Implementation of a mTOPservice within a QLD Sexual

Health Clinic

Children by Choice: Unplanned Pregnancy & Abortion in Australia Conference:

4th August 2017

Donna Pini – Nurse Practitioner Mackay Sexual Health Clinic

Introduction: Implementation: • 6 month process:

• Initial discussion: O& G Director & Exec. Dir. of Clinical Services

• Liaise with Committees

• Credentialing Committee

• Medication M’ment Committee

• Policy & Procedure Committee

• Clinical Forms Committee

Implementation Contd:

• VMO registered as MS-2 Step Medical Prescriber

• Registered community pharmacy

• Red Cross Blood Service: anti D stock

mTOP Workplace Instruction & Clinical mTOP Tool

Methods

• Cross-sectional survey

• First 19 months of service

• Descriptive of outcomes

Audit Results

1st Nov 2015 – 30th June 2017 (19 months)

Demographics:

No. of clients 90

Aboriginal/TSI status 8 (9%)

Postcode 67 (74%) lived at 4740/41 postcodes16 (18%) lived at Mackay HHS rural/remote

postcodes7 (8%) lived outside Mackay HHS postcodes

Age 14 – 16yrs: 1 (1%)16 – 18 yrs: 6 (7%)> 18 yrs: 83 (92%)

Medicare Ineligible 3 (3%)

Audit Results contd:1st Nov. 2015 – 30th June 2017 (19months)

Pre-procedure:

Client request for mTOP to 1st

assessment date is < 7 days100%

2nd mTOP request at Mackay SHS

3 clients (3%)

Consent form signed 100%

Offered analgesia and anti-emetic scripts

98% offered anti-emetic script100% offered analgesia script

Audit results contd:

1st Nov 2015 – 30th June 2017 (19 months)

Outcomes:

% who had successful mTOP procedure + f/up BHCG resolution

68 clients (76%)

% requiring curettage for RPOC 13 clients (14%)

% requiring a blood transfusion 1 client (1%)

% unsuccessful requiring referral for surgical TOP 1 client (1%)

% with adverse reactions to medications 0%

% diagnosed and treated for post mTOP infection 1 client (1%)

% of Rh neg women who received anti-D 83% ( 10 out of 12 clients)

Audit results contd:

1st Nov 2015 – 3oth June 2017

Follow up:

% DNA at 2 week f/up appt 12 (13%) did not attend follow up appt

% pre-procedural STI’s treated and followed up

4 (4%) STI diagnosis

Contraceptive uptake

LARC’s v non-LARC’s

LARC15 clients (17%) Depo15 clients (17%) Implanon NXT12 clients (13%) Mirena IUDNon-LARC20 clients (22%) (OCP)Other16 clients (18%) unknown (lost to f/up)2 clients (2%) referral for tubal ligation6 clients (7%) partner vasectomy3 clients (3%) declined contraceptive scripting

Discussion: Contraception post mTOP

• OCP immediately post misoprostol• Depo 1 week later• Implanon NXT same day • IUD with next period

• Review: • Faculty of Sexual & Reproductive Healthcare (UK) (2017).

Contraception after Pregnancy• Family Planning NSW, Victoria & True Relationships &

Reproductive Health (2016). Contraception: An AustralianClinical Practice Handbook (4th ed.).

Discussion - Lessons learnt

• Children by choice website: Aiming to offer service only to those living within Mackay HHS

• Positive anecdotal feedback

• Caution with clients re: safety issues

Lessons learnt: contd.

• Refer onto other organisations

• Costs may be a constraint

• eg: Tabbott Foundation, Marie Stopes

Lessons learnt: contd.

• LARC uptake poor, mirena insertion unavailable

• Contraceptive scripting with mTOP

• Stolen script pad

Discussion – Lessons Learnt

• Curettage rate: expected 2-7%

• Higher than expected 14%

• ? False positive USS

Pelvic USS after mTOP to diagnose RPOC

Difficult Case

• AC, 21yrs old, first pregnancy

• Presented at 7 weeks – anxious

• 27/3: Given script (told take first dose 3pm tues 28/3)

• Planned to go to friends house on Thur 30/3

• 30/3: Collapsed after misoprostol – hospitalised, bleeding heavily, vomited within an hour of taking - admitted

• 31/3 Re-given 800mg misoprostol

• 1/4 : Discharged Hb 9 – told to take iron

• 13/4: Sexual health follow up – commenced depot provera, BHCG 1891 IU/L

• 21/4 Re-presented sexual health dizzy and tired, bleeding hb78

• 21/4 Admitted MBH, 2 units blood, USS RPOC, D and C

Conclusions

• Successful service

• Underestimated need

• Unexpected demographic

• LARC uptake disappointing