Efficacy and safety of repeated transcervical quinacrine pellet insertions for female sterilization.

OBJECTIVE: To investigate the rates of tubal occlusion, pregnancy, and side effects of repeated, monthly transcervical insertions of 252 mg quinacrine as pellets. DESIGN: Clinical trial among 159 reproductive age women receiving two monthly transcervical insertions of 252 mg of quinacrine followed by hysterosalpingograms (HSGs) 1 month after last insertion and an additional monthly insertion among women without evidence of bilateral tubal occlusion. Contraception of women's choice provided until bilateral tubal occlusion achieved, and surgical sterilization provided for women failing to achieve bilateral tubal occlusion after third quinacrine insertion. Women were followed for at least 24 months for evidence of pregnancy or side effects. RESULTS: Among the 159 women completing the protocol, 73% had evidence of bilateral tubal occlusion by HSGs after two insertions of quinacrine pellets and 94% after a third insertion. These 149 women were followed for 24 months without a pregnancy failure or serious side effect. CONCLUSION: Transcervical applications of quinacrine as pellets have potential for safe, effective, inexpensive, and easily deliverable female sterilization.

PIP: Between January 1988 and April 1988, physicians inserted at least 2 252 mg quinacrine pellets into the uterus via the cervix (1 month apart during days 5 to 18 of consecutive menstrual cycles) in 159 34-to-39-year-old women at the outpatient clinic at Boulak El-Dakrour Hospital in Giza, Egypt. 1 month after each insertion, they used hysterosalpingograms to determine tubal patency. They inserted a 3rd pellet if at least 1 tube remained patent. The women used additional contraceptives from first insertion to 1 month after the last insertion to prevent unwanted pregnancy. The physicians followed the women for 24 months. Quinacrine-induced menstrual changes, e.g., intermenstrual bleeding (13.2%) and amenorrhea (26.4%), basically disappeared by 6 months. Quinacrine abated heavy or prolonged menses in women who suffered from it beforehand. 84.3% did not experience any complications or had no complaints related to quinacrine insertion. Occlusion occurred in both tubes after 2 insertions in 73% of cases and after 3 insertions in 93.7%. Women who did not have any bleeding experienced tubal occlusion more readily than those who did (after 2 insertions, 80.8% vs. 69.2%). In fact, absence of blood in the uterus resulted in 100% efficacy after 3 insertions compared to only 90.7% in those who did bleed (p = .02). After 3 insertions, women whose uterus was longer than 8 cm were less likely to have occluded tubes than those whose uterus was at the most 8 cm long (87.2% vs. 95.8%; p = .09). In fact, they had the lowest tubal occlusion rate. None of the women with 2 occluded tubes at 24 months became pregnant. They did not use any contraception beginning 1 month after last insertion. These results indicate that quinacrine pellets are an effective and safe method of nonsurgical sterilization.

Histopathologic changes in the cornual portion of the fallopian tube following a single transcervical insertion of quinacrine hydrochloride pellets.

To study the sequence of histopathologic changes taking place in the cornual portion of the fallopian tube subsequent to exposure to quinacrine, 252 mg were inserted transcervically in 12 women awaiting hysterectomy for non-malignant conditions of the uterus. All patients who underwent surgery within ten days of insertion were found to have necrosis of the epithelial lining and an acute inflammatory reaction. Later on, the changes observed included progressive absorption of the inflammatory cellular exudate, progressive fibrosis, with partial or almost complete occlusion of the lumen, and failure of regeneration of the epithelial lining. Our results support other studies indicating that quinacrine can effectively produce tubal fibrosis and occlusion.

The value of X-ray with uterine sound in the diagnosis of IUDs with missing tails.

Missing IUD tails may result from expulsion, retraction of filaments, uterine perforation or pregnancy. Missing IUD tails occur in 5-25% of all IUD insertions, and require a safe and correct diagnostic technique. Plain X-ray with uterine sound in utero is a popular, simple technique which does not require special skills. This study discusses the feasibility and accuracy of this method in 104 women presenting with a history of missed IUD. Twenty women with suspected pregnancy or uterine abnormalities were excluded from the study. The diagnosis was verified by examination of the patient under anesthesia, D & C, laparoscopy or laparotomy. The accuracy rate was 95.23% (80 women). The diagnosis was wrong in 4.76% (4 women) where the X-ray technique wrongly diagnosed intrauterine location of the device, while examination under anesthesia and laparoscopy located these 4 devices in an extrauterine location. Through the use of this technique it was possible to reduce the hospital stay to one day in 95% (80 patients). The technique is feasible, reliable and without complications; it is particularly suitable in hospitals where other diagnostic facilities are not available.

Obstetric deaths in Menoufia Governorate, Egypt.

A survey of all registered deaths which occurred during 1981-1983 in women of reproductive age was carried out in Menoufia Governorate, Egypt. Surviving family members were interviewed by trained social workers, and information was collected on symptoms of the disease that led to death. The completed questionnaires were reviewed by a panel of local physicians and a cause of death was assigned by the panel. Maternal mortality was a leading cause of death, second only to heart disease. There were 190 maternal deaths per 100,000 livebirths and 45 maternal deaths per 100,000 married women aged between 15 and 49 years. Most of the maternal deaths (63%) were due to direct obstetric causes of which haemorrhage was the main cause. Another 27% of the maternal deaths were due to indirect obstetric causes of which rheumatic heart disease was the main cause.

PIP: Trained social workers interviewed the families of 385 women of reproductive age who died during 1981-1983 in Menoufia Governorate, Egypt, to examine the women's characteristics, the causes of their deaths, and the proportion of maternal deaths due to pregnancy, delivery, and indirect obstetric factors. Maternal mortality accounted for 22.8% of all deaths to women in the reproductive age group. The dead women tended to be illiterate (76.3%), to have more than four children (51.9%), and to have died at home (53%) during the postpartum period (59%). 24% of the women died within six hours after the onset of complications. The leading cause of death in the reproductive age group was diseases of the circulatory system. The maternal mortality rate was 190/100,000 live births. There were 45 maternal deaths per 100,000 married women aged 15-49. 62.6% of the maternal deaths were attributed to direct obstetric causes, particularly hemorrhaging (51.9%). Indirect obstetric causes comprised 26.5% of the causes of death. The leading indirect obstetric cause of maternal death was diseases of the circulatory system (63.7%). In fact, rheumatic heart disease was the single leading indirect obstetric cause of maternal death, accounting for 35% of all maternal deaths. Abortion contributed to maternal mortality in 5.5% of cases. The study found various obstacles to improving maternal outcomes: late referral of patients, inadequate hospital facilities, and physicians inexperienced in the management of obstetric emergencies. Based on these findings, the researchers identified various recommendations: improve utilization of existing health facilities, increase the proportion of hospital deliveries, improve hospital care, develop a feasible system of confidential enquiries, and integrate maternal-child health centers with birth attendant teams, rural health units, family planning clinics, and local and district hospitals.

Maternal mortality in Giza, Egypt: magnitude, causes, and prevention.

This article presents results from a population-based study of the magnitude and causes of maternal mortality in the Giza governorate of Egypt in 1985-86. Deaths to women in the reproductive ages were identified through the death registration system. Family members of the deceased were interviewed using the "verbal autopsy" approach. Immediate and underlying causes of death were then assessed by a medical panel. This methodology allows for the classification of multiple causes of death and is appropriate when registration of adult deaths is nearly complete, but reporting on cause of death on death certificates is poor. Of all reproductive-age deaths, 19 percent were maternal deaths. The maternal mortality ratio for Giza is estimated to be, at minimum, 126 maternal deaths per 100,000 live births. The maternal mortality rate is estimated to be, at minimum, 22 maternal deaths per 100,000 women aged 15-49, over 100 times the rate in Sweden. An average of 2.3 causes per maternal death were reported; the most common causes were postpartum hemorrhage (31 percent of cases) and hypertensive diseases of pregnancy, such as toxemia and eclampsia (28 percent of cases). Women experiencing hemorrhage, hypertensive diseases of pregnancy, or other serious complications must have easy access to hospital and maternity centers equipped for handling these conditions. Since most deliveries occur at home, many with the help of traditional birth attendants, TBAs will need training in early diagnosis, treatment, and/or effective referral of problem pregnancies.

PIP: Researchers analyzed death records of 156 women who died from obstetric causes between August 1985-August 1986 collected from 5 health sectors in Giza, Egypt to examine incidence and causes of maternal deaths. Social workers interviewed family members about circumstances of the mother's pregnancy and death (verbal autopsy approach). The maternal mortality ratio stood at 126 deaths/100,000 live births and the rate stood at 22/100,000 15-49 year old women). The cumulative risk of maternal death was at least 1 in 155 women. 50% died at a maternity center or a hospital. Remaining deaths occurred at home, another person's home, en route to the hospital, or the traditional birth attendent's (TBA) home. 35-39 year old women had the highest maternal mortality rate (40.5) while 15-19 year old women had the lowest (6.6). 24% of maternal deaths occurred to women of at least parity 7. Even though family members and the medical panel concluded that medical complications (39.1% vs. 25%) such as heart failure and hemorrhage (19.2% vs. 30.7%) were the major causes of maternal mortality, the most frequently reported causes of death as determined by the medical panel were postpartum hemorrhage (31.4%), hypertensive disease of pregnancy (27.6%), and other maternal complications (25.6%) such as prolonged and obstructed labor. This discrepancy can be explained by the fact that 70% of the mothers died of multiple causes. The researchers emphasized the need to train TBAs to diagnose problem pregnancies and to treat or refer them to hospitals or maternity centers. Health professionals used the medical profiles produced for each deceased women to formulate prevention strategies for specific cause of death strategies. The leading policy implication of this study was that most of the maternal deaths could have been prevented.