• Confirm the pregnancy
  • Seek understanding of woman’s beliefs and wishes
    • “Wow, that’s big news, how are you feeling about it?”
  • Calculate dates
    • LMP if reliable
    • Dating ultrasound – if considering termination write ‘confirm intra-utering pregnancy between 49-63 days gestation’ or similar – this lets sonographer know that termination may be an option
  • Pathology
    • Quantitative bHCG
    • Blood group and antibodies
    • FBE
    • Other routines if unsure
    • Chlamydia/gonorrhoea PCR if considering termination
  • Any indication of trauma or coercion?
  • Risk of STI
  • Are there any signs or symptoms of ectopic pregnancy or other complication?
  • Details of pregnancy eg. date of LMP? Was it a normal period? Are they taking iodine and folate? EtOH, cigarette, other drugs?
  • Do they have information about their options and have they made a decision?
  • Emotiona state, social supports, other psycho-social information
  • If may continue, ensure basic care (e.g. supplements, avoid drugs and alcohol etc.)

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  • Consider supports, best pregnancy care options, education and investigations
  • If considering handing over the child to care of adoptive or foster parent(s) ensure this is stated in referrals
  • DHHS may have useful information for doctor and patient

Uncertain

Termination

MTOP

  • Administration of 2 medications to induce termination (MS2-Step, mifepristone and misoprostol)
  • Option up to 63 days (9 weeks)
  • Can only be prescribed by practitioners who are registered with MS Health who have done relevant training
  • The process
    • Intrauterine pregnancy <63 days confirmed
    • Contraindications discussed
      • Chronic adrenal failure
      • DIseases requiring corticosteroids (including inhaled)
      • Hypocoagulation disorders
      • Anticoagulant therapy
      • Breast feeding
    • Initial medication is administered
      • Mifepristone 200mg tablet x 1
      • Anti-progesterone medication to soften and dilate cervix and mate uterus more sensitive to prostaglandins
    • 36-48 hours after mifepristone, misoprostol taken
      • Misoprostol 200mcg x4 bucally (keep between cheek and gum for 30min prior to swallowing remaining fragments)
      • Prostaglandin effect to start uterine contractions / expulsion of contents
      • Bleeding and cramps to cause expulsion of the pregnancy occurs for most women within 3-4 hours of taking misoprostol
    • Bleeding usually continues for 10-16 days, with it being heavy for the first 2-3 days
    • F/U after 2 weeks is required to ensure there is no ongoing pregnancy – either q bHCG or US to confirm completion
    • Side effects
      • Nausea, vomiting, diarrhoea, or fevers and chills – usually <24 hours
      • Incomplete abortion 1-4% – needing surgicval suction curette
      • Ongoing pregnancy risk 1%
      • Infection <1%
      • Excessive bleeding 1:1000 – requiring transfusion

STOP

  • Legal up to 24 weeks gestation, but becomes very difficult to obtain at >12 weeks gestation
  • Process
    • Confirm intra-uterine pregnancy
    • Most occur as a short day-procedure under light IV sedation, although they can occur under local anaesthetic
    • Process takes about 15minutes
    • Cervix is dilated, then suction and curettage is performed
    • There is the option of a lARC being inserted at the same time
  • Will need a support person to drive them home
  • Risks
    • Uterine perforation or damage to cervix
    • Incomplete abortion (RPOC) in 2%
    • Ongoing pregnancy 1:500
    • Infection risk 1%
    • May be ongoing bleeding after the procedure, but usually less than MTOP