Takes place two weeks after consultation 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

Third consultation need not be face to face Low sensitivity pregnancy test can be done at home in conjunction with a follow up phonecall from the GP Multiple consultations may not suit everyone due to eg distance, transport issues, work commitments, childcare issues. Also some women may already have had more that 2 consulations if they had Ultrasound or Anti-D

Complications of Early Medical Abortion

Incomplete Abortion Incidence 3-5% Retained tissue or retained non-viable pregnancy Increased risk with advanced gestational age Suspect if ongoing pain/ heavy bleeding

Management of Incomplete Abortion 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 or 800mcg at home also could be considered

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

Management of Continuing Pregnancy Referral to secondary care for further medical management or surgical care May consider repeating MISO 800mcg but this is only effective in 30% of cases

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

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

Management of pain NSAIDs or Opioids-PO or IM Anxiolytics eg Diazepam 5-10mg PO Hot water bottle/hot bath Remove products from the os Refer

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

Management of infection 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

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

Long Term Outcomes There is no increased risk of any of the following Preterm birth Low birth weight Ectopic pregnancy Miscarriage Infertility Breast cancer

Notification

We are legally obliged to notify the Minister for Health of a termination of pregnancy within 28 days of the second consultation

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

REMUNERATION