History of iucd.


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  • difficult to know which came first
    hippocrotes or the camel
    first attempt was to cover the cervix
  • to remind me what to say
  • lk
  • Also Mirena; or Leo Nova
  • - -
    --3-6/12 later amen v. common
    bloated acne depression
    blood levels down at 2/12
  • the problems already mentioned
    And as always
    But progestagen as well as an iucd.
  • 1234556
  • History of iucd.

    1. 1. History of IUCD. • • • • • • • • • • • First IUCD.--- Stones in the uterus of camels Hippocrates --- used lead tube Cervico-uterine stem pessaries----late 1800s. Graffenberg---- silver wire rings 1930s. Lippes loop ---- New York 1962 Copper added to Lippes loop 1971 Tcu.200 --------- Tcu.380a Progestogen releasing IUS 65 ugm./day LNG-IUS 20ugms/day Dalkon shield – pelvic infection and disrepute. Now--- CuT380, GynFix, LNG-IUS-- the best.
    2. 2. Mode of Action of IUCD and IUS • • • • • • • • • • • • • Mechanism not exactly clear, but all types cause marked increase in leucocytes in endometrium and utero-tubal fluid – a typical F.B. reaction This interferes with gametes, fertilisation and implantation actual phagocytosis of sperm occurs -------------------------------------Cu - enhances the FB reaction - causes endometrial changes(enzyme systems,hormone-receptors) - probably directly toxic to sperm and ova -------------------------------------Progesterone releasing IUS - alter endometrial histology with decidual change and glandular atrophy, blocking O and P receptors -markedly reduce sperm permeability of mucus to sperm -have an anti-implantation effect -can prevent ovulation
    3. 3. Types of Device • Inert • Copper containing • Progestogen containing ------------------------• Framed • Frameless ------------------------• Design all important • Implantable GyneFix very promising
    4. 4. Advantages of IUCDs. • • • • • • • • • • Effective Safe Independent of coitus No effort required. Motivation necessary only at time of insertion Relatively cheap and easy to distribute Does not influence milk volume/composition Method is under woman’s control Continuation rates are high Nearly always reversible
    5. 5. Disadvantages • Intrauterine Pregnancy –with increased rate of miscarriage and infection. • Extrauterine pregnancy – but no increase in overall population risk • Expulsion with risks of pregnancy • Perforation – with risks of pregnancy • uterine perf. • surgery • Malposition of device - causing pain and bleeding • “Lost threads” • Pelvic infection/salpingitis - ? Infertility
    6. 6. • • • • • • • • • • • • Contraindications to the IUCD. Absolute (Temporary) Undiagnosed vaginal bleeding Suspected pregnancy Current pelvic infection Malignant trophoblastic disease with uterine wall involvement. Significant immunosuppression ---------------------------Absolute (Permanent) Markedly distorted uterine cavity or <5cms. Known true allergy Wilson’s Disease Past attack of bacterial endocarditis or the presence of a prosthetic valve replacement
    7. 7. Relative Contrainds. to IUCD use • • • • • • • • • • • • • • 48hrs. 4 weeks post partum Known HIV or AIDS Recent exposure to high risk of STD Valve heart lesion but no past history of bacterial endocarditis Past history of ectopic in nullipara Trophoblastic disease while blood hCG still detectable Previous pelvic infection Nulliparity Diabetes Mellitus Fibroids or congenital abnormality (?not GynFix) Severely scarred uterus Severe cervical stenosis After endometrial ablation/resection Memorrhagia/Dysmenorrhoea (not LNG-IUS)
    8. 8. Common Problems with IUCDs. • • • • • • • • • Intrauterine pregnancy with IUCD in situ IUCD and ectopic pregnancy Expulsion of IUCD Uterine perforation by IUCD Missing threads Pelvic infection and IUCD Actinomyces like organisms(ALOs) and IUCD Menorrhagia Pain
    9. 9. Causes of Failure • Incorrect Insertion and Malposition • Age of patient ---- over 35,first year failure rate is very low (reduced fertility) • Failure rates lower with increased duration of use • Wrong timing of removal • Wrong timing of insertion
    10. 10. Intrauterine Pregnancy with IUCD in situ • No evidence for increased risk of Fetal abnormality • 50% miscarry if IUCD left in situ • Remove IUCD if possible • Do US – if IUCD above sac - ? leave • If low and threads still accessible - remove
    11. 11. IUCD and Ectopic pregnancy • Copper IUCDs do not increase the overall risk of ectopics in a population(due more to pre-existing tubal damage) • IUCDs do not prevent ectopics as well as they do intrauterine pregnancy • The risk of ectopics increases with the duration of use and is associated with age • Every IUCD user with pelvic pain and menstrual irregularity has an ectopic until proved otherwise • IUCD is contraindicated in a patient who has had a previous ectopic – an anovulatory method is required
    12. 12. Expulsion of IUCDs • For framed IUCDs, occurs 3-15/100 women by one year • Most common during 1st. or 2nd.menses after insertion • Unnoticed expulsion causes 1/3rdof pregnancies in the first IUCD year • With proper instruction, this should not happen • Nulliparous women have higher expulsion rates • Lower in>30s – half the rate • Expulsion rates associated with precise fit or otherwise of IUCD within uterine cavity • GynFix appears to have solved this problem
    13. 13. Uterine Perforation by IUCD • Most perforations first present in pregnancy as “lost threads”. • If device is bioactive – leads to adhesion formation – may penetrate bowel or bladder • “Closed” devices associated with possible bowel strangulation • Removal is indicated • Occurs with frequency of 1 in 1000 • -- insertion during the puerperium • -- push technique insertions • -- linear devices ; loss of plastic menory • -- operator experience ; R/V uterus ; mobile • cervix
    14. 14. Missing Threads • • • • • • • • IUCD users with lost threads are either ------ already pregnant or ------ at increased risk of pregnancy The IUCD ---- will be in the uterus -- have been unknowingly expelled -- or will have perforated the uterus Establish whether pregnant and if so treat the pregnancy • If not pregnant – remove and replace the IUCD
    15. 15. P.I.D. and IUCDs. • IUCD related bacterial infections are now believed to be due to contamination of the endometrial cavity at time of insertion, from pre-existing infection, rather than to type of IUCD • WHO data base-the risk of PID was 6 times higher during the 20 days after the insertion, compared with later • Infertility is a major source of concern • 3 episodes of pelvic infection carry a 50% risk of tubal infertility
    16. 16. • Compared with the protection offered by the OCP against STD/PID, inert/copper IUCDs do not protect against STD/PID • LNG-IUS has a protective action against pelvic infections • High risk IUCD users must be advised to use barrier methods during coitus
    17. 17. IUCD and Pelvic Infections • Asymptomatic IUCD users, whose cervical cultures show gonorrhea or chlamydia infection, should be treated with recommended drugs • Removal of the IUCD is usually not indicated • If however there is clinical evidence of ascending infection, the IUCD should be removed promptly
    18. 18. IUCD and Pelvic Infection • IUCD insertion is contraindicated in the presence of current acute or chronic pelvic infection • If PID developes parenteral antibiotic treatment should be instituted and IUCD removed – but only when the serum antibiotic levels are adequate
    19. 19. IUCD and Pelvic Infection • Infections that occur 3-4 months after IUCD insertion, are considered to be due to acquired STD infection and not to the direct result of the IUCD • In patients at high risk for STDs – Doxycycline 200 mg or Azythromycin 500 mg orally should be prescribed one hour before insertion.
    20. 20. IUCD and Pelvic Infection • There is no evidence that the prevalence of bacterial vaginosis is influenced by IUCD use. • Bacterial Vaginosis should be treated but the IUCD need not be removed unless pelvic inflammation is present.
    21. 21. Actinomyces Like Organisms. – (ALOs) and IUCDs. • Normally ALOs are harmless commensals in the mouth and GI tract. • Very seldom detected in the genital tract unless an FB present • After one year of IUCD, 1-2% of smears are +ve.for ALOs. • After 5 years, 20% of smears are positive. • Frank Actinomycosis is rare. • The significance of smear ALOs is uncertain.
    22. 22. IUCD and ALOs. • If ALOs are present on the cervical smear of an asymptomatic woman, there are two different approaches• 1)remove / change the IUCD - in six months if the cervical smear is negative, replace the IUCD .It is not necessary to administer an antibiotic. • Or 2)leave the IUCD insitu • Warn the patient to report any symptoms and follow up carefully. • If uterine tenderness or a pelvic mass is present,
    23. 23. IUCD and Menorrhagia • Inert and copper containing IUCDs associated with increase in menstrual blood loss (55% with Cu IUCD) • Best treated with NSAIDS • Menstrual blood loss is reduced if device is impregnated with progesterone
    24. 24. Levonorgestrel IUS (LNG –IUS) • Nova T shaped disc – releases 20µg/ 24 hours of LNG from its reservoir through a rate limiting membrane over at least 5 years. • Acts locally by – endometrial suppression - changes in cervical mucus and and utero-tubal fluid which impairs sperm migration • Blood levels of LNG are about ¼ peak levels of POP • Most women continue to ovulate.
    25. 25. Disadvantages of LNG-IUS • Same problems as Nova-T • expulsion, perforation, malposition • High incidence in first few months of uterine bleeding • Though mainly local in action it is also hormonal with incidence of steroidal side effects • Functional ovarian cysts more common – • - usually asymptomatic • Uncertainty about harm to foetus – no data
    26. 26. Absolute Contraindications • • • • • • • • • • • • • • • IUCD Current pelvic infection Recent STD Severely distorted cavity Previous bacterial endocarditis Prosthetic Valve present Severe Immunodeficiency Suspected pregnancy Irregular vag. Bleeding Allergy to constituent Progesterone Active hepato-cellular disease Active arterial disease Active trophoblastic disease with raised hCG. (no evidence that enzyme inducing drugs weaken contraceptive effect) (may be used during breast-feeding)
    27. 27. Advantages of the LNG-IUS • • • • • • • • • • • • It has unsurpassed efficacy Rapid complete return of fertility after removal Highly convenient with few adverse side effects Also has some beneficial side effects :- dramatic reduction of menses - improvement in dysmenorrhoea - reduced PMS - provides progestogenic protection of uterus HRT - appears to reduce frequency of clinical PID - shows a reduction in extra as well as intra-ut erine pregnancy
    28. 28. • • • • • • • • • • • • • Insertion Procedure Timing “Pre-op” ---- cx screening for STDs if nec. make cx favourable Requirements – couch, light, equipment, emergency tray Well-trained Doc – “dry-runs”with plastic model Technique – pain relief uterine sound antisepsis IUCD “memory” Perforation paranoia Vaso-vagal attack – emergency-tray Follow - up advice