An Analysis of IUCD Removal Under Anaesthesia in a Tertiary Care Centre: A Combined Prospective and Retrospective study

INTRODUCTION: IUCD is an effective, reversible, and longterm method of contraception which does not require replacement for long periods and does not interfere with sexual activity. The device is commonly made of polyethylene which is impregnated with barium sulphate to render it radio opaque so that the presence or absence of device in the pelvis can be easily detected by radiograph or ultrasound. Medicated devices which contain copper, progesterone hormone and other pharmacologic agents have been introduced. There are four generations of IUCD: FIRST GENERATION: these are inert IUCDs and do not have a bioactive component. They are made of inert materials like stainless steel, a flexible ring of steel coils that cab deform to or plastic. Their primary mechanism of action is inducing a local foreign body reaction which makes the uterine environment hostile both to sperm and to implantation of embryo. SECOND GENERATION: these are copper containing IUCD and it includes CuT375, 380 A (paragard), 200, multiload 350 . copper acts as a spermicide within the uterus by increasing levels of copper ions, prostaglandins, and white blood cells the uterine and tubal fluids₂. Copper can also alter the endometrial lining, but studies show that while this alteration can prevent implantation of a fertilized egg, it cannot disrupt one that has already been implanted. THIRD GENERATION: hormonal IUCD work by releasing a small amount of levonorgestrel, a progestin. Each type varies in size, amount of levonorgestrel released and duration. The primary mechanism of action is making the cervical mucus thick and uninhabitable for sperm. They can also thin the endometrial lining, they can reduce or even prevent menstrual bleeding. As a result they are used to treat menorrhagia once pathologic causes of menorrhagia have been ruled out. FOURTH GENERATION: these are known as frameless IUCD, they are used in trials in the names of gynefix, fibroplant. It is a combination of both hormone containing IUCD. The main features of these intrauterine contraceptives are that they are frameless, flexible, and anchored to the fundus of the uterus. The WHO Medical Eligibility Criteria form the scientific foundation for client assessment regarding family planning methods. It gives detailed guidance regarding whether a woman with a certain condition can safely use a given method of family planning. The MEC has four categories: Category 1: A condition for which there is no restriction for the use of the contraceptive method. Safely use. Category 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks. Generally use. Category 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method. Generally do not use. Category 4: A condition which represents an unacceptable health risk if the contraceptive method is used. Do not use. In general, therefore, medical eligibility criteria for the immediate PPIUCD services can be grouped as follows: Category 1: Immediate postplacental, immediate postpartum<48 hours or during cesarean section > six weeks postpartum Category 2: no conditions Category 3: Between 48 hours and six weeks postpartum Chorioamnionitis Prolonged rupture of membranes (ROM)> 18 hours. • uterine anomalies Category 4: Puerperal sepsis Unresolved postpartum haemorrhage. However IUCD has its own complications. They can be divided into immediate, early and late complications. IMMEDIATE: • Difficulty in insertion, • Vasovagal attack, • Uterine cramps. EARLY: • Expulsion (2–5%), • Perforation (1-2%), • Spotting, menorrhagia (2-10%), • Dysmenorrhea (2-10%), • Vaginal infections, • Actinomycosis. LATE: • Pelvic Inflammototry disease (2–5%), • Ectopic pregnancy, • Perforation, • Menorrhagia, • Dysmenorrhea. The expulsion rate of IUCD is 5%-15%. The expulsion is common in multiparous women. The rate of perforation of IUCD is 1-2%. MISPLACED IUCD: It is defined as the condition when the IUCD thread is not seen through the os. The causes are • The uterus has enlarged through pregnancy. • Thread has curled inside the uterus. • Perforation has occurred or the IUCD is buried in the myometrium. • It has been expelled. A plain radiograph or pelvic ultrasound will show whether the IUCD is still inside or has been expelled. If it is inside , the uterine sound or another IUCD inserted in the uterine cavity will show on radiograph its proximity to the misplaced IUCD and perforation can be diagnosed. abnormal shape or location of IUCD on radiograph indicates likely perforation. If the IUCD is in uterine cavity it can be retrieved with shirodhkar’s hook, a curette or through a hysteroscope and ultrasound guidance. In case of perforation a laparotomy is needed. NEED FOR THE STUDY: IUCD removal under anaesthesia puts the patient into varying degrees of disadvantages ranging from loss of livelihood due to hospital admission to the risk of being subjected to anaesthesia and surgery which has its own complications. Hence there is a big need to analyze the best period and the patient profile most suited for IUCD insertion. World Health Organization has recommended removal of a dislocated IUD as soon as possible irrespective of their type and location . It is advised to [4] retrieve a migrated IUD by minimally invasive techniques . Endoscopic techniques such as [5] hysteroscopy, and cystoscopy , colonoscopy can be used for diagnosis and treatment depending on the location of IUD. AIMS AND OBJECTIVES: To analyze the baseline demographic characters, reasons for IUCD removal in patients planned for IUCD removal under anaesthesia and to conclude which is the best period and who are the most suited patients for IUCD insertion. To analyze the patients who came for IUCD removal under anaesthesia in the past one year. STUDY PARTICIPANTS: Patients planned for IUCD removal under anaesthesia. INCLUSION CRITERIA: Patients with history of IUCD insertion who has now come for removal • without visible threads and • those with visible threads where other methods of retrieval has been failed • With confirmed evidence of IUCD by either ultrasound / x ray. EXCLUSION CRITERIA: Patients with history of IUCD insertion with ultrasound / x ray confirmed evidence of expulsion. NUMBER OF GROUPS STUDIED: Single group. SAMPLING: Convenience sampling. POPULATION: Patients with history of IUCD insertion who has now come for removal • without visible threads and • those with visible threads where other methods of retrieval has been failed SAMPLE SIZE: 54. RANDOMIZATION: Non randomized sample. METHOD OF STUDY: This study focuses on the need for removal of IUCD under anaesthesia and analyse them on the basis of • The chief complaints of patients requiring IUCD removal • Baseline demographic characters which includes age, parity, BMI, duration of IUCD use, type of delivery – labor natural / LSCS (elective or emergency), time of insertion of IUCD. • The type of surgical method used – removal using hook or hysteroscopic or laparotomy or other method. • To calculate the total operative time, type of IUCD removed, operative findings, any other associated complications, problems involved in removal. CONCLUSION: The incidence of removal of IUD is low with only 62 subjects reporting during the study period. • The major reason for removal of IUD is pain followed by abnormal uterine bleeding. • The mean duration of IUD use was 3.9 yrs. From this study we can observe. • That previous caesarian section has got more risk of getting impacted than previous Normal vaginal delivery. The patients with previous caeserian section with IUCD has to be kept in regular follow up for the presence of thread. They have to be followed up in the same institute where they delivered atleast till the postpartum period and for every three months thereafter. • In Institute of obstetrics and gynaecology during the one-year study period a total of 349 cases of IUCD were removed in total out which 287 were removed in OPD and 62 were removed using anaesthesia, which calculates to a percentage of 18. This shows that though intrauterine contraception is one of the effective method of contraception, a significant amount of candidates are going for impaction of it and being subjected to anaesthesia which adds to the morbidity. It should be ensured that thread is directed well into the cervical os especially when LSCS is done in patients not in labour. Insertion can be done using hands than using insertors to avoid the risk of IUCD getting impacted. The final idea is to keep the candidates of IUCD in regular monitoring especially in the same institute where they delivered to avoid the risk of subjecting them to anaesthesia in future