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Paddy Moore

Royal Women’s Hospital: Choices/PAS

Medication termination of pregnancy

Opportunities and

challenges

Key elements in delivery of care

Resources available

Myths and legends

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A most dangerous drug Needs special monitoring

Pharmacists won’t stock it

High rate of failure

Many women haemorrhage and need surgery anyway

There have been many deaths overseas

Forcing women to undergo traumatic experience

Women will use this too often instead of contraception

Highly risky for the practitioner Affects insurance premiums

Practice gets targeted for adverse attention

Will be swamped by requests from patients

No clinical support available

Local hospital not supportive

Follow up is impossible

IDEAL SITUATION CURRENT CLIMATE

Personal preference Method

Length of procedure

No of appointments

Contraception provision/ convenience

Medical indications

Timing/ convenience

What is available in my region

Cost / Distance/ time off work/ family responsibilities

Confidentiality issues

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Surgical services

Locally staffed and run service with referrals from local providers

Able to respond to local need

Less travel time

Privacy / anonymity issues

MTOP service

Either run from 1 specific clinic with on site or off site pharmacy/ USS services

Group of collaborating prescribers working from their individual clinics

Early and rapid response required Essential that women have

awareness of the how and where of such a system

Developed France 1980s ru486

Antiprogestagen Works on

progesterone receptors in endometrium

Induces

abortion in 60% pregnancies< 9w

With misoprostol over 90%

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Emergency contraception

Induction of menses

Induction of abortion

1st trimester

2nd trimester

Labour in management of FDIU

Pregnancy < 63 days TGA approval and PBS listing criteria TGA approved up to 9 weeks PBS

Cost at private clinics same as or greater than for STOP

May be prescribed in th e primary care setting

Role in 2nd and 3rd trimester MTOP and mx of fetal loss

Contraindications Bleeding disorder ,ECTOPIC pregnancy ,adrenal failure, cortico steroid

dependent, porphyria, iucd in situ

Hypertension, cardiac,hepatic or liver disease,severe anaemia

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Day 1 (Clinic) Clinician counsels the woman, takes a medical history and performs an exam

and lab tests

USS to confirm intrauterine site and gestational age

Mifepristone is orally administered

Day 2-4 (Home or clinic) Misoprostol is administered and progress of miscarriage is monitored with

recourse to medical care as/when necessary

Day 7-14 (Clinic) Patient returns to the clinic for follow-up /phone contact and bhcg

Clinician assesses for the completion of the abortion Including Clinical History, Repeat BHCG( quantitative,urine) +/_ USS

Ibis Reproductive Health 9

French Regimen US: FDA Regimen Evidence-Based

Regimen

Mifepristone Dosage 600 mg (Day 1) 600 mg (Day 1) 200 mg (Day 1)

Misoprostol Dosage 400 µg, PO

Or 1mg gemeprost, PV

400 µg, PO 400 µg, PO or 800 µg, PV

Gestational Limit ≤ 49 days ≤ 49 days ≤ 63 days

Location of misoprostol

administration

At medical office/clinic At medical office/clinic At medical office/clinic

or at home

Timing of misoprostol

administration

Day 2 or 3 Day 3 Day 2, 3, or 4

Timing of initial follow-

up examination

Day 10 to 14 Day 14 Day 4 to 14

Number of clinic visits

required

Three or more Three or more Two or more

Ibis Reproductive Health 10

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93-98% leads to complete abortion

In the remainder curettage necessary to evacuate the uterus

Expectant management of RPOC is appropriate up to 2 weeks

Clinical point DO not USS everyone who

has bleeding >7 days

Effects of abortion process

Cramping Often described as similar

to menstrual cramps

Vaginal bleeding Median bleeding time 9-13

days

Often described as similar to a heavy period or spontaneous miscarriage

Common side effects

Nausea

Vomiting

Diarrhea

Headache

Dizziness

Fever, chills, hot flashes, warmth

Ibis Reproductive Health 12

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Pain and bleeding

Usually NSAIDS effective

Bleeding heavier than a period

Occasionally greater than 1 soaked pad per hour

Usually self limiting once products have been passed

Infection

Rarely severe

As significant as for surgical procedures

Warrants “screen and treat” or prophylactic antibiotics at time of misoprostol admin.

? teratogenicity Several reports misoprostol and limb defects, Mobius syndrome

Severe bleeding requiring curette 1%

Transfusion rate 0.1%

2-5% require aspiration of retained products of conception

similar to outcomes in expectant Management of miscarriage

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+ve

Choice

Ability to avoid anaesthesia

Privacy

Convenience

-ve

Prolonged bleeding

No of clinic/Dr visits

Uncertainty as to whether complete

Timing of contraception

Day 7: hCG 7 Day 3:

Gestational sac

Day 1: Gestational sac

5 mm

hCG 862

Medical abortion at a very early gestation

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OPPORTUNITIES CHALLENGES

Under new and innovative service models Provides a real alternative to surgical

procedure and attendant barriers to access i.e. rural and remote women

Community based services greatly enhanced if workable model developed

Embedding provision within a primary health care setting

Finding the most appropriate model.

Development of standardized models of care to avoid confusion and allow appropriate audit and research

Developing information and referral pathways so women meet the early gestational criteria

Follow up and contraception / Timing of Long acting reversible Contraception

ORGANISATIONAL CLINICAL

Training and support of staff

Establish Collegial links

What model of service delivery

Community awareness of service

Rapid appointment response needed

Recourse to early USS

Relationship with pharmacy

Provision of anti D

Relation ship with local services for clinical complications

Clear follow up / on call advice service essential.

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On line training and testing via Marie Stopes international MS2 website

Approx .3-4 hrs.

FRANZCOG members upload qualification

Monitoring of prescriptions continues by dispensers

Emergency MS 24 hr. advice line offered

Ongoing education for doctors/ articles webinars ,video lectures

FOR PATIENTS FOR PRESCRIBERS

Educational resources

Patient information and consent forms

Explanation of risk management programme

Explanation of 24 telephone access to nurse on call All calls recorded and complications

reported

Patient SMS service

For prescribers

Online training

Educational resources

Webinars

Video tutorials and lectures

Pertinent review articles

Find a dispenser function

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Access to early detection of pregnancy, information and advice

Liaison with local pharmacy

Provision of counselling services as needed/requested

Efficacy and safety is greatest for earlier gestations < 7 weeks

Coordinated care with

Standardised protocols

Clear follow up

Access to 24 hr advice

Availability of emergency services if necessary Clear follow-up arrangements

with the women

Engagement of /agreement with other service providers

Georgie

24 yr old

G2P0

LMP 5 weeks ago

+ home urine preg test

Request TOP

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Back packer from Germany In the area for 1 week

Staying with friend/ at her parents house

nil med hx of note

No contraindications

? Cost

? What investigations

Arrangements for day of misoprostol

Follow up

? Contraception

40 yrs old

G4 P3

Separated from children’s father

New relationship

LMP 6 weeks ago

+ preg test in office

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On the day phone contact with clinic

Heavy bleeding initially felt faint

Passed something in the toilet ?? Didn’t see it

Bleeding now settling

Advice?

Call to on call phone

Still bleeding not as heavy but every day , worse if exercises

What questions do you ask?

What advice do you give

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REFERRAL FROM GP 6 WEEKS POST MTOP

REFERRAL FROM MS 6 DAYS POST MTOP

G4P3 2NVD 1 cs MTOP 8/05/2017 at 8 weeks 3 days bleeding and clots then settled (Nurse

Phone call) Having Bhcg with Gp DNA for iud on 9/6/17 as bleeding returned Bhcg 14/6 = 8 USS 21/06/2017 disrupted endometrium Vascular area in E.C. 6x22x16 ? Rpoc ? Polyp

Management ?

G4 P3

MTOP 2o/06/17 at 6 weeks 1day

Min blood loss

25/06/17 sudden and very heavy

Soaking 2+pads /hour

Attended MMC..expectant Mx

26/2017 attended MS uss indicated sac low in cavity ?? CX ectopic .?? RPOC

Management ?

THIEN

MTOP last week through local GP

Got her script here

Still experiencing pain and some bleeding

Requests stronger pain relief

What questions do you ask

Next Steps?

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Advice re clinical set up

Guideline development to fit local situation

Mentorship/support

Referral pathway

Local service providers can contract personnel and skills.

ALL Require LOCAL partnerships.