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9/05/2018
1
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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6
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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13
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.