Third Consultation & Contraception START Waterford meeting 16/02/19

Purpose of Consultation 3 Confirm completion of termination of pregnancy Screen for and manage complications Screen for and manage any psychological concerns Discuss contraception Follow up on any STI screening results ?Consent to send report to own GP Send Notification to Minister of Health Choice of woman whether face to face or other method e.g phone

Low Sensitivity Pregnancy Tests Supplied by HSE when sign contract ORDERING MORE From PCRS website-under Account Details E-mail-PCRS.supplies@hse.ie Fax-01 8343535

Complications of Early Medical Abortion These are rare and EMA is generally a safe, well tolerated procedure.

Incomplete Abortion OPTIONS Incidence 3-5% Retained tissue or retained non-viable pregnancy Increased risk with advanced gestational age Suspect if ongoing pain/ heavy bleeding OPTIONS Referral to secondary care for further medical management or surgical care. This is the most likely option and best practice at present Observation-If haemodynamically stable and doesn`t want intervention. The retained products may pass at the next period Second dose of MISO 400mcg at home also could be considered

No bleed within 24 hrs of MISO or less than 4 days of bleeding Continuing Pregnancy Incidence 0.5-1% No bleed within 24 hrs of MISO or less than 4 days of bleeding “I still feel pregnant”-this is highly sensitive and specific. Woman should be advised to make contact as soon as possible and not to wait the 2 weeks Positive low sensitivity pregnancy test at 2 weeks (ideally should be picked up before this) Increased risk with advanced gestational age or shorter interval between MIFE and MISO Ultrasound diagnostic-cardiac activity or gestational sac present, plus rare ectopic excluded OPTIONS Referral to secondary care for further medical management or surgical care May consider repeating MISO 400mcg but this is only effective in 30% of cases

Haemorrhage The expected bleeding with EMA will be heavier than menstrual blood loss 1 in 1,000 will need a transfusion Refer if soaking more that 2 maxi pads per hour for 2 hours or if haemodynamically unstable (weak, dizzy, tachycardia etc) Lower threshold for referral if known low Hb

Pain Pain occurs after MISO, the most severe pain normally lasts no more than 45 minutes Increased risk with younger age, lower parity, history of dysmenorrhoea, history of anxiety Products trapped in the os can cause very severe pain OPTIONS NSAIDs or Opioids-PO or IM Anxiolytics eg Diazepam 5-10mg PO Hot water bottle/hot bath Remove products from the os Refer

Infection Incidence <1% Endometritis/salpingitis/undiagnosed STI/Infected retained products SYMPTOMS Abdominal or pelvic pain Foul smelling vaginal discharge Fever(>38 degrees) or chills more than 24 hrs after MISO Uterine or adnexal tenderness OPTIONS Broad spectrum antibiotics eg Doxycycline 100mg bd for one week or Co-Amoxiclav Refer if toxic/unwell, no response to oral antibiotics or suspect retained products

Hospital referral required Ectopic Pregnancy Risk of a missed ectopic pregnancy extremely low at 7/100,000 SYMPTOMS Constant lower abdominal pain on one side Unwell eg weak, faint, pale Little or no bleeding after MISO Adnexal tenderness Hospital referral required

There is no increased risk of any of the following Long Term Outcomes There is no increased risk of any of the following Preterm birth Low birth weight Ectopic pregnancy Miscarriage Infertility Breast cancer

Notification Legally obliged to notify the Minister for Health of a termination of pregnancy within 28 days of the second consultation Address Bioethics 2 Unit Department of Health Block 1 Miesian Plaza 50-58 Lower Baggot St Dublin D02 XW14

Information required Medical council number of doctor who carried out TOP In section 2 there are 4 options, tick number 4 (Early pregnancy/section 12) The county of residence (or country of residence if the woman resides outside the state) of the woman who had the TOP The date the TOP was carried out Note there is no information that would identify the woman on the form

PCRS and STCs Codes for claiming Needs Irish (ROI) patient identifier GMS, PPSN,LTI number, DPS number Does not need name Codes for claiming AH –1st visit AI - 2nd and 3rd visit combined AJ- 3rd visit

Template for 3rd Consultation Discuss procedure Opinion on 3 day wait (Audit purposes) Complications Yes/ No Low sensitivity pregnancy test done by patient is negative No symptoms of ongoing pregnancy Advised next menses should come on time i.e 4 weeks after EMA Coping emotionally Yes/ No Contraception (Consider for Audit also) STI risk assessment Consent to contact own GP Yes/ No

CONTRACEPTION POST ABORTION 39% of women who had an abortion in England and Wales in 2017 had one or more previous abortion 40% of pregnancies worldwide are unplanned (WHO) A woman can ovulate as early as 8 days post abortion 90% of women ovulate within one month Therefore post abortion contraception is a vital part of abortion provision and aftercare

Why so important? Highly motivated at this time Known not to be pregnant Currently accessing healthcare “captive audience” Reduces chances of another unintended pregnancy Chance to review contraceptive history, were they using any contraception at all? If so did it fail? If it failed why did it fail?

Contraceptive method Earliest time post medical ICGP Interim Guideline P26. Table 4: Contraception Methods and post-termination initiation timeframes Contraceptive method Earliest time post medical of initiation Earliest time of initiation termination post surgical termination Combined hormonal contraception (pills, patch or ring) Progesterone only pill Subdermal implant DPMA ( Depo-provera) Condoms & spermicide IUD/IUS Day of mifepristone As soon as intercourse resumes Once expulsion has occurred Immediately