Copper T 380A

The copper T 380A is a T-shaped polyethylene intrauterine device with 380 mm² of exposed copper and the longest duration of any intrauterine contraceptive, up to 12 years. It is the most widely used copper device in public facilities, can be inserted at interval, postpartum and postabortion visits, and is the most effective emergency contraceptive available.

Design. The frame measures 32 mm across the arms and 36 mm in length and contains barium sulphate for radio-opacity. Copper wire on the stem provides 314 mm² and a copper sleeve on each arm provides 33 mm². A 3 mm bulb at the base of the stem reduces cervical injury, and two threads pass through it.

Mechanism. Continuous copper ion release impairs sperm motility and viability and creates a sterile inflammatory endometrial reaction that prevents fertilisation.

Effectiveness. About 6 pregnancies per 1,000 women in the first year with perfect use and 8 per 1,000 with typical use.

Onset, duration and return to fertility. Protection starts at insertion and lasts up to 12 years. Fertility returns immediately on removal.

Ideal candidates. Patients wanting long-term, nonhormonal, user-independent contraception; breastfeeding patients; patients with cardiovascular, thrombotic, hepatic or oncological contraindications to hormones; patients on rifampicin, antiseizure medicines or antiretroviral therapy; and those needing emergency contraception.

Examination. Bimanual examination to assess uterine size, position and tenderness, and speculum examination of the cervix. Do not insert if cervical motion tenderness, purulent discharge or adnexal tenderness is present.

Uterine size. A uterine cavity sounding under 6 cm, or a cavity distorted by fibroids or anomalies, is category 4. The usual sounding depth is 6 to 9 cm.

Key categories. Category 1 within 48 hours postpartum, after first-trimester abortion, in hypertension, thromboembolic disease, ischaemic heart disease, migraine, liver disease and breast cancer. Category 2 for heavy menstrual bleeding, severe dysmenorrhoea, anaemia, sickle cell disease and age under 18 with nulliparity. Category 3 at 48 hours to 4 weeks postpartum. Category 4 with current pelvic infection, puerperal sepsis, unexplained vaginal bleeding before evaluation, and pelvic tuberculosis.

Counselling points. Explain the insertion, expected bleeding increase, cramping for 24 to 48 hours after insertion, how to feel the threads, the lack of STI and HIV protection, and the right to removal on request.

Regimen line. Copper T 380A, 380 mm² copper intrauterine device; transcervical insertion; start within 12 days of menses start or at any time if reasonably certain not pregnant, within 48 hours or from 4 weeks postpartum, immediately after uncomplicated first or second-trimester abortion, or within 5 days of unprotected sex as emergency contraception; no backup needed in any situation; effective up to 12 years; no interactions; no adjustment for weight, liver or kidney disease.

Insertion essentials.

• Load the device in the sterile package without touching the arms (no-touch loading) and insert within minutes of folding the arms to preserve their memory.
• Apply a tenaculum, sound the uterus, set the depth gauge to the sounded length, and release the arms at the fundus by withdrawing the inserter tube while holding the plunger still.
• Cut the threads 3 cm from the external os.

Postpartum insertion. Post-placental insertion within 10 minutes of placental delivery by long placental forceps or a dedicated postpartum inserter; at caesarean section through the uterine incision before closure; or within 48 hours of birth. Leave threads uncut at the time of post-placental insertion.

Follow up. Review at 3 to 6 weeks. If threads are not felt, give backup and arrange ultrasound, or X-ray if ultrasound does not show the device.

Duration and perimenopause. Replace at 12 years. A device inserted at 40 or over may remain until 12 months after the last menstrual period, then be removed.

Removal. Grasp the threads with forceps and apply steady gentle traction. If threads are absent, locate by ultrasound before attempting retrieval with a thread retriever or alligator forceps.

Bleeding and cramping. Heavier and longer menses and dysmenorrhoea in the first 3 to 6 months. Give ibuprofen 400 mg orally three times daily with food for 5 days during bleeding (maximum 2.4 g daily) or mefenamic acid 500 mg orally three times daily for up to 5 days. Tranexamic acid 1 g orally three times daily for up to 4 days may be added for heavy bleeding if there is no thromboembolic history.

Thread or stem contact during coitus. Usually from threads cut too short or partial expulsion. Examine; if partially expelled, remove and replace.

Expulsion. About 1 in 20 in the first year, and higher after post-placental insertion. Confirm complete expulsion by the patient’s report, ultrasound or X-ray, exclude pregnancy and reinsert or provide another method. Remove a partially expelled device.

Perforation. About 1 to 2 for every 1,000 insertions. If suspected during insertion, stop, withdraw the instruments, observe vital signs and abdominal signs, and refer for surgical review if pain is severe or vital signs change.

Infection. Treat pelvic inflammatory disease with the device in place; remove only if there is no clinical improvement after 48 to 72 hours of antibiotics.

Referral and escalation. Refer for a device embedded in the cervix or myometrium, suspected extrauterine device, ectopic pregnancy or sepsis.