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PPIUD Newsletter Issue No. 3
January-March 2016


Dear Friends and Colleagues,

 
In this issue of the PPIUD newsletter, we reflect upon the achievements of the India team in the country focus. We have a valuable contribution on managing post-insertion complications from colleagues at the WHO. The team updates you on the newly formed Contraception Working Group and provides some key statistics from our last report.

Country Focus
Peer-Learning
Project Updates

Country Focus

India

The India team hosted a very successful press conference at the All India Congress of Obstetrics and Gynaecology in January 2016. Dr Hema, the National Coordinator joined Prof. Arul the Project Director and Prof Purandare, FIGO’s President to explain the initiative and the successes so far.
 
The initiative could not be successful without the hard work and dedication of the Facility Coordinators and we would like to congratulate Drs Verma and Bhatia at GMC Surat, Drs Hegde and Gandhi at TN Medical College and BYL Nair Charitable Hospital and Drs Jussawala and Balsarkar at Wadia Maternity Hospital for their excellent leadership in promoting and delivering PPIUD to so many women in their facilities. 
 
The success of the project and support of the FIGO President has influenced the Government of India’s decision to extend the PPIUD programme across India. 

Our congratulations and thanks go to all the project team, clinicians and support staff who are working hard to ensure the success of the PPIUD initiative to save the lives of women and their children in India.

Peer Learning

Postpartum Intrauterine Devices (IUD):  Post-Insertion Complications and their Management – Mario Festin, Human Reproduction Team and Brian Nguyen, ObGyn Family Planning Fellow, Department of Reproductive Health and Research, World Health Organization

Intrauterine devices (IUDs) are among the most effective Long Acting Reversible Contraceptives (LARCs), with pregnancy rates of about 6 to 8 per 1000 women over the first year of use, and about 2 pregnancies per 100 women over 10 years of use. The IUD, especially the CuT380A, can be inserted within 48 hours after a woman gives birth. If 48 hours have elapsed after delivery, the IUD may be inserted at 4 or more weeks after delivery. Since the IUDs work mainly within the uterus to prevent pregnancy, there is no expected hormonal interaction with breastfeeding and women can continue to breastfeed while using this method.
 

Side Effects
 
Changes in Bleeding

The most common side effects are changes in the vaginal bleeding pattern, such as prolonged or heavy monthly bleeding, irregular bleeding, inter-menstrual bleeding, or menstrual cramps. These bleeding changes are not signs of illness, and usually become lighter or less frequent after a few months after insertion.
 
Non-steroidal anti-inflammatory drugs (NSAIDs) or tranexamic acid may be used for modest short term relief from heavy bleeding. Aspirin is not recommended. Iron supplements may also be given if anaemia is suspected.
 
If bleeding persists or becomes more severe, the IUD may be checked for expulsion or malposition and to check if it needs removal.
 

Vaginal Discharge
Vaginal discharge may occur when using the IUD, but is generally not problematic unless it is persistent, foul smelling, or with a change in colour or consistency from clear and thin. In such cases, consider the presence of genital tract infections, and further workup may be needed. There is no need to remove the IUD unless the symptoms are severe.
 

Pain or Discomfort
The IUD string is not usually felt during coitus. However, some men may complain of penile pain or discomfort during coitus from the thread being cut too short. One option is to cut the thread even shorter within the endocervical canal to remove the barb-like sensation. Persistence of pain during coitus may lead one to suspect other conditions such as Pelvic Inflammatory Disease (PID).
 
Cramps and pain are most common during the first two days after insertion. They may also occur during menses; these are expected to decrease in severity over time.
 

Complications
 
Severe Pain

Complications due to IUD use are extremely rare. If severe pelvic pain is persistent, and is found with tenderness (either direct or rebound), consider either PID or Ectopic Pregnancy as possible diagnoses. PID is also associated with fever and chills. Appropriate management should be given.
 
For PID, antibiotics are immediately started. Early treatment is more effective in preventing long-term complications. There is no need to remove the IUD if the woman wants to continue using during treatment. If the woman desires removal, the IUD can be removed once antibiotics have been started and an alternative contraceptive method offered. 
 

Uterine Perforation
Uterine perforation or puncture is suspected if there is sudden loss of resistance during IUD insertion or sounding. There may or may not be increased vaginal bleeding if this occurs, however one should suspect abdominal or pelvic bleeding. The IUD should be removed if already inserted and the patient as well as her vital signs observed for signs of abdominal blood loss. In such a case, the patient should be assessed for needing surgical intervention or further observation. If the woman is stable she may be sent home with advice for close follow-up.
 

Expulsion
Expulsion may be either partial or complete and usually occurs in the first few months after insertion. Partial expulsion generally requires removal and exchange for another IUD as long as the woman still wishes to continue with the method and she is reasonably certain that she is not pregnant. Otherwise, she should be offered another method.
 

Missing Threads
The IUD has a string which aids in insertion and removal, and helps to check that the IUD is in place, either by the woman or her provider. Sometimes the strings may not be felt which can be caused by displacement of the strings (most common), expulsion of the IUD, perforation of the uterus leading to the IUD’s misplacement, or pregnancy. The initial step is to gently check the cervical canal to examine for strings. If not present, the provider should suspect expulsion or displacement of the strings into the body of the uterus.
 
If the woman is not aware if the IUD has been expelled or is missing, an x-ray or an ultrasound may be performed. In the meantime, a back-up method should be offered. If the IUD is found intra-abdominally, the provider should check for signs of complications of perforation, and remove the IUD through laparoscopy or abdominal approach.

The PPIUD initiative has developed an algorithm on the management of missing threads based on work in India, Sri Lanka and Nepal, which was shared by Dr De Caestecker in January. Additional copies are available upon request
X-Ray confirming IUD is in the correct position in the uterus.
Image from radiographics.rsna.org
If the woman is pregnant, the provider should rule out an ectopic pregnancy. An IUD in a pregnant uterus increases the chance of preterm delivery or miscarriage.  If she does not want to continue the pregnancy, she should be counselled about her options. If she wants to continue the pregnancy, removal of the IUD is recommended. Early removal reduces the risks of complications during pregnancy, however even the gentle removal procedure involves a small risk of miscarriage. If she decides not to remove the IUD, close follow up is needed with attention to signs of sepsis or unexpected vaginal bleeding.
 
The IUD can never move to parts of the body outside of the pelvis or abdomen, does not increase the risk of ectopic pregnancy, and does not cause infertility in women after it has been removed. The IUD does not cause PID, but PID may develop if the IUD is inserted in a woman with active gonorrhoea or chlamydial infection. In such cases, PID is most likely to occur within the first 20 days of insertion.
 
References:
World Health Organization Department of Reproductive Health and Research (WHO/RHR) and John Hopkins Bloomberg School of Public Health/Center for Communications Programs (CCP) INFO Project, Family Planning: A Global Handbook for Providers. Baltimore and Geneva: CCP and WHO 2007 (2011 Updates).
 
Hatcher, R, Trussell J, A Nelson, W Cates, D Kowal, M. Policar. Contraceptive Technology, 20th edition. New York; Ardent Media, 2011.

Project Updates

Contraception Working Group

The FIGO Working Group on Contraception held its first meeting on 10th and 11th March in London. Chaired by Jill Sheffield, founder and president of Women Deliver, it brought together some of the key players in the field from IPPF, WHO, USAID and Population Council amongst others. The working group will address how FIGO and its member societies can actively address the Global Unmet Need for Contraception in its work to achieve the FP2020 commitments.  
 
The Working Group also acts as the Scientific and Technical Advisory Group (STAG) for the PPIUD initiative and the members have already provided valuable advice and resources to enable us to strengthen our work and our efforts to institutionalise PPIUD services. If you would like any further information about the Contraceptive Working Group, kindly contact Dr Linda De Caestecker linda@figo.org, PPIUD Deputy Director.

PPIUD Awards

The FIGO HQ team understand that the success of the initiative rests on the hard work and dedication of the country teams. The teams on the ground are able to respond quickly and effectively to issues as and when they arise – from the DCO who alerts us when there are glitches in the app, to the facility coordinators who lead local delivery and training, everyone has a part to play.

To recognise excellence and innovation, we have introduced the PPIUD awards. These will be presented in two categories – the in country Good Practice in PPIUD award will be presented to each country twice a year in May and November for facility or HQ teams or individuals who have pioneered good practice in counselling, delivery, promotion, data collection or management of PPIUD.  In addition, there will be an annual international  Innovation in Institutionalising PPIUD award and HQ teams will be asked to submit their nominations in August.
 
The FIGO HQ team will contact all country teams later in the year when the nominations process for the Good Practice in PPIUD award begins and national teams will be able to self-nominate or nominate colleagues for either of the awards.

The Latest Stats
These statistics are cumulative from the start of the initiative and based on the most recent report for the semester ending December 2015.
Bangladesh
10% of women counselled on PPIUD
972 PPIUD insertions achieved
282 doctors trained in PPIUD insertion and family planning counselling
6 counsellors trained in family planning counselling

India
85% of women counselled on PPIUD
2307 PPIUD insertions achieved
482 doctors trained in PPIUD insertion and family planning counselling
12 RMCH counsellors trained in family planning counselling

Kenya
6% of women counselled on PPIUD
116 PPIUD insertions achieved
326 providers trained in PPIUD insertion and family planning counselling
Nepal
Master Training for intervention facilities completed December 2015
28 doctors trained in PPIUD insertion and family planning counselling

Sri Lanka
33% of women counselled on PPIUD
3676 PPIUD insertions achieved
471 doctors trained in PPIUD insertion and family planning counselling
2842 community midwives trained in family planning counselling

Tanzania
Master Training for intervention facilities completed March 2016

Resources

For more information, please contact the PPIUD HQ team.
 
ROSSIER, C. BRADLEY, S. ROSS, J. and WINFREY W. (2015) Reassessing Unmet Need for Family Planning in the Postpartum Period. Available from http://onlinelibrary.wiley.com/doi/10.1111/j.1728-4465.2015.00037.x/abstract [Accessed 22nd March 2016]

 
Despite renewed interest in postpartum family planning programs, the question of the time at which women should be expected to start contraception after a birth remains unanswered. Three indicators of postpartum unmet need consider women to be fully exposed to the risk of pregnancy at different times. While the protection afforded by postpartum abstinence and lactational amenorrhea lowers unmet need, further analysis shows that women also often rely on these methods without being actually protected. Programs should acknowledge these methods’ widespread use and inform women about their limits. Also, the respective advantages of targeting the postnatal period, the end of six months of amenorrhea/exclusive breastfeeding, or the resumption of sexual intercourse to offer contraceptive services should be tested.
 
SHAH, I. SANTHYA, K.G. and CLELAND, J. (2015) Postpartum and Post-Abortion Contraception: From Research to Programs. Available from http://onlinelibrary.wiley.com/doi/10.1111/j.1728-4465.2015.00036.x/abstract [Accessed 22nd March 2016]

Contraception following delivery or an induced abortion reduces the risk of an early unintended pregnancy and its associated adverse health consequences. Unmet need for contraception during the postpartum period and contraceptive counselling and services following abortion have been the focus of efforts for the last several decades. This article discusses the validity and measurement of the concept of unmet need for family planning during the postpartum period. We then present key findings on postpartum contraceptive protection, use dynamics, and method mix, followed by an assessment of interventions to improve postpartum family planning. The evidence on postabortion contraceptive uptake and continuation of use remains thin, although encouraging results are noted for implementation of comprehensive abortion care and for the impact of post-abortion contraceptive counselling and services. Drawing on these studies, we outline policy and program implications for improving postpartum and post-abortion contraceptive use.
 
HIGGINS, J. RYDER, K. SKARDA, G. KOEPSEL, E and BENNETT, E (2015) The Sexual Acceptability of Intrauterine Contraception: A Qualitative Study of Young Adult Women. Available from http://onlinelibrary.wiley.com/doi/10.1363/47e4515/abstract [Accessed 22nd March 2016]

The IUD is extremely effective but infrequently used by young adult women, who disproportionately experience unintended pregnancies. Research has not examined how IUD use may affect sexuality, which could in turn affect method acceptability, continuation and marketing efforts.
 
Focus group discussions and interviews were conducted to explore participants’ thoughts about whether and how IUD use can affect sexual experiences. Six themes emerged: security (IUD’s efficacy can reduce sexual inhibition), spontaneity (IUD can allow for free-flowing sex), sexual aspects of bleeding and cramping (IUD’s side effects can affect sex), scarcity of hormones (IUD has a low level of or no hormones, and reduces libido less than hormonal methods, such as the pill), string (IUD’s string can detract from a partner's sexual experience) and stasis (IUD use can have no impact on sex). Some reported sexual aspects of IUD use were negative, but most were positive and described ever-users’ method satisfaction and never-users’ openness to use the method.
 
Future research and interventions should attend to issues of sexual acceptability: Positive sexual aspects of the IUD could be used promotionally, and counselling about sexual concerns could increase women's willingness to try the method.
 


Do you have something you would like to share with the PPIUD team? Just email ppiud@figo.org with additions to the 'updates', 'peer-learning', 'research', 'events' or 'resources' sections.
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