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Learning ObjectivesAt the end of this lesson, you will be able to:
Describe patient care immediately following a Quinacrine insertion.
List the four important counseling points to discuss post-procedure.
List common side effects and discuss their management.
List possible complications and discuss their management.
Patient Care Immediately After the ProcedureAs mentioned earlier, the client should remain lying down for about one hour after the insertion. This is recommended for two reasons: first, to avoid the risk of fainting, dizziness or nausea; second, because it is not yet known to what extent this may further ensure that the liquid quinacrine flows into the tubes. There is no medical reason not to resume any physical activity after the one hour recovery period. However, this should be contingent on how comfortable, physically or mentally, your client feels. This includes sexual intercourse. Quinacrine has not been found to irritate the penis.
Post-procedure CounselingAs discussed earlier, the client and her husband are much more likely to be satisfied with their choice if they have been properly counseled prior to their decision. All topics discussed below should have been discussed, perhaps to a lesser extent, with the client prior to the procedure.
After the first insertion, the client should be counseled on four topics:
1) scheduling the second Quinacrine insertion;
2) use of a backup method for the next 12 weeks;
3) signs and symptoms of potential side effects and complications; and
4) management of side effects or complications.
1. Scheduling The Second Insertion
First, you should discuss the necessity and timing of the second insertion. Studies have shown that the QS failure rate can be decreased by half when a 2nd insertion is performed. You should stress the fact that the QS procedure requires 2 insertions in order to be successful.
The second insertion should be scheduled for approximately 28 days after the first insertion, 6 to 12 days after the onset of the client's next menstrual period. If she is unable to make her next appointment, she should be counseled about the importance of using a backup method of contraception and returning for her second insertion two months later during this same time period.
2. Contraceptive Backup Methods
A contraceptive should be used starting the day of the first insertion and continuing for two months after the second insertion. In other words, it should be used for a total of 12 weeks. This ensures that during the period when the plug of scar tissue is forming, the chances of pregnancy will remain low. Options for contraceptives during this period include:
Barrier methods, such as condoms or spermicides, including foaming tablets and foam (especially if client is at risk for STDs, including HIV)
Injectables
Oral contraceptives
3. Possible Side Effects and Complications: Signs and Symptoms
As discussed in Chapter 1, nearly half of all women complain of one of the following transient side effects. The counselor should emphasize that these side effects are normal and usually last from a few hours to a few days. They do not require treatment unless the woman is uncomfortable and requests treatment. Management of these side effects is provided in a table in the following section.
Cramping, lower abdominal pain and backaches, similar to those often experienced during an IUD insertion (9-25 percent of women report these)
Headache and dizziness (9-20 percent)
Feeling hot, though not feverish (9-10 percent)
Backache (1-21 percent)
Yellow discharge, vaginal itching and irritation, caused by the leakage of quinacrine into the vagina (1-23 percent)
Discharge (5-16 percent)
Oligomenorrhea or amenorrhea, lasting for several months while the endometrium repairs itself (1-20 percent)
Infection of the uterine cavity (endometris)
Method Failure resulting in ectopic or tubal pregnancy. It is critical that each client is aware of the signs of a tubal pregnancy and knows how and where to seek diagnosis and treatment. She may experience any one or more of the following signs:
a missed period
severe pain in the lower abdomen
dizziness or fainting, weakness
vaginal bleeding (other than that associated with
the normal menstrual period)
tender breasts and other signs of pregnancy
Uterine Perforation
Pelvic inflammatory disease
Hematometra
Menstrual irregularities
Anaphylactic Reaction
Management of Side Effects and ComplicationsThe following tables will show the most serious health problems and complications associated with Quinacrine insertions and the steps to evaluate and manage these as well as commonly-encountered side effects.
SIDE EFFECT OR PROBLEM | ASSESSMENT | MANAGEMENT |
Anaphylactic Reaction | See Appendix E | See Appendix E |
Vaginal discharge | Most reported cases of "discharge" are only the yellow quinacrine. If purulent discharge is present, rule out cervicitis or PID | Treat cervicitis or PID if present. Yellow discharge is transient and requires reassurance only. |
Dyspareunia | Rule out PID or emotional problems | Treat infection if present; reassure client, if no infection |
Ectopic pregnancy | Amenorrhea or irregular bleeding with or without symptoms of pregnancy, pelvic pain or tenderness, or palpable adnexal mass | Refer to appropriate facility for complete evaluation |
Headache | Rule out hypertension and visual disturbance | Treat specific disorder. Most cases are transient, requiring reassurance and aspirin or an antiprostaglandin. |
Hematometra | Absence of menses, pelvic pain, uterine enlargement | Pass sound through obstruction of cervical canal |
Itching (pruritis) | Evidence of contact dermatitis or more severe allergic reaction | Mild reactions are self-limited and require counseling or hydrocortisone cream. Rare, severe allergic reactions require hospitalization |
Lower abdominal pain | Rule out ectopic pregnancy or PID | Treat specific condition. Most cases are transient and controlled with aspirin or an antiprostaglandin |
Menstrual irregularities | Rule out PID, dysfunctional uterine bleeding, cancer of the cervix or endometrium, cervical or uterine polyps, abnormal perimenopausal bleeding, leimyomata and postcoital spotting | For most cases, the condition is transient, requiring counseling; if persistant, definitive diagnosis and specific treatment are required |
Pain on urination | Urinanalysis to rule out urinary tract infection | Treat urinary tract infection if present, otherwise reassure client |
Suspected uterineperforation | The sound or inserter advances beyond the estimated length of the uterine cavity and cervix | The sound or inserter is removed. Closely observe for signs of infection or internal hemorrhage. Take blood pressure and pulse every 15 minutes for 90 minutes. From resting position, have client sit up rapidly. Observe for signs of syncope or pulse greater than 120/minute.If negative after 2 hours, discharge with instruction for warning signs which would require immediate return to the clinic.If the quinacrine pellets were inserted into the peritoneal cavity, severe pelvic pain is to be expected. This may last for a few days and be accompanied by tinnitus. Besides medication to control severe pelvic pain, aggressive treatment of signs of infection is needed. Symptoms of shock will require exploratory laparotomy. |
Uterine synechia | May be detected on sounding of uterus or in hysteroscopic examination | No treatment indicated if asymptomatic. Adhesions can be lysed, if painful. |
Client Take-home MaterialsIn Appendix B of this manual, you will find a sample of a QS brochure for clients. If your client is literate, giving her a copy of this material or a similar type of take-home material can act as a reminder of some of the post-procedure issues we have discussed in this chapter.
End of lesson. Proceed to the case study.
Case Study VClient X comes into the clinic very distressed. Having heard from neighbors that it is very dangerous to have a tubal pregnancy she feels certain that the strange side effects she is having are related to a tubal pregnancy. She presents with the following symptoms: headache, yellow discharge and itching.
Is client X having a tubal pregnancy?
If not, what should she have been told during her post-procedure counseling session that might have prevented her from becoming distressed and making a trip to the clinic?
Check your answers against those provided on page 49.Return to the chapter text for any information you did not understand.
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