1. Takes place two weeks after consultation 2

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

3. 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

4. Complications of Early Medical Abortion

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. Notification

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

18. 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

19. REMUNERATION