Aunty Jane in Practice: What Clinicians Need to Know

August 2023 marked a significant milestone for sexual and reproductive health access in Australia. Legislative and procedural changes reduced barriers for general practitioners (GPs) and pharmacists to prescribe and dispense the medical abortion (mifepristone and misoprostol). Historically, these professionals were required to undertake additional training and registration, which had poor uptake nationwide. This contributed to substantial barriers, particularly for people in rural and remote areas, in accessing abortion services.

These changes include:

• GPs are no longer required to undergo mandatory training, registration, or re-registration to prescribe the medical abortion.
• Pharmacists are no longer required to register to dispense medical abortion medication.
• The PBS scripting process has been simplified to Streamlined Authority.
• Nurse Practitioners and Endorsed Midwives are now authorised to prescribe medical abortion medication.

For decades, abortion services in Australia have primarily been managed by the private sector, leading to a deskilling of public sector clinicians in handling pre- and post-abortion care. This article provides clinicians with essential insights into best practices for managing medical termination of pregnancy (MTOP) in light of these changes.

To Scan or Not to Scan

Before MTOP

Eighty percent (80%) of clients do not require an ultrasound prior to MTOP. Adopting a no-scan protocol can reduce unnecessary barriers to access without compromising client safety. However, clinicians should carefully assess eligibility for no-scan protocols based on the following criteria:

Eligibility for No-Scan MTOP- https://www.health.qld.gov.au/__data/assets/pdf_file/0024/1361436/f-top-no-scan-mtop.pdf

After MTOP

Retained Products of Conception (RPOC)

Routine pelvic ultrasounds within six weeks after a termination are not required unless clinically indicated. Unnecessary ultrasounds can cause undue stress for clients and may lead to avoidable misoprostol administration or surgical interventions (e.g., dilation and curettage, D&C). Ultrasound findings should complement clinical reasoning and assessment of client signs and symptoms.

Signs and Symptoms Indicating Clinical Need for Ultrasound:

• Prolonged or excessive bleeding.
• Persistent cramps or lower abdominal pain.
• Uterine tenderness.
• Fever (suggesting endometritis).
• Visible tissue at the cervical os.

Diagnosing RPOC

Diagnosis may be made based on:

• History: Prolonged or heavy bleeding, pain, or fever.
• Examination: Uterine tenderness or visible tissue.
• Ultrasound Findings: Endometrial thickening and heterogeneous, echogenic material in the uterus.

Management of RPOC should be tailored to the severity of symptoms and client preferences. Ultrasound findings alone should not dictate surgical intervention if the client is otherwise well.

Management Options:

1. Conservative (Expectant) Management:
   • Mild symptoms may resolve naturally with subsequent vaginal bleeding or the next menstrual period.
2. Medical Management:
   • Misoprostol dosing for incomplete abortion:
     • 800 mcg buccally as a single dose.
     • If tissue does not pass within 4 hours, follow with 400 mcg buccally as a single dose.
3. Surgical Management:
   • Persistent heavy bleeding or cramping typically requires surgical intervention.
   • Clients should be briefly consulted on the D&C process and referred to either private or public services as appropriate.
   • Clinicians should prepare a written referral and contact the Early Pregnancy Assessment and Management (EPAM) or gynecology team where possible.

Conclusion

The changes implemented in 2023 represent a significant step forward in improving access to abortion care in Australia. As clinicians, it is essential to remain informed and confident in managing both pre- and post-abortion care. This ensures that clients can access safe, evidence-based care while avoiding unnecessary interventions or stress. By adopting streamlined processes and leveraging the broader prescribing capabilities of nurse practitioners and midwives, we can collectively reduce barriers to essential sexual and reproductive health services.

The information provided on this website by Aunty Jane in any format or medium, are for general information purposes only and are not intended as medical advice or as a substitute for consultation with a qualified healthcare professional. The information made available by Aunty Jane do not provide personalised medical advice, diagnosis, or treatment.  To the extent permitted by law, Aunty Jane disclaims all liability for any outcomes resulting from reliance on the information provided.  For specific medical concerns, please consult a qualified healthcare professional.

1. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG): Clinical Guidelines for Abortion Care. Available at: https://ranzcog.edu.au
2. Queensland Health: Medical termination at or less than 63 days of pregnancy. Available at: https://www.health.qld.gov.au/__data/assets/pdf_file/0034/735298/f-top-ms.pdf
3. BJOG: An International Journal of Obstetrics & Gynaecology: Effectiveness, safety and acceptability of no-test medical abortion (termination of pregnancy) provided via telemedicine: a national cohort study. Available at: https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.16668
4. Royal Women's Hospital: Early Medical Abortion Clinical Pathway. Available at: https://www.thewomens.org.au/health-professionals/clinical-resources/early-medical-abortion-ema/ema-clinical-pathway
5. World Health Organization (WHO): Abortion Care Guideline. Available at: https://www.who.int/publications/i/item/9789240039483
6. Royal Hospital for Women Guidelines: Guidelines for the management of patients with problems in early pregnancy. Available at: https://www.seslhd.health.nsw.gov.au/sites/default/files/groups/Royal_Hospital_for_Women/docs/GuidelinesfortheManagementofpatientswithProblemsinEarlyPregnancy.pdf
7. Auckland District Health Board's Miscarriage Management Guidelines: Miscarriage: Expectant, medical, and surgical management. Available at: https://nationalwomenshealth.adhb.govt.nz/assets/Womens-health/Documents/Policies-and-guidelines/Miscarriage-Expectant-Medical-and-Surgical-Management-.pdf
8. Journal of Obstetrics and Gynecology of India: Conservative management of incomplete miscarriage: A review. Available at: https://link.springer.com/article/10.1007/s13224-023-01873-6
9. European Journal of Obstetrics & Gynecology and Reproductive Biology: Wait-and-see strategy for retained products of conception. Available at: https://www.ejog.org/article/S0301-2115(19)30302-1/abstract