1. START Clinical Meeting
Consultation 1
START Clinical Meeting

2. 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

3. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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)

12. 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

13. 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

15. 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

16. 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

17. 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

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