LEVONOGESTREL INTRAUTERINE SYSTEM IUGS (MIRENA)

Intrauterine Contraceptive DevicesMs. Sarah Mr. Ten

What is an IUCD?

A device inserted into the uterus (womb) to prevent conception (pregnancy).A set - and - forget methodTypes of IUCD1) Copper-releasing IUCDMultiload Cu-250 - emits 60 - 100g copper/day, lifetime up to 3 yearsCopper T200 - emits 50g copper per day, lifetime up to 4 yearsMultiload - 375 - lifetime up to 5 yearsCu T380A - lifetime up to 10 years

- Failure rate = 0.8%

Who is an ideal candidate for IUCDUniparous

Monogamous

With out any pelvic infection

Who is willing to check the threads every dayTiming of insertionCan be inserted at any timeCan be inserted immediately after delivery (Post placental insertion) or within 48 hours after deliveryPreferably 2 - 3 days after the menstrual period is over. Lactation amenorrhea - anytimePostpartum: after 4-6 weeks when uterus in involuted to near normal sizeConcurrently with I trimester abortionAfter first period following spontaneous/medical II trimester abortionWithin 5 days of unprotected intercourse

Hormone impregnated IUCD

Levonorgestrel-releasing intrauterine system, or LNG-20 IUS - Contains 52 mg levonorgestrel, released at rate 20g per day- Lifetime up to 5 years Failure rate: 0.2%

Advantages of Copper IUCDLong term highly effective reversible contraceptive methodEffective immediately after insertionCan be replaced without any gap as many times as the woman desiresOne time procedureCost effectiveCan be used by lactating womenDoes not interact with medicines taken by the womanFertility returns promptly on removal

Advantages of Hormonal IUCDMore effective than copper bearing IUCDsDecreases the amount of bleedingImproves haematocrit

Hence can be used in women with AUB Reduces pain and cramps in dysmenorrhoea and endometriosisBeneficial effects on fibroids DisadvantagesVery expensiveMay not be affordable by many womenOligomenorrhoea }Amenorrhoea } may not be acceptable to many womenIrregular spotting or bleedingInsertion requires a special technique

Mechanism of actionBiochemical and histological changes in endometrium with non specific inflammatory reaction - which have gametotoxic and spermicidal property. Macrophages phagocytize spermatozoa.Tubal motility increases. Quick migration of fertilized ovum into uterine cavity before the endometrium is suitable for implantation.Impaired sperm ascentMechanism of action4) Copper device - ionized copper prevents implantation and initiates the release of cytotoxic cytokines5) Hormone releasing devices - acts by thickening of cervical mucus inhibits mobility and capacitation of sperms 6) Induce progestational changes that result in endometrial gland atrophy

Methods of insertionHistory taking and vaginal examination - exclude contraindicationsInformed consent prior to procedureNSAID (Ibuprofen 200 400mg) may be given 30 minutes before procedureStrict sterile conditions, female chaperones if male doctorPlace device inside the inserter - no touch insertion techniqueIUCD loaded into inserter without opening the sterile packageNot to touch IUCD with vaginal wall and speculum when inserting through cervical canalHow to insert IUCD?

Demonstrate how to insert the deviceTake informed consent prior to procedureInstruments must be sterile, chaperones needed for male Patient is placed in lithotomy positionPick up handle of inserter, with threads released hanging freelyPlace thumb on sliderCheck arms are horizontal and aligned with the centimeter scale of insertion tube facing up Load Mirena , by pulling the threads into the insertion tubeKnobs at the ends of the arms will meet to close the open end of the insertion tube

Check proper loadingSecure threads in the bottom cleft to keep Mirena in loaded positionGrasp a tenaculum forceps with other hand and apply gentle traction to align the cervical canal with the uterine cavity Gently insert the insertion tube through cervical canal and into uterine cavity until flange is 1.5 to 2cm from eternal os. Maintain distance of flange to allow sufficient space for arms to open (when released) in the uterine cavityRelease arms of Mirena by pulling slide back until top of slider reaches the markGently advance the inserter into uterine cavity until flange meets the cervix and fundal resistance felt

Insertion of the IUCD Release device and withdraw the inserterWhile holding the inserter steady, pull slider all the way down to release device. Threads will release automatically from the cleftCareful not to pull on threads can cause displacement of device.Cut threads perpendicular to the thread length, with a curved scissor, leaving 3 cm visible outside the cervixCheck correct placement of Mirena with a transvaginal ultrasoundInsertion of IUCDComplicationsImmediate complications:I) Cramp like painTransient, 1/2 to 1 hourAnalgesic or antispasmodic drugs

II) Syncopal attackNulliparousdevice is large, distend

Partial or complete perforationFaulty technique of insertionLactational period when the uterus remains small and soft.

Complications2) Remote complications:Painproportionate to the degree of myometrial distension

Abnormal menstrual bleedingExcessive bleeding (flow, duration, intermenstrual)Anaemia -> iron supplement, tranexamic acid

Pelvic infection (PID)The risk is 210 times greater The risk is more in the first 3 weeks.Chlamydia, rarely actinomycetesComplicationsSpontaneous expulsionUsually within few months following insertionFailure to palpate the thread -> report to doctorHigher risk following post abortal or puerperal insertionsMarkedly reduced in successive years

Perforation of the uterusIncidence: 1 in 1000 insertionsmigration may also occur following initial partial perforation with subsequent myometrial contraction.

Complete perforation

Migration into bowel

Migration into bladder

Pregnancy Pregnancy rate with the device in situ : 2 per 100 women years of use

Risk of ectopic pregnancy (0.02 %)

If thread visible, remove it to minimise complications like - Abortion, - Preterm labour, - Sepsis, - LBW babyIf thread not visible: leave it, but counsel about the risk in continuing pregnancyMissing ThreadsPossible reasonThread coiled insideThread torn throughDevice expelled outside unnoticed by the patientDevice perforated the uterine wall and is lying in the peritoneal cavityDevice pulled up by the growing uterus

How to identify missing thread?Exclude pregnancy first

2. Uterine SoundInstrument used to probe and dilate the uterusNegative finding on exploration

Ultrasonography

HysteroscopyDirect visualization of the uterine cavity

X-rayIf sounding of uterine cavity is negative, do X-ray with uterine sound in the uterine cavityAP and lateral viewReveal the presence of IUCD, existence in or outside uterine cavity

Removal of IUCDIndications for removal:Persistent excessive regular or irregular uterine bleedingFlaring up of salpingitisPerforation of the uterus IUD has come out of place (partial expulsion) Pregnancy occurring with the device in situ Woman desirous of a babyMissing threadOne year after menopauseWhen effective lifespan of the device is over.Removal of IUCD

ii. Artery forcepsi. Loop Hookiii. Uterine curetteUnder direct vision by hysteroscopy

Outside the uterus but inside the abdominal cavity: Laparoscopy Laparotomy (rarely).