[IUD insertion during cesarean section and its most frequent complications]. / DIU transcesárea y sus complicaciones más frecuentes.

A prospective and cooperative study was done in 152 patients that were submitted to cesarean section. Seventy eight patients received intrauterine device (IUD) T CU 220 during cesarean section, and the other 74 patients only got the cesarean section without IUD. The events that were analyzed during the puerperium were pain, bleeding and infection. We didn't find any difference in the results between both groups, these were analyzed with the help of the square chi (X2). These results suggest that with an adequate selection of the patients, the insertion of the IUD during the cesarean section is a secure and helpful method for the fertility control for patients with high risk of reproduction.

PIP: 78 women were fitted with copper T 220 IUDs during cesarean deliveries at a Mexican Institute of Social Security hospital in Cardenas, Tabasco, between August 1991 and December 1992 in a study of the suitability of IUD insertion during cesareans. A control group consisted of 74 women undergoing cesarean deliveries who did not have IUDs inserted. The average age was 20.6 years for IUD acceptors and 24.9 years for controls. The average number of pregnancies including the current one was 1.3 for the IUD group and 3.2 for the control group. Average gestational age at the time of delivery was 38.5 weeks for the IUD group and 40.1 weeks for the control group. The indication for cesarean was fetopelvic disproportion for 51.2% of the IUD group and 40.5% of controls. The volume of bleeding was normal for 98.7% of IUD acceptors and all in the control group. The IUD was vaginally removed two hours postpartum in the one IUD acceptor with postpartum hemorrhage. The average duration of bleeding was 23.8 days for the IUD group and 22.0 days for the control group. Pain during the postpartum period was described as light for 91.0% and moderate for 9.0% in the IUD group and as light for 93.2% and moderate for 6.8% in the control group. Four cases of endometritis (5.1%) were observed in the IUD group. Three cases of endometritis and one of abscess of the abdominal incision were observed in the control group, for an overall infection rate of 5.4%. One IUD expulsion occurred on the fifteenth postpartum day, for a rate of 1.28%. The strings could be seen in only 21.7% of cases at the six-week check-up. The IUD was visualized by X-ray for 71.7% at the control visit. IUD insertion did not significantly increase postoperative pain, hospital stay, the volume or duration of bleeding, or frequency of infection. The results suggest that IUD insertion during cesarean is a safe and effective method of fertility control for patients at high reproductive risk.

A bright future for IUDS: new technology and research trigger expanded interest.

PIP: Refuting research findings on IUDs from the early 1980s, and controversy over the safety of the Dalkon Shield, research published over the past 10 years indicates that modern IUDs are safe and effective for most women. Better understanding of pelvic inflammatory disease (PID) reveals PID to present no more frequently among IUD user selection, insertion, and monitoring techniques are followed. Following such guidelines, and avoiding use in women at high risk for infection from sexually transmitted diseases (STD) will generally provide effective, acceptable, and inexpensive protection against pregnancy. The TCu 380 A IUD has in fact proved to be as effective as injectables or newly- developed hormonal implants. Accordingly, expanded use around the world is encouraged. The IUD has already become the most widely used from of reversible contraceptive with 85 million users in China, developed nations, Indonesia, Mexico, Egypt, and India. China claims 60/85 million users. Family Health International clinical trials involving 10,000 women in 23 developing countries during the period 1985-89, found declining removals due to complications, with increasing rates of method continuation. Women having a baby are ideal candidates for IUD acceptance and insertion. Such women may receive IUD insertion 10 minutes following expulsion of the placenta, while not posing risks to safe breastfeeding. Method drawbacks include the need for trained health professionals in insertion, removal, and follow-up exams over the 1st 3 months following insertion. IUDs also do not protect against STDs.^ieng

[Bilateral tubal pregnancy with intrauterine device -- a case report]. / Gravidez tubaria bilateral em portadora de DIU -- relato de um caso.

PIP: Ectopic pregnancy occurs in Brazil in 1/300 cases. 99% are in the ovarian tubes and are almost always unilateral. The incidence rate for bilateral ectopic pregnancy has been described in literature to be 1/1,580 ectopic pregnancies. The article reports a case history at the maternity hospital of the Federal University in the Minas Gerais region. A 31 year-old leukodermatous patient in December 1980 began using an IUD (Lippes loop), followed by episodes of menorrhagia accompanied by abdominal colics of medium intensity during the following months. After the 3rd cycle menstrual delay occurred with abdominal pains localized mostly in the hypogastrium, but also in the lumbar and anal regions. After the diagnosis of ectopic pregnancy, the IUD was removed, resulting in minor bleeding a few days later. Subsequent ultrasonographic tests exposed a posterior pelvic tumorous mass at the uterus, 5.0x6.5 cm in diameter, and absence of uterine abnormalities, suggesting an ectopic pregnancy on the left. Following a complete physical examination including specular examination of the inner genitals it was decided to perform a diagnostic peritoneoscopy. It revealed an abdominal cavity presenting a large quantity of blood spread diffusely, uterus of normal size, and a cystic mass to the left+-6 cm in diameter apparently with hemorrhagic content. Laparotomy with transversal suprapubic incision was then performed. Final examinations indicated a bilateral tubal pregnancy ruptured on the left. The patient had a normal postoperative period and was discharged from the hospital after 6 days. Diagnosis is generally difficult since the unsuspected opposite tube may be infected and edematized due to bilateral endosalpingitis. For IUD users 2 etiological aspects of tubal pregnancies may be involved: Greater incidence rate of pelvic infection, modified tubal motility altering contractibility and possibly reversal of peristaltic wave. The necessity for examining both tubes when suspecting tubal pregnancy is stressed.^ieng

[In situ IUD and pregnancy. Follow-up of 27 cases]. / Gravidez e DIU in situ. Evolucao de 27 casos.

PIP: 27 pregnant patients with IUDs in situ were diagnosed in health care centers in Belo Horizonte, MG, Brazil. The pregnancies were followed up and analyses of the complications were carried out in 2 groups. Group A consisted of 15 (55.6%) patients that did not have the IUD removed, and Group B consisted of 12 (44.5%) patients that had the IUD removed before the 12th week of pregnancy. 85.2% of the patients were using the Lippes Loop IUD, varying from 1 to 41 months. 48.1% of the patients were in age group 25-29, and 59.2% had between 2 and 3 children. In group A, 53.3% of the patients had spontaneous abortions, comparing with 8.3% in Group B, and 91.7% of the patients in that group had uncomplicated term deliveries. The results showed a significantly higher abortion rate in patients that did not have the IUD removed. The IUD should be removed as soon as possible when pregnancy is confirmed. If it is not possible, the patient should have careful follow-up.^ieng

[Ectopic pregnancy in the presence of an intrauterine device. Communication of a case and review of the literature]. / Embarazo ectópico en presencia de un dispositivo intrauterino. Comunicación de un caso y revisión de la literatura.

PIP: A rare case of cervical pregnancy in the presence of an IUD is described. A 25-year-old woman with 2 children was treated with injectable hormones for intermittent vaginal bleeding after insertion of an IUD. She was later seen in a health center where removal of the IUD was recommended because of a suspected strangulating endocervical polyp. Uncontrollable hemorrhage during the removal resulted in emergency admittance to the General Hospital of Acapulco and a total hysterectomy and bilateral salpingo-oophorectomy. The postoperative course was uneventful. The case met some of Rubin's criteria for a true cervical pregnancy established in 1911: the uterine cavity was empty, and the site of implantation of the blastocyst was below the internal orifice of the cervix and 1 cm above the external cervical opening. Schneider applied the term cervical pregnancy to all cases in which the pregnancy is "obviously and predominantly" situated in the cervix, whether the placenta extended to the isthmus or the endometrium. No pregnancy of greater than 12 weeks is available for histologic proof because of the growth of the placenta in areas contiguous to the cervix and the effacing effect of the growing ovisac. Numerous etiologic factors for cervical pregnancy have been proposed, of which the 3 finding greatest acceptance have been lack of an adequate endometrium for nidation of the trophoblast, a rapid passage of the egg through the uterine cavity, and a premature closing of the internal opening of the cervix. The frequency of cervical pregnancy has been estimated at 1 in 1000 to 1 in 16,000 pregnancies, but its true frequency is unknown. The case described is of great interest because it occurred with an IUD in place.^ieng

[Pelvic inflammations]. / Inflamaciones pelvianas.

PIP: Pelvic inflammations account for approximately 1/4 of the economic resources expended for maternity care in Chile. The use of IUDs has replaced abortion as the primary cause of pelvic inflammation. Sexually transmitted diseases are increasing but have not yet become a major cause of pelvic inflammations. A retrospective study was conducted of women hospitalized for pelvic inflammations in the septic unit of a hospital in Santiago, Chile, in 1980-83. Among the 313 women admitted with a diagnosis of pelvic inflammation, ages ranged from 17 to 57 and averaged 30.4 years. 11.1% were nulligestes, 25.2% were primiparas, 55.5% were multiparas, and 7.9% were grand multiparas. 45 of the 313 reported an induced abortion prior to the pelvic complication. 126 women (40.2%) reported use of an IUD. 36 women had postpartum infections, and no risk factor was identified for the remainder. The major clinical symptoms were abdominal pain in 67.7%, fever in 48.5%, metrorrhagia in 14.0%, and palpable mass on gynecological examination in 52.3%. Sonography was performed in 92 cases and laparoscopy in 20. Use of laparoscopy increased greatly after the study period and has proven to be extremely valuable in diagnosis. 121 of the 313 patients were treated medically and 192 were treated medically and surgically. The average hospital stay was 8.8 days, with a maximum of 80 days and a minimum of 1 day. The admission diagnosis was incorrect in 138 cases and correct in 175. A purulent acute appendicitis was discovered in 1 patient with a presumed tubo-ovarian abscess. The mortality rate was 1.2%.^ieng

[Endometrial cytology of IUD smears: endometrial reaction study]. / Citologia endometrial de esfregacos de DIU: estudo da reacao endometrial.

PIP: The objective of this research was to ascertain possible abnormal endometrial reactions to the IUD. The Family Planning Clinic of the Gynecology and Obstetrics Department of the Federal University of Minas Gerais, Brazil, used 110 cases from patients with IUDs who used the clinics from July 1981 to December 1982. Pap smears from 102 of these cases were made from material contained on the IUD. Several parameters were used, represented by endometrial cells and associated elements, including the IUD model, the user's age, and the day of the menstrual cycle on which the IUD was removed. The breakdown of endometrial cells was greater in Lippes Loop users than in TCu 200 and Copper 7 users. There was no significant difference in the amount of endometrial cells in the various stages of the menstrual cycle. The large number of cells in 90% of the smears leads to the suggestion that these smears be used for determining exclusion or diagnosis of cancer in the perimenopausal age group when the IUD is removed. A special histiocyte reaction was evident only in Lippes Loop users. A greater frequency of plasmocytes and leukocytes in the pre- and postmenstrual stages should be considered as physiological. A greater frequency of plasmocytes was found in Lippes Loop users, and a smaller frequency of lymphocytes observed from the 8th to 14th days of the menstrual cycle should be considered physiological. The lymphocytes were more frequent in users of the TCu 200 and Copper 7, but not significant enough to suggest the use of medicated IUDs.^ieng

[Intra-uterine contraceptive devices in nulliparous women: a retrospective study]. / Dispositivo intra-uterino na contracepcao de mulheres nuligestas: um estudo retrospectivo.

PIP: The insertion of intrauterine devices (IUDs) in nulliparous women is a controversial subject, with no unanimous opinion on whether or not to use this method. A study was undertaken to analyze retrospectively the complications of the TCu-200 IUD in nulliparous women compared to complications encountered in multiparous women using the same device. In 1982 and 1983, the Family Planning and Human Reproduction Clinic of the UFMG Medical School in Belo Horizonte, Brazil, inserted 114 IUDs in nulliparas. The principle characteristics of the study group were a low socioeconomic condition, regularity of menstrual flow, and absence of vaginal infection at the time of examination. The choice of method was the spontaneous decision of the women. It was noted that nulliparas requested IUD insertion after previous unsatisfactory experience with other contraceptive methods. 56% of the group were single and 38% married. For comparison, 300 records of multiparous TCU-200 IUD users were studied retrospectively. All insertions were made by the same clinic. The racial, social, and economical characteristics were typical of the users of any free family planning service. Among early complications, pain and lipothymia were encountered at an elevated incidence in nulliparous women when compared to multiparas (p0.01). Among late complications, the appearance of vaginal discharge and metrorrhagia were significant when compared to multiparas (p0.05). Pelvic infection and dysmenorrhea, although more frequent in nulliparas, were not statistically significant. The authors concluded that the IUD should not be used as the contraceptive method of 1st choice in nulliparous women, using it only in exceptional situations.^ieng

Preliminary report on a postpartum CuT 200 study, Santiago, Chile.

An analysis is presented of a study of the Copper-T 200 (CuT 200) intrauterine device at the Barros Luco Hospital in Santiago, Chile. The devices were inserted in 1142 postpartum patients. The expulsion rate was high, 32.1% at 3 months. Of the 372 women who expelled devices, 349 received a replacement CuT 200. The expulsion rate for these reinsertions was 7.7% at 12 months with a continuation rate of 86.4%.

PIP: An analysis is presented of a study of the Copper-T 200 (CuT 200) IUD at the Barros Luco Hospital in Santiago, Chile over the August 16, 1976 June 30, 1978 period. 1142 IUDs were inserted in postpartum women, the majority of whom (96.1%) received their IUDs within 72 hours of giving birth. Data were recorded on standard forms designed to obtain demographic and medical information and were processed by the International Fertility Research Program (IFRP). The CuT 200 used in this study consisted of a plastic T-shaped device with 200 sq mm of copper wire wound around the vertical arm. The mean age of women in this study was 24.0 years; the mean number of live births was 2.4 57 (5.0%) of the women reported having had 1 or more induced abortions. There was no previous incidence of pelvic inflammatory disease (PID) reported by the patients, and none of them showed evidence of inflammation/infection of the genital organs at the time of insertion. There were no complications or complaints reported for women at insertion. There were no complications or complaints reported for women at insertion. 945 (82.7%) patients returned for 1 or more follow-up visits. Cervical perforation was found at follow-up in 2 (0.2%) women, and 9 (0.7%) women were hospitalized during the study period. From this latter group, women were hospitalized because of retained placentas and 2 women because of a perineotomy infection. 4 women were hospitalized for endometritis and 1 for the spontaneous abortion of a pregnancy conceived with the IUD in situ. 158 (13.8%) women were diagnosed as having 1 or more incidents of inflammation/infection. Included among these were 19 (1.7%) cases of adnexitis and 20 (1.8%) cases of endometritis. Dysmenorrhea was reported by 23.7% of the women. Intermenstrual bleeding/pain was reported by 297 (20.0%) of the women and 113 (9.9%) reported intermenstrual spotting. The continuation rate after 1 year was 55.5. The 3 month termination rates were 0.3 for accidental pregnancy, 32.1 for expulsion/displacement, 0.2 for bleeding/pain, and 1.3 for other medical reasons. Most expulsions occurred within 1 month postinsertion. 372 (32.6%) women who received CuT 200s in this study expelled them; 370 of them received a replacement IUD. 349 received a 2nd CuT 200 and 21 received Lippes Loop IUDs. 92.8% of the women who received replacement CuT 200s returned for follow-up and were diagnosed as having 1 or more infections. 19 of the women who expelled their 1st CuT and received a replacement also expelled their 2nd device and had a 3rd CuT 200 inserted. No complications or complaints were reported at insertion for this group. At follow-up 4 women were diagnosed with trichmonas and 1 with an unspecified inflammation/infection. 7 women expelled their IUDs and 1 woman had her IUD removed for other personal reasons.

[Evaluation of a type of biomedicated IUD (model Copper 7 200) in a family planning clinic]. / Avaliacao de um tipo de dispositivo intra-uterino biomedicado (modelo "7 de cobre 200") em uma clinica de planejamento familiar.

PIP: In October 1978, 95 patients were inserted with a model 7 Cu 200 IUD at the Family Planning and Human Reproduction Clinic of the Federal University of Minas Gerais, Belo Horizonte, Brazil. Patients varied in age between 16 and over 40, the great majority being in the age group 21-30, and in parity between 1 and over 4, the majority with parity over 4. Most patients, or 76.19%, had previously used OC (oral contraception); 84 of the original 95 patients were followed up at 1, 6, 12, and 18 months after insertion of the device. Continuation rate was 86.7%; there were 36 cases, or 42.85%, of menstrual disorders, mostly hypermenorrhea; 8.23% of patients complained of pain, and 16.47% of discomfort. There was 1 ectopic pregnancy, or a Pearl index of 0.82%, 12 expulsions, or 9.88% of cases, and 1 case of pelvic inflammatory infection. There was 1 removal for hemorrhage, and 2 removals on request from the patients. Hemoglobin levels were measured in 7 patients before insertion and after 14 months, and changes were not significant. These results show that the device was well tolerated and side effects and complications were minimal.^ieng

[Translocation and inversion of the intrauterine contraceptive device (Author's transl)]. / Translocacao e inversao de dispositivos intra-uterinos.

PIP: This article presents 3 cases in which an IUD had to be removed from the uterine cavity after X-rays and hysterography had shown translocation and inversion of the device. In 2 cases the device was withdrawn after dilatation of the cervix and 1 case laparotomy was necessary. The article also reviews the literature on the subject, and gives some suggestions about IUD insertions.^ieng

[Actinomycosis of the female genital tract]. / Actinomicosis del tracto genital femenino.

PIP: Actinomycosis is a rare infection caused by 2 different types of bacteria. Actinomycosis develops in the mouth, on the face, in the lungs, or in the digestive tract. Abdominal, pelvic, or genital actinomycosis is very rate; up to now there are only 300 cases reported in the published literature. This article presents the 3rd case that ever occurred in Chile. A 27 year-old patient, wearer of a Lippes Loop, was hospitalized for recurrent abdominal pains and for purulent discharges from the vagina. A diagnosis of endometritis and bilateral tubo-ovarian abcess was followed by laparotomy, which revealed an abdominal cavity filled with pus and with necrotic tissues. After extensive laboratory examination actinomycosis was diagnosed and the patient successfully treated with antibiotics. Since 1973 the association between actinomycosis and IUD use has been made several times, although the mechanism of association is not well known. Several types of IUDs have been involved in actinomycosis cases. The disease, which was once fatal in 80% of cases, is today treated with penicillin and tetracycline, and by surgery.^ieng

[Genital actinomycosis caused by the use of intrauterine devices. Report of 2 cases]. / Actinomicosis genital asociada al uso de dispositivo intrauterino. Informe de dos casos.

PIP: 2 patients aged 31 and 35, multiparous, and wearer of a Dalkon Shield IUD for a period of 3-5 years, were hospitalized for bilateral tubo-ovarian actinomicosis. Both patients were surgically treated, and in both cases there were necrotic materials. An adequate diagnosis of actinomycosis would be incomplete without careful citological examinations of cervico-vaginal exudations. It is also important to stress that any type of IUD should not be worn for longer than 2 years. The article presents a review of the published literature on the subject.^ieng

[Prevalence of premalignant lesions of the cervix uteri. Comparative study between a female population using contraceptives]. / Prevalencia de lesiones premalignas y malignas del cuello uterino. Estudio comparativo entre población femenina usando anticonceptivos.

PIP: A comparative retrospective study of cervical lesions was conducted in Jalisco, Mexico. 154,784 cytologic studies were done; 36.7% of women observed used either hormonal contraception or the IUD. Dysplasia was found in 1.71/1000 women, but in 1.2/1000 of those using contraception. Incidence of carcinoma in situ was 1.97/1000 overall, but 1.84/1000 for women on contraception. Patients who used contraception, and who had either dysplasia or carcinoma, tended to be younger than patients who did not use contraception; the difference was 5 years for dysplasia, 10 for carcinoma in situ, and 16 for invasive carcinoma. To obtain more reliable data it would be necessary to conduct a perspective study, to augment the number of cases observed, and to prolong investigations for at least 5 years.^ieng

[Removal from the abdominal cavity of an intrauterine device by culdoscopy]. / Remoción de cavidad abdominal de un dispositivo intrauterino por culdoscopía.

PIP: The article reports on the case of a 21-year old patient whose Lippes Loop D had translocated into the abdominal cavity causing uterine perforation and amenorrhea. The device was easily removed by culdoscopy, and amenorrhea, caused by the partial distruction of the endometrium, treated with hormonal therapy.^ieng

[Clinical study on the therapeutic efficacy of a chemotherapeutic agent ectopia of the cervix]. / Estudio clínico sobre la eficacia terapéutica de un agente quimioterapico en ectopia del cervix.

PIP: The study was conducted on 26 patients, aged 23 to 45, all using contraceptive methods (oral contraceptives in most cases, IUDs in 2 cases), suffering from ectopia and vaginal discharge, were treated with methacresol sulphonic acid with methanal. Schiller's test was performed before and after treatment, as well as biopsy and cytological studies. In most patients (88%), the ectopia disappeared, as well as the discharge (95%). One patient was not considered in the study because carcinoma in situ was diagnosed. This medication is useful in the treatment of these problems.^ieng

[Prolonged use of intrauterine devices]. / Uso prolongado de dispositivos intrauterinos.

PIP: Analysis was done on 70 cases of regularly controlled use of an IUD for 4 years or more. No distinction was made among devices used. 64.2% of the sample had used an IUD from 4 to 5 years, 20% from 5 to 6 years and 15.8% for more than 6. 37% of the sample was between 20-29 years of age, 58.5% between 30-39, and 4.2% over 40. All had more than 2 children and 74.1% had had at least 1 abortion; 12.8% had had between 4-6 abortions. 85.7% were considered to have normal menstrual periods; 8.5% experienced menorrhagia, 2.8% hypermenorrhagia, and 2.8% metrorrhagia. 92.8% had no inflammatory complications. There was 1 case of endometriosis, 3 of adnexitis, and 1 of parametriosis, all of which responded favorably to antibiotics without necessitating removal of the device. Laboratory studies revealed that 50% of the sample had cervicitis. It is concuded that menstrual disorders and genital inflammations need not, if properly treated, be reasons for removal of the device, and further, that with adequate controls IUDs are suitable for long-term use.^ieng

[Ectopic Lippes' intrauterine devices. Hysterography]. / Dispositivos intrauterinos de Lippes ectópicos. Estudio histerográfico.

PIP: Statistics on the indicence of ectopia (displacement) of Lippes loop vary significantly by author; from .5/1000 to 6.81/1000 insertions. It is not clear whether ectopia occurs as a result of uterine perforation or of progressive migration. In all reported cases, however, hysterography was used to investigate. 50 patients from a control group of 1064 active Lippes D users chosen from the Family Planning Center of the San Camilo Hospital in San Felipe were studied between 1965-1969. Observations were made using x-ray and hysterography at 10 days, 1 month, 3 months, 6 months, and 1 year or more after insertion. Also studied were some of the characteristics of the loop and techniques for its insertion. In the 50 patients the device was found to be out of place in 6 (an ectopia rate of 5.6/1000 insertions), in a normal position in 30, and in an abnormal one in 14 (the distal part near or across the neck). All the ectopia was observed in patients between 20-34 years who had had 2-5 births. Those with 7-13 births did not seem to be prone to the complication. 8 of the 50 had a retroflexed uterus and 2 of those were displacement cases, suggesting that anomaly of position could be a predisposition for ectopia. Incidence of displacement was not found to vary significantly with doctor. None of the ectopic cases had severe side effects (pain or heavy bleeding) after insertion. In each case displacement was found to have occurred between 1 week and 6 months postinsertion, 2 of them within 2 weeks. It is probably that the later diagnosis of the others was due to the patient not having noticed the disappearance of the threads. It is concluded that ectopia is due to uterine perforation and not to progressive migration. The different positions in which the device was found when it was removed by laparotomy indicated that such perforation was due to the structure of the device and the resistance of the uterine cavity. Through modification of the loop this complication could be avoided. Disappearance of the threads did not necessarily mean that ectopia had occurred, but it was an important sign, especially if it occurred early on after insertion. With respect to abnormally positioned devices, it was not thought to be a reason for IUD removal, espcially since the abnormal positioning was found to have occurred in every case in an abnormally positioned uterus.^ieng