Second Visit Issues to address at second visit

Second Visit • • • Issues to address at second visit Review of medications Expected side effects, complications (when to seek help) Safety/risks of medical abortion Consent

• No requirement to repeat history/examination • Re-certification if different doctor doing second visit • Review U/S report, blood results where applicable • Medications – Mifepristone 200 mg to be taken at visit Misoprostol 800 mcg 24 -48 hours later • Patient to sign – Consent form, STC • Dr to sign – Consent form, notification to MOH

Medications • Mifepristone 200 mg PO – Take in surgery at visit 2 • Misoprostol 800 mcg (2 x 400 mcg) buccally – take 24 -48 hours later at home

Mifepristone • 200 mg taken in surgery (note not 600 mg!) • Anti-progesterone • Blocks progesterone receptors in decidua → Endometrial degeneration, detachment of trophoblast from uterus • Increases contractility of uterus (may cause mild cramping, bleeding) • Potentiates actions of misoprostol • Rapidly absorbed – peak levels 1 -2 hours (rpt if vomits < 90 mins) • Potent anti-glucocorticoid – caution in steroid dependant patients

Misoprostol (Cytotec) • Prostaglandin E 1 – 800 mcg (2 x 400 mcg) buccally • Taken 24 -48 hours later, at time and place of woman’s choosing • 1 x 400 mcg into each cheek, hold for 30 mins, then swallow residue with water. No eating or smoking during this time. • Rapid absorption and onset of action – peak levels within 30 mins • No need to repeat if vomits • Unpleasant taste • ? Give extra 400 mcg in case of no bleeding

Side Effects • Common, usually self limiting • Mifepristone – Generally well tolerated May have mild bleeding/cramping Nausea (50%), vomiting (33%) - ? Pregnancy related Repeat if vomits < 90 mins • Misoprostol – More likely to cause s/e Nausea (30%), vomiting (21%) – consider Domperidone Diarrhoea (58%) Fever/chills (45%) – may last > 8 hours Headache (13%)

Expected effects • Pain - Begins within 4 hours of taking Misoprostol (usually 1 -2 hours) - Often more severe than normal period cramps (≥ 6/10) - Pain peaks at time of expulsion - Manage with NSAID, hot water bottle etc - Products trapped in os may cause severe pain + vagal reaction • Bleeding - Usually begins within 1 -2 hours - Heavier than normal period (heavier with more advanced gestations) - May pass large clots or visible products - Heaviest bleeding within 24 hours then settles - Light bleeding typically for 2/52, but maybe up to next period - Concern if no bleeding within 4 hours of taking Misoprostol

Management of side effects

When to seek help • Ensure woman has contact details of helpline in case of concern or potential complication • After Mife – severe abdo pain or vomiting within 90 mins • After Miso - Heavy bleeding (more than 2 pads per hour x 2 hours) - Infection (Fever lasting > 24 hours, foul PV discharge, malaise, flu-like symptoms etc) - Severe abdo, pelvic or shoulder tip pain - No/light bleeding only (consider ongoing pregnancy, ectopic) - Persistent symptoms of pregnancy (‘I still feel pregnant’)

Risks of Medical Abortion • • EMA is SAFE Complication rate approx 4% - lower than risk of ongoing pregnancy Incomplete abortion requiring surgery 2. 9% Continuing pregnancy 0. 4% Haemorrhage requiring transfusion 0. 1% Infection 0. 2% Mortality - Med Journal Australia 2012, study of 11, 000 EMAs, 1 death from sepsis (had failed to follow up on symptoms) • Ectopic – no need to r/o at low gestation unless previous hx • Risk post EMA 0. 07% (compared to risk post U/S diagnosis of complete miscarriage 6%)

No increased risk of • • • Preterm birth Low birth weight Ectopic pregnancy Miscarriage Breast cancer • No long term risk to fertility if carried out safely and is not complicated by PID • Mental health – the relative risk of mental health problems among adult women who have a single, legal 1 st trimester abortion of an unwanted pregnancy is no greater than the risk among women who deliver an unwanted pregnancy.

Informed consent • Decision taken without coercion and of her own free will • Medications – how to take, mode of action, side effects, risks • Risk of failure, and possibility of surgical intervention if fails • Once started must be completed – risk of teratogenicity • Clarify contact details for helpline for any concerns • Woman agrees to take responsibility for confirming success of procedure

Summary Visit 2 • Review U/S, bloods if appropriate and agree to proceed • Informed consent • Patient to take Mifepristone 200 mg in surgery • Discuss timing of Misoprostol, how to take etc, dispense 2 x 400 mcg tablets (? ? Give extra dose of 400 mcg in case of no bleeding) • Ensure has support person and/or contact details of helpline • Agree follow up/visit 3 (may consider contacting patient after 24 hours) • Sign STC (combined STC for Visit 2+3)