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

2. No requirement to repeat history/examination
Re-certification if different doctor doing second visit
Review U/S report, blood results where applicable
Medications – Mifepristone 200mg to be taken at visit
Misoprostol 800mcg hours later
Patient to sign – Consent form, STC
Dr to sign – Consent form, notification to MOH

3. Medications Mifepristone 200mg PO – Take in surgery at visit 2
Misoprostol 800mcg (2 x 400mcg) buccally – take hours later at home

4. 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

5. Misoprostol (Cytotec)
Prostaglandin E1 – 800mcg (2 x 400mcg) buccally
Taken 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
? Give extra 400mcg in case of no bleeding

6. 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%)

7. 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

8. Management of side effects

9. 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’)

10. 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%)

11. 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.

12. 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

14. 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)