High quality follow up support and care

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1 High quality follow up support and care

2 How do you think the benefits of high quality follow up care? Client satisfaction Safe and effective continuation of the method

3 What are the tasks involved in routine follow up visit? Assess client s satisfaction Assess for common side effects Screen for warning signs Address any question or concern Review key messages

4 Where do SE and Complication come from? IUD MOA and IUD insertion and removal and Infection prevention measures

5 Define terminology How to assess these? How to identify these? How to manage these?

6 How do you define side effect /complication? Side effect Unpleasant effect of IUD that happen in addition to the main effect Complication A new problem or illness following IUD insertion

7 What are side effects and complications? Side Effects Bleeding or spotting Heavy menstruation Cramping Complications Pregnancy Perforation Infection Expulsion String problems

8 What are the warning signs of possible complications? P Period related problems or pregnancy symptoms A I Abdominal pain or pain during intercourse Infection or unusual vaginal discharge N S Not feeling well, fever, chills String problems

9 How do you know possible side effects and complications? Pain Unexplained pain during uterine sounding Pain during menstruation Lower abdominal pain within 3 weeks of IUD insertion Pain during sexual intercourse SE Cx

10 How do you know possible side effects and complications? Bleeding Increase in amount of menstruation Increase in duration of menstruation Spotting between periods Bleeding accompanied by anemia Bleeding after sexual intercourse SE Cx

11 How do you know possible side effects and complications? SE Cx Fever Amenorrhea & UCG + Purulent or foul smelling discharge Missing or shorter or longer string

12 How do you assess changes in menstrual bleeding? Spotting/light bleeding between periods heavy bleeding Twice >8 days as long or twice as much prolonged as usualbleeding

13 How do you manage bleeding? Menstrual bleeding changes Very bothersome to the client within 3-6 months Continued beyond 6 months Remove IUD if she wishes Reassurance Oral iron supplement Ibuprofen or Mefanamic acid or Tranexamic acid during menstruation Suspect gynaecologic problems and refer

14 How do you assess pregnancy with an IUD in place? Missed or overdue menstrual period Pre-existing pregnancy and IUD insertion: without proper pregnancy screening Pregnancy following IUD insertion: rare

15 How do you manage pregnancy with an IUD in place? Confirm pregnancy/determine trimesters 2 nd or 3 rd trimester 1 st trimester Rule out ectopic pregnancy No ectopic pregnancy Ectopic pregnancy Leave IUD in place Closely monitor Counseling Remove IUD Refer for management pregnancy

16 How do you assess uterine perforation? During insertion procedure Sudden loss of resistance Uterine depth > expected from uterine sound Unexplained pain Discovered within few days/weeks Unexplained Pain and cramping Pain during sexual intercourse Missing string

17 How do you manage perforation? Uterine perforation During insertion procedure A few days or weeks 6 weeks or more Embedded in the wall of Ut Outside the uterus Stop the procedure Observe vital signs for 1 st hour If stable, advise to avoid sex for 2 weeks Close follow up Refer for removal

18 How do you assess Pelvic Inflammatory Disease? Fever What signs/symptoms expected? Lower abdominal pain Bleeding during sexual intercourse cervicitis Pus discharge Cervical excitation tenderness

19 How do you manage PID? Lower abdominal pain Severe Mild -moderate Remove IUD Refer No need to remove IUD Treat PID with Cefixime 400mg stat Doxycycline 100mg bd x 14 days Metronidazole 400mg bd x 14 days

20 How do you assess expulsion of IUD and string problem? Missing Shorter string Longer string Longer string with pain during sex

21 How do you manage expulsion of IUD? IUD Expulsion Partial expulsion Complete expulsion Remove IUD Rule out pregnancy and infection Rule out pregnancy Reinsert IUD Reinsert IUD

22 How do you manage missing or shorter string? Rule out pregnancy No pregnancy If pregnant Probing cervical canal Counseling and further management The strings are drawn out Leave it in place Not drawn out X-ray or USG Located inside uterus Not located (expulsion) Located outside uterus Leave it in place or removed by special trained provider Management of expulsion Management of perforation

23 What are the differences between side effect and complication of IUD? Side effects Complications Common Not serious Usually relieved over few months Rare Serious Not relieved and progressive Handled by provider May need referral

24 What are the side effects? Bleeding Cramping pain during monthly menstruation

25 What are the complications? 1. Pregnancy with IUD in place 2. Partial perforation 3. Infection that can be treated with regular course of antibiotics 4. Expulsion 5. String problems

26 What are the adverse events? 1. Unintended major surgery, including laproscopy 2. Blood loss requiring transfusion 3. Infection requiring IV antibiotics or hospital admission 4. Death

27 Thank you!

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