- Ensure case-notes and appropriate documentation available.
- Check consent form is signed
- Check certificate A has 2 signatures.
- Ensure confirmed intra-uterine pregnancy.
- Complete paperwork in ICP/electronic record
- Check the patient is sure of their decision.
- Administer mifepristone 200mg PO in accordance with drug kardex. Patient may go home thereafter.
- Advise patient to return to the place of administration if she vomits within 1 hour.
- Ensure advice is given to the patient regarding pain and/or bleeding she may experience over the following 24-48 hours.
- Ensure the patient has the ward telephone number.
- Advise the patient to bring appropriate clothing for admission.
48 hours following mifepristone.
- Nurse enquires about pain/bleeding/passage of products of conception.
- Check BP, pulse and temperature.
- Explain the procedure to the patient.
- Patient is NOT routinely required to fast.
- Confirm contraceptive plan, and prescribe/administer as indicated.
- Misoprostol 800 micrograms PV.
- Diclofenac 100mg PR as prophylactic analgesia unless contraindicated. (If contra-indicated cocodamol 30/500 PO).
- Patient to use bed pan throughout procedure to aid identification of POC.
- If products ARE passed, follow the discharge procedure.
If no POC passed within 6 hours:
- If POC are not passed within 4 hours administer 400 micrograms of misoprostol sublingually.
- If no POC passed within one hour, perform speculum examination to ensure POC are not in cervix/vagina.
If POC are not identified following a second dose of misoprostol or during vaginal examination:
- If pain and bleeding are satisfactory, the patient should be discharged home. The patient should be offered either follow-up scan by appointment at Sandyford after 7-14 days or a pregnancy test after 21 days. If the patient chooses the latter option, the pregnancy test kit should be supplied to the patient on discharge. If she chooses the scan option, then Sandyford contact details should be given so that she can make an appointment.
- For patients who are <10 + 0 weeks gestation and pass what is thought to be incomplete POC – follow up is scan is NOT required. Advise the patient that bleeding is to be expected, however ensure ward contact details are given so that the patient can contact staff should they be concerned that their bleeding is heavier than anticipated.
If excessive bleeding occurs before/after POC passed:
- Perform speculum examination to evacuate clot and remove any POC identified.
- If bleeding continues contact middle grade or consultant gynaecologist.
- Fast patient.
- Site venflon.
- Check P/BP/T/O2 saturation every 15 minutes/high-flow facial O2 if bleeding continues.
- Send FBC.
- Cross-match and check clotting screen if signs of shock.
- Give misoprostol 400 micrograms sublingually.
- Give ergometrine 500 micrograms IM unless contra-indicated for the patient. This can be given at the same time as misoprostol, as it will be effective before the misoprostol has its maximum effect.
- If bleeding persists or there are clinical signs of shock (tachycardia, hypotension), an urgent surgical evacuation should be arranged by medical staff.
DISCHARGE PROCEDURE FOR ALL PATIENTS
- Record the patient’s BP, pulse and temperature prior to discharge.
- Contraception must be supplied or a contraceptive plan agreed.
- Anti-D is NOT required for rhesus negative women.
- All patients with a multiple pregnancy require a follow-up scan at Sandyford
Scan Post TOP
If scan shows RPOC < 3cm – advise patient to seek referral if increased PV bleeding, pain or offensive PV loss.
If scan shows RPOC > 3cm the patient should be offered surgical evacuation of uterus if clinically indicated i.e. excessive bleeding.
If the patient declines surgical evacuation she may be managed conservatively with anti-biotics (co-amoxiclav 375mg TID for 7 days). A further scan will be required after 7-10 days to ensure RPOC is decreasing in size.
If scan shows a continuing pregnancy the patient should be given the option of MTOP or STOP depending on their gestation.