|Year : 2020 | Volume
| Issue : 2 | Page : 155-158
Twin gestation: An unusual intrauterine contraceptive device failure outcome
Afolabi Korede Koledade, Zubaida G Abdullahi, Tokunbo O Adeoye, Oladapo Sunday Shittu
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Submission||27-Sep-2019|
|Date of Decision||29-Sep-2019|
|Date of Acceptance||25-Aug-2020|
|Date of Web Publication||9-Oct-2020|
Dr. Afolabi Korede Koledade
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
The copper-T intrauterine contraceptive device is an effective long-acting reversible contraceptive option. However, there exists a slim chance of failure. The Copper T 380A has a 1 year failure rate of 0.8% and a 12 year cumulative failure rate of 2.2%. On long-term basis, the cumulative life failure rate for Copper T 380A is 22/1000 long-acting contraceptives after a single application from the 1st to 10th year of insertion, comparable to 18.5 for all tubal sterilisation procedures. When failure happens, the patient is usually at the crossroads of either to terminate the pregnancy or continue with the unplanned pregnancy. Therefore, the patient ought to be adequately counselled on management options, which includes termination of pregnancy where there are no restrictive laws, intrauterine contraceptive device (IUCD) removal if accessible otherwise leave in situ with risks of miscarriage, pre-labour rupture of membrane, and pre-term delivery. The patient's choice is usually laden with emotional and psychological adjustments, especially if the IUCD failed with twin gestation, as seen in this case of a 39-year-old multipara who had Copper-T IUCD inserted 6 months after her last delivery. She opted to carry on with the pregnancy despite associated medical conditions. Attempt at IUCD removal failed at 19 weeks gestational age (GA), and she subsequently drained liquor and was delivered of live pre-term babies at 32 weeks GA. The IUCD was picked up extra chorion and not embedded close to the cervical internal os. Her gestational diabetes and hypertension were co-managed with physicians, while the neonatologists managed the pre-term babies before they were all discharged.
Keywords: Contraceptive, failure, intrauterine contraceptive device, management
|How to cite this article:|
Koledade AK, Abdullahi ZG, Adeoye TO, Shittu OS. Twin gestation: An unusual intrauterine contraceptive device failure outcome. Niger J Basic Clin Sci 2020;17:155-8
|How to cite this URL:|
Koledade AK, Abdullahi ZG, Adeoye TO, Shittu OS. Twin gestation: An unusual intrauterine contraceptive device failure outcome. Niger J Basic Clin Sci [serial online] 2020 [cited 2021 Jan 18];17:155-8. Available from: https://www.njbcs.net/text.asp?2020/17/2/155/297601
| Introduction|| |
The copper-T intrauterine contraceptive device is an effective non-hormonal long-acting reversible contraceptive which can be used for child spacing and family limitation because of its advantage of being actively effective for up to 10 years. Other advantages include, early onset of action and prompt return to fertility upon removal, it is safe for lactating women and women on any type of medication, it is non-hormonal and does not cause weight gain or affect mood or sex drive.,
The Copper T 380A has a 1 year failure rate of 0.8% and a 12 year cumulative failure rate of 2.2%. On long-term basis, the cumulative failure rate for Copper T 380A is 22/1000 procedures after a single application from the 1st to 10th year of insertion, comparable to 18.5/1000 for all tubal sterilisation procedures. However, intrauterine contraceptive device failure is frequently attributable to malposition or displacement of the device rather than inefficacy. These are usually as a result of congenital or acquired anatomical reasons which distort the uterine cavity as well as ill-fitting from poor insertion technique.
When contraception fails, its consequences can take various social dimensions, including disharmony between couples, the brunt of which fall on the female, often based on the suspicion that the failure was as a result of her carelessness. It is not unusual for such reactions to manifest as emotional, economical or even physical violence. Consequently, when women experience these rare contraception failures, there is a tendency to anticipate their partner reactions, and hence, they manifest with confusion and anxiety, even before the information is disclosed to their spouses, but such is just the beginning of their travail.
Very challenging to these women is the additional decision of what to do with the unplanned and unexpected pregnancy. There are usually two options before them, to either terminate the pregnancy or to continue with it. Between these choices lie a host of additional psychological, medical, social and sometimes even spiritual fears and concerns. Continuing with the pregnancy requires a psychological readjustment to accept it and invest in its safety and well-being by undertaking early antenatal registration, complying with all obstetric interventions and availing the newborn of the same affection as were enjoyed by its older siblings. On the other hand, opting to terminate the pregnancy first involves a contention with religious inclinations and the psychological stress of either 'parting with the unwanted' or 'parting with one of her own'. Additional to these are concerns of the risks of pregnancy termination procedure to her health, and of course, those of confronting the prevalent restrictive laws on abortion (if she is conversant with it). Being confronted with a woman in such a dilemma can be a clinical nightmare, and even more so when it is in a setting with high fertility rate, unsafe abortion rate, maternal mortality and morbidity and low contraception use. It is on this backdrop that this case of failed contraception and resultant twin pregnancy is presented and discussed.
| Case Report|| |
A 37-year-old gravida 3, para 2+0 Yoruba, prison warden is presented, whose last childbirth was 9 years before presentation. She was unsure of her last menstrual period but presented to the antenatal booking clinic of the Ahmadu Bello University Teaching Hospital Zaria, Nigeria with an early ultrasound scan report that had estimated her gestational age (GA) to be 17 weeks and 3 days.
She had been having regular menses until she missed her period and suspected pregnancy, despite wearing a copper-T intrauterine contraceptive device (IUCD) that was inserted 6 months after her last delivery. A urinary pregnancy test which came out positive and an ultrasound scan confirmed two gestational sacs with the IUCD still in situ, at 5 weeks GA. She experienced exaggerated symptoms of early pregnancy, but they were not severe enough to warrant hospital admission. She had an episode of spotting per vaginam at about 6 weeks and had a second check scan at 11 weeks, which showed live intrauterine twin gestation with the IUCD in close proximity with the cervical internal os. She had a fever at about 16 weeks for which she took self-prescribed antimalarial treatment using Artemether and Lumefantrine combination. She did not seek medical treatment when she had vaginal bleeding or fever because she hoped for spontaneous abortion. When the pregnancy was about 17 weeks and remained viable, she discussed with her husband that she wanted to procure an abortion, but he was vehemently against it. The pregnancy though unplanned, she had to carry on with it and even looked forward to successful delivery.
Her first and second pregnancies were 11 years and 9 years, respectively, before presentation. Both were supervised, but the first was complicated with pregnancy-induced hypertension. while the second pregnancy was uncomplicated. At term, she had spontaneous vaginal deliveries of the live healthy male infant that weighed 3.8 kg and female infant that weighed 3.3 kg, respectively, in a hospital.
Although the patient was neither a known hypertensive nor diabetic before the pregnancy, her mother was both hypertensive and diabetic. She worked as a prison warden and was in her first order of marriage to a 42-year-old businessman, in a monogamous marriage.
At antenatal booking, she had no complaints, weighed 95 kg with a height of 1.65 m and had no pedal oedema. Her pulse rate was 94 beats per minute, while her blood pressure was 220/110 mmHg. The symphisio-fundal height was consistent with 33 weeks gestation, which was in excess the GA of 17 weeks and 3 days computed from early ultrasonography. Urinalysis revealed proteinuria (+) and glycosuria (++). Her blood group was O positive, genotype was AA, while her packed cell volume (PCV) was 32%. Serologic tests for HIV, venereal disease research laboratory, hepatitis C virus and hepatitis B surface antigen screening were all non-reactive. Oral glucose tolerance test revealed blood sugar and glycosuria values consistent with gestational diabetes, notably fasting blood sugar of 5 mmol/L and glycosuria + with a high 2 h value of 10.8 mmol/L and glycosuria +++. Serum urea and electrolytes, as well as liver function test were all within the normal limits.
She was admitted on account of severe pregnancy-induced hypertension and gestational diabetes. She was co-managed along with Endocrine physicians and was placed on α-Methyldopa 500 mg thrice daily, Nifedipine 30 mg daily, subcutaneous combination of soluble insulin and protamine-crystallised insulin aspart (NovoMix-30®) 12 i.u before breakfast and 6 i.u before supper, alongside dietary modification. The insulin dose was adjusted until the fasting blood sugar, as well as 2 h post-prandial values fell within the normal limits. She was also placed on routine antenatal supplements: Ferrous sulphate 200 mg twice daily, folic acid 5 mg daily as well as sulphadoxine-pyrimethamine combination for Intermittent Preventive Treatment for Malaria and Tetanus Toxoid.
When the patient became stable on admission, a repeat ultrasound scan revealed the Copper-T IUCD location was posterior, at the level of the cervical internal os and appeared not to be in contact with the foetal membranes. She was counselled on the need to attempt removal of the IUCD since it appeared accessible to improve the chances of carrying the pregnancy to term. She was informed on the possibility of pre-labour rupture of membrane, pre-term delivery and its attendant likely complications if the IUCD was left in situ. She consented to an attempt at IUCD removal. Under analgesic cover, vaginal examination did not reveal the IUCD string, and then an attempt at gentle probing of the extra-chorionic area around the internal os was done for possible removal of the IUCD failed. However, no bleeding or drainage of liquor was provoked. The conservative care was continued, and a decision was made to repeat the ultrasound scan after 4 weeks. She spent 10 days on admission, during which her vital signs, including blood pressure and blood sugar, remained controlled and stable with treatment. She was then discharged to be seen at the antenatal clinic bi-weekly, where her management continued along with foetal surveillance.
Her blood pressure, urinalysis, and blood sugar remained within the normal limits throughout the remaining course of the pregnancy. The biophysical profile done at 30 weeks and 5 days for foetal surveillance was normal. However, at the attainment of 32 weeks of gestation, the patient presented to the labour ward with symptoms of minimal liquor drainage of 6 h duration but no labour pains. There were no antecedent genitourinary symptoms. The liquor drainage was confirmed by sterile speculum examination. She was admitted and placed on Erythromycin 500 mg thrice daily as well as two doses of intramuscular Dexamethasone injection 12 mg, 12 h for foetal lung maturation. The patient's vital signs, urinalysis, blood sugar and biophysical profile done on admission were normal while her PCV was 34%. She was counseled for a caesarean section and tubal ligation, both of which she consented to. She was delivered 24 h after completion of the dexamethasone, of live male and female babies that, respectively, weighed 1.10 kg and 1.45 kg, with APGAR scores of 7, 9 and 5, 9, respectively, at 1 and 5 min. The copper-T IUCD was not embedded and was picked up from the left lower uterine segment wall about 2 cm from the internal cervical os. The estimated blood loss was 500 ml. The babies were nursed at the Special Care Baby Unit as pre-mature babies and had intravenous fluids, prophylactic antibiotics and phototherapy for neonatal jaundice on the 3rd day of life and were subsequently discharged on the eighth while their mother was discharged on the 9th day on antihypertensive drugs but was weaned off insulin as she remained euglycaemic after delivery.
| Discussion|| |
The Copper T 380A is one of the proven effective and tolerable modern long-acting reversible contraceptive options; however, the intrauterine device (IUD) uptake is a meagre 1%. Data from tertiary health-care institutions in Nigeria suggest it is the choice of most women with the uptake of 22.5%–56.7% with failure rates of 0.51% and below.,, In general, the failure rate in the 1st year of insertion is 4.1/1000 long-acting contraceptives after a single application, which is even better than that of tubal sterilisation, which is 5.5. On long-term basis, the cumulative life failure rate for Copper T 380A is 22/1000 long-acting contraceptives after a single application from the 1st to 10th year of insertion, comparable to 18.5 for tubal sterilisation. The copper-T IUCD failed in the 9th year following its insertion in the patient 6 months after her last childbirth.
Malposition and displacement of IUCD are identifiable factors for the IUCD failure. They generally occur as a result of too small uterine cavity, congenital or acquired distortion of the uterine cavity and ill-fitting by inexperienced personnel. These could be the case here based on the ultrasound scan done at 5 weeks 4 days, which showed malposition and displacement of the copper-T into the lower uterine segment, as seen on in the 5 weeks 4 days scan [Figure 1].
|Figure 1: Ultrasound at 5 weeks gestational age showing 2 gestational sacs and Copper-T in the lower uterine segment|
Click here to view
Studies have shown that expertise of the provider, copper content of IUCDs as well as the age of the woman are identifiable risk factors for IUD failure. The largest copper surface areas of IUCDs, increasing female age and no history of IUD expulsion have a significant relationship with the reduction in failure rates. levonorgestrel intrauterine system (LNG-IUS) LNG-IUS (Mirena) is the most effective of IUDS however, an age-adjusted regression analysis using LNG-IUS as reference showed pregnancy risk increased 2.7 times with copper surface of 375 mm2 (Gyne T380, MLCu375 and Gynelle 375), 7.2 times for surface of 200 mm2 and silver core (Nova T), 8.45 times for surface of 300 mm2 (Sertalia) and 24.4 for Gynaefix device. Futhermore, there are significantly low IUD failure rates for women aged 35 years or more compared to those younger., The patient presented here was, however, 37 years and was on copper T 380A; therefore, a rare occurrence for failure going by these variables. Not only did the IUCD fail, but it failed with the conception of twin pregnancy. Identifiable risk factors for twinning were advance maternal age and that she is African from the Yoruba ethnic group in southwest Nigeria, known for the highest incidence of spontaneous twin conception worldwide. The variables are similar to a 36-year-old woman who had LNG-IUS (MIrena) failure with twin pregnancy after 2 years of insertion following vaginal delivery, as reported by Kumari et al.
Management is multi-disciplinary in patients with medical conditions in pregnancy. The patient had pregnancy-induced hypertension alongside gestational diabetes; hence was co-managed with the physicians who ensured her blood pressure and blood sugar were controlled throughout the duration of the pregnancy.
The pregnancy though unplanned was, however, desirable more so that she was pregnant with twins which are seen as blessings and a thing of joy in the southwest of Nigeria where she is from. Furthermore, she had just two children before in a country where the total fertility rate is 5.7; hence the financial burden of raising two more children would not have been as bad as it would have been if her parity was high. Worth mentioning is the fact that Nigeria has restrictive laws on abortion, making the option of termination of pregnancy not readily available, thus increasing the risk of unsafe abortion with its attending morbidity or mortality. Other possible options would have been to give up the babies off for adoption after safe delivery.
Her choice to keep the pregnancy and look forward to a successful delivery was eventual. She had hoped the pregnancy would spontaneously abort and had even considered terminating the pregnancy when it was obvious the pregnancy remained viable against all odds. The vehement refusal of her husband to support termination of the pregnancy played a role in her decision to carry on with the pregnancy. This was unlike the case reported by Kumari et al. where the pregnancy was terminated via suction and evacuation under ultrasound guidance and LNG-IUS (Mirena) removed at the same sitting. Despite the choice to keep the pregnancy, she did not present to the hospital having missed her period with a positive pregnancy strip test at home and even spotting per vaginam at 6 weeks. This suggests poor health seeking behaviour as she could have been in danger. This is so against the background recommendation which requires that ectopic gestation be ruled out first once pregnancy occurs with an IUD in situ. As the cumulative ectopic pregnancy rate has been reported as 0.4% for Copper T 380A.,
Before the attempt at removal of the IUCD, the patient was counselled on the possible complications, including the possibility of the copper T IUCD eroding surrounding tissues. This was the most probable cause of the pre-labour rupture of membranes at 32 weeks of gestation. Pre-term pre-labour rupture of membranes has been reported on 7.7% of cases of failed Copper T IUCD left in situ with ongoing pregnancy. Other possible adverse pregnancy risks include miscarriage, septic abortion, chorioamnionitis, and pre-term delivery compared with the general obstetric population. The chances of success at removal would have been better if the IUCD string was protruding through the cervical os.
Earlier, when she was stable on admission, in line with high success rates with few complications in patients without visible strings as documented by Schiesser et al., attempts at removal of the IUCD based on the ultrasound report which suggested the relative possibility of access at the internal cervical os and retrieval was abortive and was abandoned for conservative management with the device left in situ and close monitoring.
She was counseled and delivered by caesarean section, which afforded the opportunity for tubal ligation as she had completed her family size.
| Conclusion|| |
Copper T IUCD though an effective long-acting reversible contraceptive option, can fail rarely with twin gestation. Management depends on the patients' choice to either terminate or continue with the pregnancy after adequate counselling. As measures to reduce failure, we recommend training and re-training of providers to improve insertion techniques. Women should also ensure they feel for the IUCD strings at least once a month for as long as they have it inserted.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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