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 Possibly commence contraception-pills, implant, depo.

ARE YOU FEELING OVERWHELMED?

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%)

People who have unwanted pregnancy have higher rates of mental illness than the general population. A review of 180- studies found that women who have an abortion do NOT have higher rates of mental illness than women who decide to carry their pregnancy to term.

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

“How to take Misoprostol” TAKE IBUBROFEN 600MGS BEFORE TAKING YOUR MISOPROSTOL Your doctor has given you 2 tablets of Misoprostol 400mcg to take home. This medication is to be used no earlier than 24 hours (but between 24 and 48 hours later) after taking the Mifepristone at the Doctor’s surgery. It will be absorbed quickly, helped by wetting the tablet. Hold for 30 minutes.

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

Early medical abortion: efficiency in % 20 15 10 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Before miso (hours after misoprostol) unknown uncertain More than 24 h later Time to expulsion of the sac in 1720 women with successful termination of pregnancy. The women took mifepristone on day 1 and misoprostol 48 hours later. Uncertain means expulsion at some point during 24 hours following misoprostol. Unknown means expulsion at some point later than 24 after misoprostol. Source: The New England Journal of Medicine, 1998; 338 (18): 1244 Medical abortion - clinical aspects, C. Fiala

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%)

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)