Consultation 3 Takes place two weeks after consultation

Consultation 3 Takes place two weeks after consultation 2

Purpose of Consultation 3 • Confirm completion of termination of pregnancy • Screen for and manage complications • Screen for and manage any psychological concerns • Discuss contraception • Follow up on any STI screening results • ? Consent to send report to own GP • Send Notification to Minister of Health

• Third consultation need not be face to face • Low sensitivity pregnancy test can be done at home in conjunction with a follow up phonecall from the GP • Multiple consultations may not suit everyone due to eg distance, transport issues, work commitments, childcare issues. Also some women may already have had more that 2 consulations if they had Ultrasound or Anti-D

Complications of Early Medical Abortion

Incomplete Abortion • Incidence 3 -5% • Retained tissue or retained non-viable pregnancy • Increased risk with advanced gestational age • Suspect if ongoing pain/ heavy bleeding

Management of Incomplete Abortion • OPTIONS • Referral to secondary care for further medical management or surgical care. This is the most likely option and best practice at present • Observation-If haemodynamically stable and doesn`t want intervention. The retained products may pass at the next period • Second dose of MISO 400 mcg or 800 mcg at home also could be considered

Continuing Pregnancy • Incidence 0. 5 -1% • No bleed within 24 hrs of MISO or less than 4 days of bleeding • “I still feel pregnant”-this is highly sensitive and specific. Woman should be advised to make contact as soon as possible and not to wait the 2 weeks • Positive low sensitivity pregnancy test at 2 weeks (ideally should be picked up before this) • Increased risk with advanced gestational age or shorter interval between MIFE and MISO • Ultrasound diagnostic-cardiac activity or gestational sac present, plus rare ectopic excluded

Management of Continuing Pregnancy • Referral to secondary care for further medical management or surgical care • May consider repeating MISO 800 mcg but this is only effective in 30% of cases

Haemorrhage • The expected bleeding with EMA will be heavier than menstrual blood loss • 1 in 1, 000 will need a transfusion • Refer if soaking more that 2 maxi pads per hour for 2 hours or if haemodynamically unstable (weak, dizzy, tachycardia etc) • Lower threshold for referral if known low Hb

Pain • Pain occurs after MISO, the most severe pain normally lasts no more than 45 minutes • Increased risk with younger age, lower parity, history of dysmenorrhoea, history of anxiety • Products trapped in the os can cause very severe pain

Management of pain • NSAIDs or Opioids-PO or IM • Anxiolytics eg Diazepam 5 -10 mg PO • Hot water bottle/hot bath • Remove products from the os • Refer

Infection • Incidence <1% • Endometritis/salpingitis/undiagnosed STI/Infected retained products • SYMPTOMS • Abdominal or pelvic pain • Foul smelling vaginal discharge • Fever(>38 degrees) or chills more than 24 hrs after MISO • Uterine or adnexal tenderness

Management of infection • Broad spectrum antibiotics eg Doxycycline 100 mg bd for one week or Co-Amoxiclav • Refer if toxic/unwell, no response to oral antibiotics or suspect retained products

Ectopic Pregnancy • Risk of a missed ectopic pregnancy extremely low at 7/100, 000 • SYMPTOMS • Constant lower abdominal pain on one side • Unwell eg weak, faint, pale • Little or no bleeding after MISO • Adnexal tenderness • Hospital referral required

Long Term Outcomes • There is no increased risk of any of the following • Preterm birth • Low birth weight • Ectopic pregnancy • Miscarriage • Infertility • Breast cancer

Notification

We are legally obliged to notify the Minister for Health of a termination of pregnancy within 28 days of the second consultation

Information required • Medical council number of doctor who carried out TOP • In section 2 there are 4 options, tick number 4 (Early pregnancy/section 12) • The county of residence (or country of residence if the woman resides outside the state) of the woman who had the TOP • The date the TOP was carried out • Note there is no information that would identify the woman on the form

REMUNERATION