Despite her preventative measures, K was shocked to find that she was pregnant.
K, 33, had a copper-T intrauterine contraceptive device (IUCD) fitted 2 months after she gave birth to her second child a year ago. She knew something was awry when she felt ill for a few weeks. “I was feeling nauseous and I would just throw up once in a while,” said K. She then decided to take a pregnancy test to see what was amiss.
She was calm and cheerful when she came for the consultation. There was no abdominal pain or vaginal bleeding. Pelvic examination revealed that she was 6 weeks pregnant. The strings that were attached to the IUCD could be seen protruding slightly out from the cervix. Vaginal ultrasound showed a gestation sac of 6 weeks wedged between the cervix and the IUCD in the upper part of the uterus.
What is IUCD?
IUCD is a popular, reliable and reversible form of contraception. It is a small T-shaped plastic device with two strings attached and is inserted through the cervix into the uterus. About 15% of women of reproductive age worldwide are using this method of contraception .
Types of IUCD
There are two types of IUCD:
1) Non-hormonal (Copper device) (fig 1)
It acts by releasing copper ions which are toxic to the sperm and makes the cervical mucus unfavorable for the sperm to move up the genital tract. It also acts as a physical barrier in the uterus preventing implantation of the fertilized egg.
2) Hormonal (Mirena) (fig 2)
It works by releasing the hormone, progestogen into the cervix, which thickens the cervical mucus and prevents the sperm from entering the uterus. It alters the uterine lining chemically and acts as a physical barrier preventing fertilized ovum from implantation.
How is insertion of the IUCD done?
Insertion of IUCD is a simple procedure that can be done by the doctor in the clinic. No general anesthesia or sedation is required and the procedure takes no more than 15 minutes. It is best inserted during the menstrual periods as it is at this time that pregnancy is unlikely to occur and the cervix, being softer and slightly open, makes insertion easier. Oral painkillers may be given to help with the slight abdominal cramps that may occur during and after the procedure.
What Causes an IUCD to Fail?
According to the Centers for Disease Control and Prevention (CDC) of USA, copper IUD has a failure rate of 0.8%, while the hormonal IUCD has a failure rate of 0.1–0.4%
Failure in IUCD could be due to the following:
Expulsion: IUCD could fall out of the vagina during menstruation. . According to the American College of Obstetricians and Gynecologists (ACOG), the expulsion rate is 2–10% within 1 year of IUCD insertion. Expulsion usually occurs unnoticed. Thus, it is important for the patient to be reviewed by a doctor regularly to check the placement of the device.
Expiry: If the device is kept longer than the suggested duration of 3-5 years, chances of getting pregnant increase.
Translocation: Women who breastfeed or who have an IUCD inserted shortly after giving birth are more likely to have the IUCD shifted out of position in the uterus, a condition called translocation. The woman may be unaware that translocation has taken place as this usually occurs without any sign.
Types of pregnancy when IUCD fails?
2 types of pregnancy can happen.
Intrauterine pregnancy which is a normal pregnancy.
Ectopic pregnancy in which the embryo grows outside the uterus usually in the fallopian tubes. This condition can be life threatening.
How to manage intrauterine pregnancy with IUCD?
Intrauterine pregnancy in the presence of IUCD is known to have increased risks of complications such as uterine infection, miscarriage, premature birth, bleeding from placenta and cesarean section delivery.
However, termination of pregnancy is not a necessary option.
If the mother chooses to continue the pregnancy, an ultrasound examination should be done to determine whether the IUCD is still in the uterus.
If the IUCD strings are visible and the pregnancy is less than 13 weeks, early retrieval with or without a hysteroscope should be done to minimize complications.
If the strings are not visible or the mother is more than 13 weeks pregnant, removal may be difficult. She should be counseled regarding the risk of complications. Proper antenatal follow-up is essential to reduce the risk.
K was counseled and she was quite happy to continue with the pregnancy. The IUCD was removed with ease without hysteroscopy. There was slight vaginal bleeding for 2 days. The pregnancy progressed normally without complications. She is in her last trimester now.