Medical abortion in primary care

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Welcome to the Australian Prescriber Podcast. My name is Ashlea Broomfield and I'm here with Professor Deborah Bateson, who is the Medical director of Family Planning New South Wales and who has also co-authored the inaugural chapter on medical termination of pregnancy in the Australian Therapeutic Guidelines and is also a medical termination of pregnancy provider. And from here on in we're going to be referring to medical termination of pregnancy as MTOP. Welcome to the podcast.

Thank you.

So, Deborah tell me why you decided to write an article for Australian Prescriber on MTOP.

It's a really good question. So, the reason that myself and my co-authors knew we had to write this article is because we know that medical abortion, or MTOP, it's ideally suited to general practice. We know GPs have that trusted relationship with women they want to come to have that provision with their local GP. But we know that very few GPs actually provide it. So somewhere around 2000, I think it was 2850 out of the workforce of around 41,000 GPs. So we wanted to really demystify it and just give that advice about the fact it's not a scary thing, there's good guidance, there's good information to support you and now of course we've got the guidelines and this article as well.

So, now there's the article which describes what is MTOP, what the medications are, how they work, some of the considerations in terms of potential higher risk of complications. The article also says that to be accredited to prescribe MTOP, you need to do further training, which I think is a really important point to make it.

It is. You can't prescribe unless you've actually done the online MS Health training. Takes about three to four hours, it's online and it just provides you with that information, and this is a little bit of a taster in a way.

So, what is MTOP and how is it different from a surgical termination of pregnancy?

So, an MTOP is an abortion, which occurs through the use of medications. And there's two medications. Mifepristone, it blocks progesterone and stops the pregnancy. Then that's followed by the second step, that's the misoprostol, that's a prostaglandin and that softens the cervix and contracts the uterus to expel the pregnancy. Obviously, with surgical abortion, it entails going to a clinic, it's usually under sedation. It's often a on-step process. It tends to be a bit more expensive than MTOP. There’s a small risk of complications and obviously there're some people where the anaesthetic risk is going to mean that it's preferable to have an MTOP. With MTOP, women really value that autonomy, that privacy, that convenience. We can actually deliver MTOP entirely by Telehealth. For women with obesity, for instance, MTOP is preferred because again, you haven't got that anaesthetic risk.

It's fine for multiple pregnancies, suitable in breastfeeding. But I think again, people need to be aware of what's going to happen. It doesn't entail expected bleeding and cramping. So, someone needs to have a support person and be relatively close to emergency services in those rare cases of complications, but it's just providing that information so people can make that choice. Firstly, you might see someone because someone's got an unintended pregnancy and we know that most people have actually made their mind up about whether they're going to terminate the pregnancy or continue the pregnancy. Sometimes they may need some additional support or counselling. Once someone's made that decision about proceeding with an abortion, it's giving that information to support their decision around whether it's a medical versus a surgical abortion.

In terms of the timing of the difference, when is the MTOP no longer able to be used in terms of duration of pregnancy?

That's a very important point. So, obviously gestation is important. It's licensed up to and including day 63, up to 63 days. So, obviously, if you're seeing someone beyond that gestation, then they're not eligible for medical abortion, it needs to be a surgical abortion, but yes, up to that time and we'll talk about the investigations we do need to make sure it's an intrauterine pregnancy and we need to confirm that with an ultrasound.

So, I guess you're referring there to wanting to exclude an ectopic pregnancy.

Yes, it's really important. We are doing some research into very early medical abortion. It's really important in the current status quo that you confirm that you see an intrauterine pregnancy, that's either a yolk sac or a fetal pole. It's usually visible between about five to six weeks of pregnancy. So, sometimes we don't want to do ultrasounds too early because then the woman will end up having to have a repeat ultrasound.

So, we're really looking at a duration of use between six weeks and nine weeks of pregnancy then?

Something like that. It depends when that pregnancy becomes visible.

And the two biggest complications that I talk with women about is the risk of bleeding and the risk of it not working. Could you talk us through some of those?

There's a few complications because even if you are not prescribing, you may see people who've had an abortion of course, so important to know. The first one is a small risk of very heavy bleeding, requiring a transfusion. It’s a very low risk, 0.1%. So, it's important to warn people when they need to present to hospital and we've got guidance. That's a very good printable information sheet you can give to your patients actually, which tells them what's too much bleeding and when to go to a hospital, so that's important. It's a contraindication to be on an anticoagulant or have a bleeding disorder, someone with severe anemia wouldn't be a good choice. The next complication you mentioned is a continuing pregnancy and that occurs, again rare, about 0.8% of pregnancies. What happens there is that the woman will take the mifepristone, that's followed 36 to 48 hours later by the misoprostol, and really that's when the abortion process starts.

It can be a small amount of bleeding. Sometimes even the pregnancy may be passed before the misoprostol, but we want women to take the misoprostol. What we would know, so we have a system we've talked about in the article, it's important to follow people up around three days later, just to listen to what's happened, listen that they've had the expected bleeding, the expected cramping, and if they haven't, it can mean that there's a continuing pregnancy. And then you would need to confirm that usually with ultrasound, not always but generally we would do that, and then you can either offer a repeat medical abortion if they're within that nine weeks or they may opt to a surgical abortion. There's a couple of other complications that you need to be aware of.

There's a low risk of severe infection of the upper genital tract, so endometritis. The signs can be quite subtle sometimes. So, if someone is having ongoing pain, if certainly if they've got fever or malodorous vaginal discharge, just feeling faint or unwell, then it could indicate an infection and that needs to be treated immediately. And then the last one, Ashlea, which is the most common one I suppose, is retained products of conception, which can occur in up to 3–5% of women having an MTOP. It's signified by ongoing bleeding, that's sometimes with pain, it can be associated with infection.

There’re good clear guidelines on how to manage this. And it's important to be aware of what the expected bleeding patterns are. So the women know as well what's out of the ordinary and needs attention. You're guided by the symptoms, how much bleeding there is, again whether there's any pain, you might do an ultrasound, check the quantity of the retained products, what it's looking like on the ultrasound and you can either do expectant management or you can give some extra doses of the misoprostol, sometimes you might do a surgical curettage. But the main thing is not to feel worried about these complications. Obviously, women need to know about them, but there's very straightforward guidance on how to manage them as well.

So, those quite severe complications, the incidence is actually quite low and even in terms of the retained products, that the majority of women are passing complete products.

It's great actually, we have got very large studies that have been done across the Marie Stopes Clinics. Fifteen thousand women in the second series and we've got good robust data, which highlights how safe medical abortion is.

I remember that being a big concern, early on when MTOP was introduced, that particularly amongst GPs being concerned about then referring on if there was a complication or retained products to their gynecology specialist colleagues for dealing with the outcomes.

Yes, that's important actually and I know because actually Family Planning in New South Wales, we introduced MTOP and then later surgical abortion at the beginning of 2020, and certainly those were some anxieties that people had. You could manage the majority of complications yourself, but if you do need referral to a public hospital setting, what we're finding is it's important to have those pathways in place and luckily there are changes going on across the country. There's also communities of practice, there’s one called AusCAPPS, where providers of MTOP or would-be providers can talk to other peers and get that advice and support. When it was first introduced, I think that GPs could feel a bit isolated and not have that peer support, but that's all changed.

So, now that MTOP is a bit more widely available for people who aren't willing to prescribe for their own ethical reasons, where can they refer to now? Because part of the legislation is that if you can't provide it, you need to refer on and because there’s much more access, how can people go about referring?

Yes, thank you for the question. So, we do know that some GPs, they won't be providing themselves and now the legislation has changed across many of the states and territories and of course there is that requirement to refer on in a timely manner. So, there are different resources in different states. So, in New South Wales there's now a New South Wales Health government website and there's actually a phone line which can be used by providers as well as consumers to find out about the nearest provider. More and more Family Planning organisations are providing medical abortion as well and slowly we are overcoming that stigma I suppose associated with medical abortion. But the other key thing of course is that we know Family Planning New South Wales, many services, Marie Stopes are offering Telehealth and that's a really important development.

And I think it was really interesting that you did say in the considerations for MTOP, if you're not within a tertiary centre that could deal with a bleeding complication of two hours, that was a useful consideration.

When we say tertiary centre it's a public hospital setting, but can provide a blood transfusion. I think that's what we need to be able to say. And I know that some people may say, look, that's quite restrictive if we're thinking about the Northern territory, large distances, so it's not an absolute of course, but you do need to let your patient know that they do need to be able to access hospital services in those rare cases of complications.

And I guess people that come to see them are also used to traveling for services, so it might just be giving the advice to do the MTOP in a location that you're supported emotionally and in terms of proximity.

I think that's right. And I think that support that you've mentioned actually is really important. We do want the patient for those 24 hours really as soon as the misoprostol has been taken because the cramping and the bleeding can start usually within the first one to four hours after taking the misoprostol and people do need that support. If there are young children at home, someone needs to be looking after the children and just in the rare case that someone does feel unwell and needs to get to a hospital, then you need that support person to take them. And we provide information, as many services do, to take along to the hospital so the person doesn't need to go through their story. It's all written down and so the emergency department understands what's going on.

For the women who are not sure about what they would like to do with the pregnancy, how are MTOP providers supported in terms of the process to counsel women for and against?

So, MTOP providers can undertake some training and to be able to provide that non-directive counselling. And in fact patients can access up to three Medicare-rebated sessions. They could come to somewhere like a Family Planning organisation, there's social workers, psychologists who offer this. The state-based websites will provide that information about where to access that counselling but GPs are very well equipped of course, to provide that counselling as well.

So, what's in it for GPs?

That's a very nice question. There's a lot in it for GPs actually, because we know that GPs are hugely trusted members of the medical world and trusted by their patients and so for women to be able to feel that they can go to their trusted GP, to not be judged of course, and to receive this treatment is an excellent thing. And it's very satisfying for GPs that been involved in some of our research. So, they really value being able to provide that care to their patients. So, their patients don't have to go somewhere else. They don't have to be referred to another service. They can then meet other needs such as their contraceptive needs as well, can be just a very satisfying part of practice really, where you really are offering that holistic care as part of reproductive healthcare.

How can clinicians access the MTOP training if they finish listening to this and decide that that's something that they want to do?

So, the mandatory training is to just go online and literally put in MS Health medical abortion training. It's free of course, there's no charge associated with it. You can do it in bits and pieces or do it in a single go. So, that's the mandatory report. Then there's other additional courses, Family Planning New South Wales, we've got an online course and as I've mentioned the communities of practice as well, there's all those resources, but the essential is to be able to do that. It's not available at the moment for nurses, but that may change.

Another thing to mention I suppose is we talked about hospital access, but the other access you do need is the pharmacy access. So, it's good to have a friendly pharmacist that you know because not all pharmacists will stock the medications. They actually just need to be registered and it's an individual pharmacist rather than a pharmacy.

And so for all of our pharmacy listeners out there, how would they go about being someone who can provide that service?

The pharmacists just need to register on the MS Health website as well. There's actually no mandatory training, but there is excellent training through the Pharmaceutical Society just to support your practice as well, which is always useful. But again, you do need to be registered on the MS Health website.

And can practice nurses do the MS Health training as part of being part of the general practice team if they’re not a prescriber?

Not at the moment, but I do believe that this may change soon, which will be good because we know that nurses actually play a really important role. The nurses provide that day three follow-up, and then there is a requirement actually for a follow-up consultation, two to three weeks after the abortion. That's just to check that everything's gone according to plan, exclude any complications, but also to make sure that any contraceptive needs are met and people are feeling well supported after their abortion.

Are there any other considerations when we're arranging MTOP outside of the process of the medications and the process of the termination?

I think it's important to explain that it's very normal to feel some emotion associated with an abortion and that can include a feeling of sadness or grief, but we know that these are usually short lived and often there's relief as well of course. So, there is no association with adverse mental health outcomes associated with an abortion, although for a person with a history of mental health disorder, they may need some additional supportive care. I suppose the other thing is around some of the precautions – like insulin-independent diabetes and difficult-to-control asthma – again, the GP’s in an ideal position to be able to manage those because they know their patient intimately and they know what's going on with their health care.

I think we could say that they're probably covered in the training modules and the articles so that if someone was interested, then they can go and have a look or do the training. As a GP, if I'm listening to this and I'm not a prescriber and I haven't done the training, what would make me want to go and do the training? And I think we've had that discussion. It's easy, it should be part of a generalist skill set. It's got enough data behind it now that people can feel confident that it's safe to do in the community and there's adequate support.

It's amazing actually. Pushed all these good things forwards and we don't need anti-D anymore and all that stuff. We've caught up with the rest of the world and the Blood Authority has changed its guidance which is great.

Thank you so much for joining us, Deborah. It was lovely catching up with you again on the podcast here at Australian Prescriber.

An absolute pleasure, Ashlea. Thank you.

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