1. first trimester medical abortion: adherence and staff effort
follow-up after
first trimester medical abortion: adherence and staff effort
Tika Okuda1 & Kirsten Duckitt2
September 15, 2017
1University of British Columbia, Island Medical Program, BC
2 Department of Obstetrics and Gynecology, Clinical Associate Professor UBC, Campbell River, BC

2. Affiliations University of British Columbia Faculty of Medicine
University of Victoria, Island Medical Program
Island Health Authority

3. Disclosure
I have no disclosures

4. Understanding the Problem
Map notes locations of medical first trimester abortion providers
Vancouver Island is 31,285km2 and 460km long
South Isl1: (61-64)
Pop: 383,360
Central Isl1: (65-70)
Pop: 270,418
North Isl1: (71,72,84,85)
Pop: 122,233
Distance to providers can be great due to the large geographical area and limited motorways.
Eg. driving time from Port Hardy (northern end) to Campbell River is 2.5 hours. In addition multiple small Island communities are served with infrequent sailings.
This study is based in Campbell River 2:
1; Statistics Canada Campbell River [Population centre], British Columbia and British Columbia [Province] (table). Census Profile Census. Statistics Canada Catalogue no X Ottawa. Released August 2, 2017.
(accessed August 23, 2017).
1) Statistics Canada 2016 Census Population 2) Image:

5. Methods
Retrospective chart review of medical abortions following SOGC 2006 guidelines1
January December 2016
Protocol used Methotrexate and Misoprostol and successful treatment was noted by a serial drop in quantitative B-hCG of > 80%
Every patient was considered to require one from the medical provider
Lost to follow-up: inconclusive B-hCG and no response to or telephone communication
Extra correspondence: any patient requiring more than one
Completely lost to follow-up: unknown status post chart review (May 2017)
Serial labs= 1 pre treatment B-hCG and 2 subsequent tests 7 days after each other. 1)

6. Results 469 requested medical abortion services
462 prescriptions given
7 declined prescriptions
278 B-hCG drop in initial set of 2 labs
179- more than one
5 presented to ER for RPOC
5 D&C
116 < 80% B-hCG drop or less than 2 serum levels
16 no bleeding, no labs drawn
47 required extra prescriptions
15 ed in with signs & symptoms of success
57 lost to follow up
44 D&C
16 D&C
47 Successful medical abortion
33 completely lost to follow up
24 found through chart review
RPOC= retained products of conception
D&C= dilatation and curettage
Yellow= required extra communication
Red= lost to follow up
462 people requested and received counselling for the procedure.
18 successful medical abortion
6 D&C

7. Results Adherence rates 12.3% (57/462) lost to f/u Staff effort
38.7% (179/462) required extra communication

8. Results Staff effort 8.9% (16/179) emailed-in no bleeding → D&C
26.3% (47/179) required an extra prescription
24.6% (44/179) needed to return for a D&C
Compliance with serial B-hCG levels
16.3% 72/( ) had less than 2 lab tests
3.4% 15/( ) ed in signs of success
See the breakdown of s sent by the medical provider.

9. This is a retrospective chart review, which is limited to a patient population on Vancouver Island. The noted trends could be biased due to location or patient population of the provider.
Extra correspondence was set based on each patient requiring one from the care provider. However, this does not reflect the number of extra s or time required for each response.
Limitations

10. Discussion: Adherence to Follow-up and B-hCG
Patient compliance
Only 16.3% completed less than 2 B- hCG values.
Considering limited laboratory locations, barriers to travel like distance, and poor public transportation this is a small number of non compliant patients
adherence rates are acceptable
A Canadian Study from 2015 notes complete lost to f/u rates for telephone and office visits at 4.8% and 5.6% respectively1
This f/u study had a complete lost to f/u rate of 7.1%.
Of note 3.4% of the 16.3% of laboratory non-adherence ed in with perceived signs of successful medical abortion; including, return of menstruation. ing the care provider presumed signs and symptoms of a successful medical abortion is not an encouraged form of follow-up but allowed the patient to communicate with their medical provider and overcome some of the noted barriers to this patient population.
Comparing office and telephone follow-up after medical abortion.
Chen MJ, et al. Contraception Authors
Chen MJ1, Rounds KM2, Creinin MD2, Cansino C2, Hou MY2.
1)Chen MJ. et al., Comparing office and telephone follow-up after medical abortion:

11. Discussion: Staff Effort
is a viable tool
A Canadian Study on medical abortion f/u from 2015 notes 43.9% required more than one telephone call1.
The noted 38.7% of patients who required extra communication is expected.
Templates can streamline f/u
MIFEGYMISO might decrease % requiring extra communication
Clinical Pearl
The legal risks of communications are clearly outlined by the Canadian Medical Protective Association and a consent form is available2.
Each physician should look at the communication statement from their governing College of Physicians and Surgeons
Comparing office and telephone follow-up after medical abortion.
Chen MJ, et al. Contraception Authors
Chen MJ1, Rounds KM2, Creinin MD2, Cansino C2, Hou MY2.
1)Chen MJ, Comparing office and telephone follow-up after medical abortion: 2)

12. In 2016 medical abortions made up 3
In 2016 medical abortions made up 3.8% of Canadian first trimester abortions1. With the recent approval of MIFEGYMISO in Canada this number will hopeful increase..
Future studies should include and compare rural and urban populations
Pragmatic, preference trial to compare lost to f/u rates and staff effort with; office, telephone, telemedicine and follow-up
Qualitative study on patients’ perceptions of communication and privacy
Investigate barriers to physician uptake of emaeil correspondnce
Future Directions
Our site about 40% are medidal of campbell river has
MIFEGYMISO (mifepristone and misoprostol tablets) which has less teratogenic effects
1) Guilbert, E., etc., First-trimester medical abortion practices in Canada