First trimester termination of pregnancy – challenges in secondary care

1. First trimester termination of pregnancy – challenges in secondary care Dr. Noirin Russell Consultant obstetrician and gynaecologist, maternal fetal medicine specialist

2. Conflicts of interest • Daughter  • Sister • Wife • Mother • Friend • Doctor/ Obstetrician & Gynaecologist/ Maternal Fetal Medicine Specialist  • Pro-choice • Pro-life • Advocate for termination of pregnancy • Advocate for perinatal palliative care Twitter addict ! • Big Pharma do not pay me money

3. Numbers • USS • EMA in hospital • Hospital resources • Other concerns

4. Patients- how many? In 2016, 415 women from South South-West Hospital Group (SSWHG) accessed abortion services in England and Wales • 241 Cork • 56 Waterford • 49 Kerry • 69 Tipperary • The National Women and Infants Health Programme (NWIHP) estimate 10,000 women will access abortion annually • WHO estimate 12,000 per annum • SSWHG 20% of Irish births (circa 14,000 pa) => 20% of TOP ? 2000- 2400 pa

5. Ultrasound • Which patients? • Which staff? • What training? • Where?

6. Ultrasound –which patients? • The literature does not support routine ultrasound pre EMA • The risk of missed ectopic after EMA is 7 per 100,000 Cleland et al Obstet Gynecol 2013 • Most pregnant people are accurate in dating their pregnancies with over 90% identifying their LMP and estimating GA accurately Schonberg et al Contraception 2014 • HOWEVER, most common reason for referral will be uncertainty regarding gestational age • USS must be readily available and easily accessible in a timely manner • ALL women > GA 9 weeks (63 days )?

7. Ultrasound – which staff? • A national commitment exists to providing anomaly scans for all pregnant people (National Maternity Strategy, 2016; NWIHP Implementation Plan 2017). • Neither dating nor anomaly scans are universally provided by all maternity hospitals in Ireland in 2018. • Pregnant people being referred for a pre-TOP scan will be ‘competing’ with people who need a dating or anomaly scan. • Hospitals may have to choose between providing one service or the other as they do not have the staffing levels to provide both. • Possible conscientious objection by midwife sonographers?? • Need for USS in community setting – GP/ IFPA/other

8. Ultrasound- What training? • Ultrasound in early pregnancy is complex • potential for error is high • appropriately trained staff essential

9. Ultrasound- Where? In CUMH, dedicated early pregnancy clinic (Aislinnsuite) • 5 days a week, 8am-1pm • Staff - 2 sonographers, SHOs on a rotational basis and 1 secretarial staff BUT • Is this the ideal location for pre TOP scans? • Have to be separate lists at different time • ? Community based – GP / IFPA/ Radiology/other

11. USS- resources • Ideal – regular weekly “pre-TOP” lists and access to emergency scans • Challenges • service will be “competing” with the existing USS commitments • Only 1/19 Early Pregnancy Units in Irish maternity hospitals have consultant sessions allocated • Majority of EPU currently staffed by sonographers with cover from a doctor in training

12. Complications after EMA • How common are complications post EMA? • Where will these women present ? • How do we best look after them?

13. Efficacy and safety of medical abortion using mifepristone and buccal misoprostol through 63 days (n=13,373) Gatter et al contraception 2015 • Infection requiring hospitalisation 0.01% 29-35days: 1 case 43-49 days: 1 case 50-63 days: 0 cases Blood transfusion requiring hospitalisation 0.03% • 22-28 days: 1 case • 29-49 days: 0 cases • 50-56 days: 3 cases • 57-63 days: 0 cases • Aspiration for pain/bleeding 1.8% • 43-49 days: 1.43% • 50-56 days: 2.04% • 57-63 days: 2.49% • Continuing pregnancy 0.5% • 36-42 days 0.15% • 43-49 dasy 0.27% • 50-56 days 0.73% • 57-63 days 1.63%

14. Early Medical Abortion using low dose mifepristone followed by buccal misoprostol: a large Australian observational study (n=11,155) Goldstone et al MJA Sept 2012 • Retrospective study of 13,345 EMAs (<63days) • Follow up data for 11,155 EMAs (83.4%) • Complication rate 3.5% • Incomplete abortion requring surgical aspiration – 2.9% • Continuing pregnancy – 0.6% • Haemorrhage – 0.1% • Known/Suspected infection – 0.2%

15. EMA in primary care • Private • Woman centred • At home at a timing of her choice • Safe • Low complication rate • EMA in hospital • post EMA complications • when GA > 63 days post LMP

16. Early pregnancy attendances at the ER Staffing 3 midwifes Trainee doctor “cover”

17. Patients needing abortion care in hospital • Patients requiring TOP post 63 days will be “competing” for beds and theatre access with • patients having medical and surgical evacuations for early and late pregnancy loss • elective gynaecology patients, many of whom have waited for over one year to have their surgery • REALITY- If an “emergency” TOP needs an inpatient bed +/- theatre slot => a gynaecology patient’s elective surgery will be cancelled • Potential for workplace conflict between Gynaecologists. Gynae-oncologists, uro-gynaecologists, fertility specialists and endometriosis specialists Dedicated funding must provided for protected scans, inpatient beds and theatre slots . EMA in primary care cannot be safely provided without ring fenced resources in secondary care.

18. Who will perform surgical TOP? • It is very different to ask Obstetricians & Gynaecologists if they support right to choice versus whether they personally would be happy to facilitate medical TOP or perform a surgical TOP. • - urgent requirement for values clarification training in this area for obstetric, theatre nursing, and anaesthetic staff. It is a reality, that has never been publicly addressed, that MANY Obstetricians and Gynaecologists will not perform TOP (especially surgical)

19. Surgical evacuation (ERPC) risks • Intrauterine adhesions/ Asherman’s syndrome 0.7% • Uterine perforation (0.6-0.8%) • Intra-abdominal trauma 0.1% • Cervical damage • Haemorrhage • Infection (2-3%) • Repeat procedure 2% • GA in pregnancy Additional challenges with surgical TOP Ossification if fetal bones Loss of bodily integrity of the fetus

20. Ongoing pregnancy post TOP The risk of ongoing pregnancy post medical TOP is 0.5% • Follow up ultrasound is not routinely advised • Follow up urine hCG is essential and needs to be arranged by the provider at time of administering misoprostol • Risk of teratogenicity from the medications used Given the litigious environment surrounding medical practice in Ireland, this is a serious cause for concern and necessitates detailed pathways of care and legal advice!

21. Anti-D • Evidence does not support anti-D at GA <9/40 (63 days) • If surgical evacuation, anti D recommended • If medical evacuation after 9/40 , evidence conflicted but probably in favour of administering

22. Final concerns

23. Private provider clinics vs. public hospitals • Concerns within the medical community regarding the safety of women and staff if this service is provided in an easily identifiable stand-alone site. • Governament appear “committed” to provide a publicly funded, publicly provided, community –led local service. • HOWEVER major resources will be required!!!

24. Expectation vs reality discrepancy • Clinical lead appointed last week! • No clinical guidelines • No implementation plan • No ring-fenced resources • No agreed model of care • No consideration of regional differences • No attempt to get all stakeholders together

25. Staff morale • Obstetrics /Gynaecology • Cervical Check • Gynaecology waiting lists • HIE/ birth asphyxia/ rising medical claims • Consultant recruitment crisis • General practice • FEMPI • GP recruitment crisis No attempt to prepare hospital staff for culture change - disruptive, personally & professionally challenging and unwanted by many • Zero work on staff engagement Knowledge that doctors will be blamed if service not high quality!

26. Stakeholders (to name but a few….) • Department of Health • Minister • CMO • HSE programmes • NWIHP • Sexual Health and Crisis Pregnancy Programme • Perinatal Mental Health / Clinical Programme Lead • Bereavement Standards Programme • Professional bodies • IOG • RCPI • College of Anaesthetists • ICGP • NMBI • Other agencies • Crisis pregnancy agency • IFPA • Dublin well woman clinic • Dublin rape crisis clinic • Cork sexual health centre • NWCI • Abortionrights.ie • Others?

27. Differing opinions Anecdote and opinion Evidence based best practice

28. Conclusion • We are not the first country to introduce a termination of pregnancy service • We should learn from experience of others • Need to stop working in silos • Need to bring all stakeholders together • We can and should provide a safe, accessible, high quality abortion service • but will it be ready for January 2019????????????

29. “No law that has ever been passed and no law that ever will ever be passed can prevent a determined woman from trying to end an unwanted pregnancy. Society and hospitals must accept their role in keeping women safe in that process.” • John J Sciarra, Emeritus Professor of Obstetrics and Gynaecology, past president of FIGO (2013)