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

No requirement to repeat history/examination Re-certification if different doctor doing second visit Review U/S report, blood results where applicable Confirm that woman wishes to proceed 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

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.

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 Option to 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’)

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

Planning for Consultation 3/Follow-up Low sensitivity pregnancy test (detects HCG > 1000 iu) – to be taken at 2/52 after Mife – Should be NEGATIVE ‘High’ sensitivity test, HCG >25, likely to still be positive at this point, but negative by 4/52 Arrange with woman how/when follow up will take place Encourage face to face follow up, espec if required for contraception etc. Ensure correct contact details - ? Consider making contact after 24 hours

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)