YOUR PRACTICE LETTERHEAD <> 

Dear Family Planning Tasmania (<Preferred location>),

Thank you for seeing <PtFullName> for consideration of MTOP.

DOB: <PtDoB>
Address: <PtStreet>, <PtCity>, <PtPostcode>
Mobile number: <PtPhoneMob>

Medicare Number: <PtMCNo>     Concession Card number: <PtPensionNo>

LNMP: <LMP>

Current Gestation (dates): 

Current Gestation ( USS ):

Contraception choice post MTOP if applicable:

Allergies: 
<Reactions>

Medications: 
<SelectedRx>

Past History including obstetric: 
<PMHActive>
<ObstetricHx>

Investigations to be organised.
Please request copies of pathology tests and Imaging to be electronically sent to FPT 

• FBC, Blood Group, Quantitative HCG
• Dating Scan: Book the USS appointment. Mark request form “pregnancy options dating scan”.
• Swabs: Self obtained lower vaginal swab and first pass urine collection for chlamydia. 

Patient has been given  FPT Patient Handout on MTOP @ FPT  (pages following this referral)

Referring Doctor Details: <DrName>
Provider Number: <DrProviderNo>
Referring Doctor Signature: _____________________________
Date: <TodaysDate>

Women wishing to have an MTOP need to have an ultrasound and pathology tests done and the results of those tests need to be conveyed to the MTOP prescribing doctor with enough time for medication to be prescribed before the 63 day cut off. 

FPT will contact the patient on receipt of this referral. 

Launceston: 269 Wellington Street Fax: (03) 6343 6766
Burnie: 199 Mount Street Fax: (03) 6434 6743
Glenorchy: 421 Main Road Fax: (03) 6273 9203

Glenorchy
  421 Main Road Glenorchy 7010 
Clinic (03) 6273 9117

Launceston
261 Wellington Street, Launceston 7250
Clinic (03) 6343 4566

Burnie
199 Mount Street, Upper Burnie 7320
Clinic (03) 6431 7692

What is a medication termination?
A medication termination of pregnancy (MTOP) or abortion involves taking two (2) separate doses of different medications (tablets) for the purpose of causing a miscarriage. The effect of the medication is firstly to stop and then to expel (push out) an early pregnancy, without the need for surgery or anaesthetic. A woman can choose to have a medication abortion if the first day of her last menstrual period was less than 9 weeks ago (63 days). 
What medication is involved?
Both medications come in tablet form. The first tablet, swallowed whole, called mifepristone, works by blocking a hormone called progesterone (this hormone is necessary for a pregnancy to continue). When progesterone is blocked, the lining (endometrium) of the uterus (womb) breaks down, stopping a pregnancy from continuing. 
The second medication, dissolved in the mouth at home, called misoprostol, is taken approximately 36 hours later. Misoprostol makes the muscles of the uterus contract (tighten). This causes bleeding, cramps and a miscarriage (pushing out the early pregnancy from the womb) to take place. 

What are the more common experiences of women having a medication termination?
•	Although most miscarriages happen within 4 to 5 hours after taking the second dose of tablets, the timing of this can be unpredictable - a few (around 1 in 25) women will miscarry before they take the second dose of tablets. 
•	Some women will have nausea (on average 50 percent of women), vomiting (on average 30 percent of women), diarrhoea (on average 20 percent of women), dizziness, headaches and fever after taking the second dose of tablets. 
•	Most women will have strong period-like cramps and most women find the experience more painful than their usual period pain.
•	Bleeding can sometimes be heavy and some women will pass blood clots which may be the size of a lemon.
•	Unpredictable, irregular or prolonged bleeding can last for up to 4 weeks after treatment.
•	About 5 percent (1 in 20) of women will need to have follow up testing to check that their pregnancy has completely terminated.

What are the less common experiences of women having a medication termination?
•	Haemorrhage (very heavy bleeding), where the woman requires a blood transfusion – this happens to less than 1 in 1000 women. 
•	Infection, where the woman needs antibiotic treatment – this happens to 1 in 100 women. 
•	An ectopic pregnancy (pregnancy in the tubes) that is not diagnosed before medication is taken - this happens to 1 in 7,000 women.
•	In around 1-2 percent of cases the medication does not work and the woman may then require a surgical termination.

Who can have a medication termination?
Most women can have a medication termination, however, you should not have the treatment if you:
•	Are unsure about your decision to terminate.
•	Have ever had a reaction to the medications misoprostol or mifepristone.
•	Cannot stay close (less than one hour) to your local hospital during the time that the miscarriage is likely to happen. 
•	Do not have a support person who can stay with you from the time you take your second dose of tablets until the miscarriage has happened.
•	Cannot return to the clinic for follow up appointment. 

The treatment may not be suitable for you, if you have certain medical conditions. 
An ultrasound is essential to confirm that the pregnancy is less than 63 days and that an ectopic pregnancy (pregnancy in the fallopian tubes) is unlikely. 

What are the main steps involved in having an MTOP at FPT after you have had an ultrasound?
Phone Call:  An FPT Doctor will phone you at a pre-arranged time. The phone call will take 30 minutes and during that time the Doctor will be discussing your ultrasound result and checking whether it is safe for you to have an MTOP. 
Medication appointment. Arrive 15 mins early prior to appt. This appointment will take one hour. 
•	Your Doctor will talk to you about your long term contraceptive options. 
•	Around 15 % of women will need an injection of a blood product (Anti D) into the muscle in the upper arm to avoid problems with later pregnancies.
•	We will ask you to sign a consent form.
•	After this, the first medication, called mifepristone, is taken at a time agreed by you and the doctor. This involves swallowing one tablet with water.
•	The doctor will give you the second medication, called misoprostol to take home. You will need to take misoprostol at home usually 36 hours after taking mifepristone. Your doctor and nurse will tell you how and when to take the misoprostol tablets and also give you detailed instructions, aftercare information and a follow up appointment. 
•	The doctor will give you some other medicines to help reduce pain and nausea. 
	
Phone Call: FPT Nurse will phone you 48- 72 hours after your Medication Appointment to check on your progress. 
Appointment 3: FPT Follow Up Appointment. 
Your doctor will confirm that the MTOP has worked and check that you have no ongoing problems. If contraception has not already been started, we will talk to you about this. 

What can I expect to happen after taking each medication?
After taking medication abortion tablets, you can expect the following:
•	After taking mifepristone you may not have any symptoms or you may have some vaginal bleeding and cramps. Sometimes, the miscarriage happens before taking the second dose of tablets, if this does happen it is still important to take the second lot of medication. 
•	After taking misoprostol at home you may experience nausea, and also cramps in the lower abdomen, diarrhoea, dizziness, headaches and fever.
•	Most women pass the pregnancy (miscarry) within 4 to 5 hours of taking the second dose of tablets. This will cause heavy vaginal bleeding and cramps in the lower abdomen.
•	Some women keep having pain and cramps for the next few days and irregular vaginal bleeding can last for up to 4 weeks after.
•	Some women keep having some of the symptoms of pregnancy, including tender breasts, for around 2 weeks after.
•	It is normal for a pregnancy test to be positive for 2 to 3 weeks after the miscarriage. This is because hormone levels have not yet gone back to normal.
Managing bleeding
After taking the medication, bleeding can be much heavier than a normal period. Have maxi pads ready when you take medication. Using pads not tampons until your next period will help lessen the risk of infection.
Managing pain 
After taking the medication, you can help manage the pain and cramps by:
•	Using pain medicine such as ibuprofen or paracetamol. 
•	Resting.
•	Wearing loose, comfortable clothes.
•	Using a heat pack on your tummy.
•	Taking strong pain medication that is supplied 

How will I feel afterwards? 
Physically, most women feel better once the pregnancy has passed.
Mentally, how you feel after a medication termination will depend on the reasons for having it and how comfortable you feel about your decision. The majority of women feel relieved that they made the decision that was right for them at the time. If you do need emotional support, please let your Family Planning Tasmania doctor or nurse or GP know.

How can I prepare for a medication termination?
From the time you take misoprostol (home medication) until you have had your miscarriage:
•	You will need a responsible adult to stay with you for support and to help you look after any children or adults you care for.
•	Make sure you have enough pain medication and sanitary pads (for heavy blood flow).

What if I have any concerns? 
You will be given detailed information about what to do if you have any problems. You will be given the contact details of emergency medical services in an information sheet and a letter to take with you to if you need to see another doctor at the hospital or your GP.  

Follow up 
The doctor will give you a pathology request form for a blood test to be taken 7 to 10 days after the Medication Appointment.  This blood test is very important to confirm that the medication termination has been successful and is the ONLY way to check that the medication termination has worked. 
After approximately 2 weeks you will need to come back to the clinic for a follow up appointment. Although the termination medication is very effective, it is still extremely important to have a follow up appointment to make sure it has worked. If the medication termination has not worked, and you are still pregnant the medication can cause serious birth defects if the pregnancy continues. 
If the medication termination has not worked, we will refer you to a provider that will provide a surgical termination. 
What do I need to bring to the appointment?
You will need to bring the following to your appointment:
•	Your Medicare Card or number. 
•	Any health care or pension cards.
•	Enough money in your account for payment of the consultation. The FPT Fee Schedule is available on the FPT website: www.fpt.asn.au/clinics/fees
•	Financial assistance is available for eligible women of all ages. The FPT Nurse will assist you to apply for this funding if you are eligible. 
•	A list of any questions you would like answered.
•	You are welcome to bring a support person to the appointment, but please be aware that we will need to speak to you on your own for some of the appointment (this is to check that you are consenting to the process of your own free will).