method of
contraception because of its safety, cost effectiveness
and suitability across all reproductive ages
168 POSTPARTUM RESPONDENTS
21 ± 4 years age bracket
One child (23.2%)
A high school graduate (43.2%)
Married or with a partner (53.5%)

168 POSTPARTUM
RESPONDENTS
21 ± 4 years age bracket
One child (23.2%)
A high school graduate (43.2%)
Married or with a partner (53.5%)
Sable, P., Bagul, R., &
Singh A. (2019)
Less than 25 years old was the
commonest age group who accepted
the postpartum IUCD (65%) and
postpartum IUCD was the method of
contraception preferred by women
with at least 1 living children (58%)
 168 POSTPARTUM Sable, P., Bagul, R., &
RESPONDENTS Singh A. (2019)
Less than 25 years old was the commonest
21 ± 4 years age bracket age group who accepted the postpartum
One child (23.2%) IUCD (65%) and postpartum IUCD was
A high school graduate (43.2%) the method of contraception preferred by
Married or with a partner (53.5%) women with at least 1 living children
(58%)
Rosales et al. (2019)
There was no statistically significant
association between expulsion of the
IUD and age or number of children.
 IUD EXPULSION RATE

15.47% WITHIN ONE WEEK

POSTPARTUM
BEYOND ONE WEEK BUT
8.3% WITHIN SIX WEEKS
POSTPARTUM
 IUD DISCONTINUATION RATE

6.55% WITHIN ONE WEEK

POSTPARTUM
BEYOND ONE WEEK BUT
4.76% WITHIN SIX WEEKS
POSTPARTUM
 IUD expulsion is an uncommon
complication with a frequency ranging
from 2 to 8% during the first year of use.

2.3% spontaneous expulsion rate and an overall method

discontinuation rate of 5.5% by the end of 6 weeks
Muganyizi et. al, 2018
17.7% expulsion rate conducted at
a tertiary hospital in India
Kumar et al., 2014
Among the postpartum women in the
family medicine units in Mexico, the
expulsion rates of IUDs during
immediate postpartum and after a
delayed period were 16% and 2.7%,
respectively
Rosales et al., 2005
 IUD EXPULSION MECHANISM
The probable mechanism behind the increased expulsion
rate in patients who delivered vaginally is cervical dilation
as well as development of the thin lower segment.

Spontaneous expulsion of IUD may also be due to

puerperal uterine remodeling although low insertion
of the IUD may also be a contributory factor.

Sucak et. al, 2015

Adherence to the standard guidelines including insertion of
the IUD high up in the fundus using long curved Kelly
forceps can reduced rates of complications.

Difference in insertion techniques also plays a role in

the difference of expulsion rates.

Hooda et. al, 2016

Pooled rates of expulsion varied by timing of IUD placement:
 1.9% with interval placements (4 weeks postpartum or greater)
 10.0% for immediate placements (10 minutes or less after placental delivery)
 29.7% for early placements (greater than 10 minutes to less than 4 weeks postpartum)

Immediate and early postpartum placements

were associated with increased risk of expulsion
compared with interval placement.

Jatlaoui et. al, 2018


Although immediate IUDs have a
higher expulsion rate, immediate
placement is a cost-saving strategy
from a health care perspective.
Washington et al., 2005
In low resource countries, timing of
postpartum intrauterine device
insertion immediately after childbirth
is ideal since women do not return
for postnatal follow‐up visits because
of cost or distance.
 Parity and operator experience
are risk factors for IUD expulsion.

Jatlaoui et. al, 2018

MOST COMMON
COMPLICATIONS
DISCOMFOR
T
CRAMPING
CONCLUSION
AND
RECOMMENDATI
POSTPARTUM IUD PLACEMENT
A coitus-independent, reversible and effective form of
family planning with immediate contraceptive action.
FINDINGS FROM THE
STUDY
1 Viable contraceptive option

2 IUD expulsion postpartum more common after 1 week after

procedure.
Cramping and discomfort were among the most common
3 complications apart from postpartum expulsion and IUD
discontinuation.
4 Increasing parity also increases the risk of postpartum IUD expulsion.
 POSTPARTUM IUD INSERTION
Dependent on the skills Additional training for IUD insertion for IUD
of the health personnel providers
at both the national and international level
For all postpartum women before the insertion of
Counselling IUD to give emphasis on common maternal
outcomes of IUD insertion

Increase health-seeking On how to assess IUD expulsion to prevent pregnancy

behavior and follow up appointment for reinsertion of IUD
THANK YOU