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

2. 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

3. Low Sensitivity Pregnancy Tests
Supplied by HSE when sign contract
ORDERING MORE
From PCRS website-under Account Details
Fax

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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?

19. 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