Medical Termination of Pregnancy (MTOP) in WGH – The Re-audit Dr Gayatri Ranjan (Associate Specialist) Sarah Horseley (CNS Pregnancy Loss) Mattie Thomas (Gynae Services Co-ordinator) CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Background Once weekly dedicated clinic. Counselled , scanned and dates for TOP arranged. Up to 12 wks and up to 2 terminations. Mifepristone 200mgm PO , followed by misoprostol 800 microgram after 36-48 hrs ,3 doses. Follow up (2-3/52) CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Aims To assess whether we are maintaining the published high standard of care To assess whether recommendations are fulfilled from previous audit Assess the level of patient satisfaction CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Method Retrospective case note study: 1st January – 31st December 2008 GP referral letter Proforma Patient questionnaire to assess patient satisfaction CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Standard for Audit Royal College of Obstetricians & Gynaecologists Guideline: Care of women requesting induced abortion Local Hospital Guidelines CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Results CEAD Hywel Dda NHS Trust 2009

Total number of patients who attended the unit = 366 CEAD Hywel Dda NHS Trust 2009

Of the 366 patient’s who attended the unit: CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Age CEAD Hywel Dda NHS Trust 2009

GP referral to hospital appointment CEAD Hywel Dda NHS Trust 2009

Hospital appointment to 1st visit (Mifepristone) * 2 undecided, 1 some other appointment CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Gestation * 12+1 – 12+5 CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Blood Group CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Counselling 35 (12.5%) patients received counselling 2 patients had phone contact CEAD Hywel Dda NHS Trust 2009

Outcome (Misoprostol) CEAD Hywel Dda NHS Trust 2009

Of the 42 patient’s with an outcome of incomplete: Conservative Management Misoprostol = 6 Misoprostol & Evac = 1 Evacuation = 5 CEAD Hywel Dda NHS Trust 2009

Of the 17 patient’s who did not pass any product: Misoprostol = 1 Conservative Mx = 6 Surg. Evacuation = 1 Repeat MTOP with 600mg of mifepristone = 3 Repeat MTOP with 600mg (failed) – surgical Evac = 1 CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Overall Outcome No intervention needed Complete 231 SSPT –ve on f/u 13 No RPOC 9 Conservative Mx with small RPOC 18 Total 271 (93.2%) Secondary intervention Surgical Evacuation 9 Repeat MTOP 3 Misoprostol 7 Total 19 (6.5%) DNA 1 CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Complications Major complications = Nil Other complications = 20 (6.9%) Heavy bleeding requiring 3 units transfusion and evacuation = 1 (5%) Increased temperature = 5 (25%) Bleeding = 11 (55%) Increased pain = 2 (10%) Vomiting = 1 (5%) CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Hospital Stay 17 (5.8%) patients stayed overnight: ● Bleeding = 9 (1 patient stayed two nights) Social problem = 2 (Cardigan/Haverfordwest) Epileptic = 1 Increased temperature = 1 Swollen abdomen = 1 Not passed product (4th dose) = 3 CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Histopathology One patient diagnosed with Partial Molar pregnancy CEAD Hywel Dda NHS Trust 2009

Comparison Of Results With 2003 Audit CEAD Hywel Dda NHS Trust 2009

Total number of patients 2008 = 291 2003 = 288 CEAD Hywel Dda NHS Trust 2009

GP referral to Hospital appointment CEAD Hywel Dda NHS Trust 2009

Hospital appointment to 1st visit (mifepristone) CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Outcome CEAD Hywel Dda NHS Trust 2009

Secondary Interventions Overall Scores Secondary Interventions Surgical Evacuation 2008 6.5% (19 patients) 2.95% (9 patients) 2003 7.6% (22 patients) 6.2% (18 patients) CEAD Hywel Dda NHS Trust 2009

Patient Satisfaction Questionnaire Random questionnaire November 2007 – April 2008 71 answered CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009

Number of patients who answered the questionnaire = 71 CEAD Hywel Dda NHS Trust 2009

Comments/Suggestions Excellent Thanks Compassionate En-suite toilet Rooms not comfortable (hot) Something to entertain (TV/Radio) Doctors to discharge early in the morning CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Recommendations Adherence to guidelines  Patient’s to be cared for separately to other gynae patients  Change of antibiotics policy  Supply of contraception (first depot)  MTOP leaflet  Patient satisfaction survey  Infection screening  CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Action Plan Continue to maintain the high standard of care . Infection screening. Follow up (3 weeks for incomplete and 2 weeks for not passed anything). CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Acknowledgements Audit Department. Staff of Gynae Suite. Patients. CEAD Hywel Dda NHS Trust 2009

CEAD Hywel Dda NHS Trust 2009 Thank You CEAD Hywel Dda NHS Trust 2009