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 200mg to be taken at visit Misoprostol 800mcg 24-48 hours later Patient to sign – Consent form, STC Dr to sign – Consent form, notification to MOH

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

Mifepristone 200mg taken in surgery (note not 600mg!) 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 E1 – 800mcg (2 x 400mcg) buccally Taken 24-48 hours later, at time and place of woman’s choosing 1 x 400mcg 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 400mcg 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 1st 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 200mg in surgery Discuss timing of Misoprostol, how to take etc, dispense 2 x 400mcg tablets (?? Give extra dose of 400mcg 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)