START Clinical Meeting Consultation 1 START Clinical Meeting

Overview Pre-TOP counselling Psycho-social assessment Valid Consent Assessment of Gestation Relevant medical hx STI risk Contraindications to mifepristone/misoprostol Preliminary contraception discussion Relevant physical examination Ultrasound Rhesus Testing Other investigations Certification Plan for 2nd consult, follow-up Referral & emergency pathways

Counselling & Consent Confirm certainty of decision Confirm capacity Rule out coercion Social supports during TOP Reiterate not reversible once commenced Consider independent translator Assess for child protection issues if a minor HSE & ICGP consent forms

Assessment of Gestation Dated from Day 1 of LMP Close to or >9/40 → Refer for US US if unsure of dates: 1. Irregular cycle 2. Use of hormonal contraception (including EC) 3. Breastfeeding 4. LMP lighter than normal/not at expected time GA by LMP correlates closely with ultrasound

Risk Factors for Ectopic Pregnancy Bleeding/Pain Hx of PID/Salpingitis Previous ectopic pregnancy Previous Fallopian tube surgery ART pregnancy Tubal ligation IUD in situ If + risk factor → US If signs/symptoms of ectopic → urgent referral to secondary care

Relevant Medical History VTE: Known thrombophilia or past history of same Assess for signs/symptoms anaemia Hx of haemorrhagic disease Anti-coagulant use Medical conditions that preclude use of mifepristone/misoprostol Dependence on oral/inhaled glucocorticoids

STI Risk Assessment Invite discussion re: STI screening Assess individual risk Active STI should not delay/preclude TOP Treat as per local/national guidelines – antibioticprescribing.ie

Contraindications to Mifepristone/Misoprostol ABSOLUTE Dependence on oral steroids Ectopic pregnancy Known hypersensitivity to mifepristone/misoprostol Valvular heart disease Bleeding diathesis Sickle cell/Thalassaemia Porphyria RELATIVE Chronic adrenal failure Hepatic/Renal failure Ischaemic heart disease Anti-platelet agents Mild anaemia (Hb >9.5g/dl) Thrombophilia/VTE

The following are NOT contraindications to EMA: 1. Previous C-Section 2. Obesity 3. Uterine abnormalities including fibroids 4. Chronic mild anaemia 5. Rhesus negative (but note guidelines) 6. Previous/Current multiple pregnancy Breastfeeding

Preliminary Contraception Discussion Enquire re: current contraception – was pregnancy a result of no contraception or failed contraception? Invite discussion of ongoing contraception needs Offer contraception at time of TOP if women would like (Depo/Implanon)

Relevant Physical Examination/Investigations Abdominal examination – fundal height, signs ectopic Baseline vital signs Signs anaemia High sensitivity urinary HCG FBC only if suspicion Hb <9.5g/dl Rhesus testing/Ab screen where indicated Ultrasound where indicated STI screening where appropriate

Ultrasound Not routine < 9/40 Local referral via Healthmail to Affidea Refer if: 1. Uncertainty re: dates 2. Close to or > 9/40 3. Risk factors for ectopic pregnancy 4. Patient request

Rhesus Testing If <7/40 → No need for Rh testing If ≥ 7/40 → Rh status & Ab screen at first visit If Rh negative, refer to secondary care for Anti-D Can be given from 0-72 hours after taking mifepristone If known Rh -ive and family complete, can sign disclaimer after informed discussion

Planning for 2nd Consult/Follow-Up Complete certification form if certain re: GA Complete & sign STC Arrange 2nd consult after 3-day wait elapsed Outline what will occur at 2nd visit Discuss timing of taking meds Give PIL & copy of consent forms Discuss post TOP follow-up Reassure re: future fertility/pregnancy outcome

Emergency Care Contact details for prescribing GP My Options helpline number for clinical triage Emergency number/location for local maternity unit +/- OOH number Useful to also update patient contact details & confirm preferred method of communication

Local Referral Pathways Ultrasound: - Email referral form via Healthlink - ultrasoundsupport@affidea.com Referral to secondary care (CUMH): - Phone 087 – 7037628 - Phone held by senior midwife - In emergency refer to ER