CHAPTER 3 TEACHING POINTS: PRE-ABORTION EVALUATION

EXERCISE 3.1

Purpose: To review key steps in early pregnancy evaluation and pregnancy dating.

  1. A 25-year old G1 P0 patient calls your office for a telehealth visit about options for an undesired pregnancy, following a positive home pregnancy test.
    1. What history do you need to appropriately triage the patient?
      • Start with current history including LMP, last unprotected sex, recent contraceptive use, pregnancy symptoms, results of recent pregnancy tests, and review of ectopic symptoms and risks (vaginal spotting, unilateral abdominal pain, history of ectopic or PID, IUD in place at time of conception).
      • If not already established, review how the patient feels about this pregnancy.
      • Review medications, allergies, past medical, surgical, gynecological, and obstetric history. Note any chronic medical conditions, history of anemia, hemorrhagic disorders, Rh type if known, history of STIs, prior pregnancy history and outcomes, and history of abdominal surgeries.
      • See xx for abortion medical history form.
    2. How will you determine the patient’s estimated gestational age?
      • In early first trimester (<70 days) pregnancy, LMP alone has been shown to be an accurate means of estimating gestational age with low rates of under- or over-estimation in abortion evaluation to mid first trimester or 63 days (Bracken 2011, Schonberg 2014, MacCaulay 2019)
      • Pairing bimanual exam with LMP dating may increase the accuracy of gestational age estimation but is not required to proceed with a medication or aspiration abortion (Bracken 2011).
      • If estimated pregnancy dating by LMP >70 days, LMP is uncertain beyond +/- 1 week, or if there are any signs or symptoms of ectopic pregnancy, an ultrasound may be warranted (Bracken 2011, Raymond 2020).
    3. What additional diagnostic data would you consider obtaining?
      • No labs are required unless:
      • Rh if EGA >56 days and unknown Rh (Mark 2019, Horvath 2020, Hollenbach 2019)
      • Hgb or Hct only if recent history and / or symptoms of anemia
      • CT / GC if symptoms or risk factors (See Chapter 5)
      • Tests pertinent to underlying conditions
        1. Glucose for patients with insulin-dependent diabetes mellitus
        2. INR for patients on certain anti-coagulants (Warfarin) > 12 weeks

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EXERCISE 3.2

Purpose: To review appropriate uses for different types of pregnancy tests. For each scenario, indicate whether you would use clinical assessment alone, a high sensitivity urine pregnancy test (HSPT), or a serum quantitative hCG test and why; and / or answer related questions.

  1. A 20-year-old G2 P1 patient at 4 weeks 2 days by LMP comes to your office requesting pregnancy confirmation and to discuss options.
    • A HSPT is the most useful test to confirm an early pregnancy, both for home and office-based confirmation of pregnancy.
    • A HSPT can detect levels as low as 20 mIU/ml. These levels may be seen in urine as early as a week after conception or before a missed period (although 95% sensitivity may not be reached until cycle day 32-35). Up to 10% of pregnancies have a negative HSPT at the time of missed menses, due often to delayed ovulation & implantation and to variable hCG concentrations in urine (Paul 2009; p.67). Furthermore, not all HSPT tests are the same; some detect hCG levels at 20 mlU/ml, while others at 50 mIU/ml.
    • If positive, assess if pregnancy is desired, and proceed with clinical dating. If negative, patient should retest in a week if menses does not start.

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  1. A 27-year-old G3 P2 patient is 6 weeks by LMP with a pregnancy of unknown location (transvaginal ultrasound examination shows no intrauterine gestational sac and no ectopic pregnancy). The patient has been spotting intermittently but is otherwise asymptomatic.  The quantitative hCG you draw comes back at 1000, and another 48 hours later comes back at 1400. 
    1. What is the differential diagnosis?
      • Research indicates that the minimum expected hCG rise for a viable IUP is 35-53% at 48 hours. This patient’s hCG rise is 40% in 48 hours.  The differential still includes early pregnancy loss, ectopic, and early viable pregnancy. The hCG patterns need to be combined with EGA and clinical symptoms when clinically managing patients.
    2. Would your approach to care differ with a desired vs. undesired pregnancy?
      • According to prediction models (Morse 2012), 99.9% of viable IUPs will have a rise in hCG of at least 35% in 48 hours. However, because some viable IUPs will have a slower rise, it is important to obtain a third hCG measurement and repeat the ultrasound if the pregnancy is desired (Zee 2014).
      • If the pregnancy is undesired, offer a diagnostic uterine aspiration, because that will expedite the evaluation for possible ectopic pregnancy.  If pregnancy tissue is found in the aspirate, an ectopic pregnancy can be ruled out.  In the more likely case that pregnancy tissue is not found, a repeat hCG level 24-48 hours after the aspiration will be helpful.  If the gestational sac was aspirated, the hCG level will drop by more than 50%.  If the patient is symptomatic or the hCG does not drop by 50%, an ectopic pregnancy becomes more likely, and a referral is warranted.

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  1. A 32-year-old G2 P1 patient returns for a follow-up visit 5 weeks after a first trimester aspiration because of intermittent bleeding since their procedure, and have been sexually active since the uterine aspiration.
    • The HSPT is helpful if negative, but can stay positive 4+ weeks post-abortion.
    • If there are ongoing symptoms or signs of pregnancy or retained tissue, consider serial hCGs to assess trend. Repeat US may also be helpful.

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EXERCISE 3.3

Purpose: To review key information about ultrasound in early pregnancy.

  1. What is the differential diagnosis of the following ultrasound findings? What steps would you take to clarify the diagnosis?
    1. A 36-year-old G4 P2 patient at 5 weeks by LMP. In the longitudinal view of the uterus, a gestational sac is elliptical, fundal and eccentric to the midline. Mean sac diameter is 18 mm with no yolk sac or embryo visible.
      • This is an intrauterine gestational sac. The mean sac diameter of 16-24 mm with no yolk sac or embryo is highly suggestive of a non-viable pregnancy in this case, although early viable pregnancy and ectopic are still in the differential. If the mean sac diameter was ≥25 mm without an embryo, it would be diagnostic of early pregnancy loss (anembryonic pregnancy).
      • If a pregnancy is undesired, there would be no reason to delay uterine aspiration to wait for diagnosis; and diagnostic aspiration will assist in the evaluation of a possible ectopic pregnancy.
      • If a pregnancy is desired, diagnosis will be clarified by repeating US in 7-10 days.
    2. Embryonic pole length 8 mm with no visible cardiac activity
      • Embryonic pole length > 7 mm with no cardiac activity is diagnostic for early pregnancy loss (Doubilet 2013). Management options including aspiration, medication, or expectant management.  See Chapter 8 for more on EPL counseling and management.
    3. A 24-year-old G2 P1patient at 5 weeks and 3 days by LMP reports having intermittent right-sided pelvic pain and cramping. On ultrasound, you visualize a small 3 mm x 3 mm intrauterine fluid collection in the endometrial canal. The shape of the collection is triangular and there is no double decidual sign.
      • This case is concerning for ectopic pregnancy. By 5 3/7 weeks, or 38 days, the mean sac diameter should be 8 mm. A normal sac should also be eccentrically placed and not centrally located in the uterine cavity. Combined with the unilateral cramping pain, findings consistent with a pseudosac should prompt ectopic pregnancy workup.
    4. A 30-year-old G3 P0 patient reports they are 10 weeks by LMP and having intermittent spotting. On ultrasound, there is a flattened gestational sac without embryo or yolk sac, with cystic changes in the decidua present resembling “swiss cheese”.
      • This suggests molar pregnancy, which may appear with heterogeneous or mixed-density echoes on ultrasound. The classic moth-eaten, “swiss cheese” or “snowstorm” appearance on ultrasound may not be visible until 9-10 weeks EGA.
      • For suspected molar pregnancy, is tissue diagnosis is needed, so uterine aspiration is recommended over medication abortion. If uterine size is over 12 weeks, refer for inpatient management due to increased bleeding risk.
      • When aspiration is performed, tissue should be sent for pathologic examination, and baseline serum hCG obtained. If molar pregnancy is confirmed, hCGs should be monitored according to established protocols (ACOG 2004).

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EXERCISE 3.4

Purpose: To consider management of case scenarios prior to uterine aspiration.   Not all material is covered in the Chapter.

  1. A 41-year-old G4 P3 patient presents for aspiration at 5 weeks LMP. Pelvic examination reveals an irregular uterus that is 17 weeks in size. Ultrasound examination shows a 5-week intrauterine gestation and multiple uterine fibroids.
    • Because aspiration procedures may be incomplete in patients with fibroids, a discussion is warranted about the patient’s preference between a medication abortion vs. procedural abortion.
    • Rarely, a small gestational sac can be high in the fundus “behind” the curve of large or multiple fibroids, and it may be very difficult to reach. Refer to a higher-level setting with an experienced provider if necessary.
    • Consider checking hemoglobin, as patients with significant fibroids can be anemic, and also may bleed more than others during abortion.
    • Ultrasound guidance may be a helpful adjunct to any procedure with fibroids.

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  1. A 17-year-old G1 P0 patient who is 5 weeks pregnant presents for uterine aspiration. As you insert the speculum, the cervix looks inflamed and friable and has pus at the os.
    • CT / GC testing and initiation of empiric pre-procedural treatment is indicated, as cervical infection with these pathogens increases risk of post-abortal endometritis (Achilles 2011). Uterine aspiration should not be postponed. An appropriate treatment regimen (CDC 2015 Guidelines) includes:
      • Chlamydia: Azithromycin 1 gm single oral dose OR Doxycycline 100 mg orally twice daily for 7 days are the recommended regimens.
      • Gonorrhea: Ceftriaxone 250 mg intramuscular PLUS treatment for Chlamydia.
    • Symptomatic BV at the time of aspiration should be treated with metronidazole 500 mg orally twice daily for 7 days, without need to delay the abortion.

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  1. 40-year-old G4P3 patient at 7w4d presents for an abortion procedure. They have a BMI of 35 and a history of three previous cesareans.
    • The patient’s BMI and previous cesarean sections put this patient in the moderate risk category for hemorrhage (Kerns 2013) and a possibly challenging uterine aspiration. Consider medication abortion for this patient.
    • If considering aspiration abortion, the following should be considered:
      • Have uterotonic medications and supplies accessible to manage bleeding.
      • Add vasopressin to paracervical block.
      • Consider intraoperative ultrasound guidance.
      • With additional risk factors, consider referring to center with transfusion capability, anesthesia, and / or interventional radiology.

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  1. A 29-year-old G5 P2 patient presents for aspiration at 7 weeks gestation, with history of venous thromboembolism, currently anti-coagulated on warfarin; INR is in the therapeutic range.
    • Additional blood loss in anti-coagulated patients was not clinically significant in a small study of anti-coagulated patients seeking aspiration < 12-weeks gestation compared with matched controls (Kaneshiro 2011). A likely explanation is that myometrial contraction is the primary mechanism of hemostasis after uterine aspiration.
    • Cases such as this can be done in the outpatient setting with appropriate preparation for unlikely bleeding. A risk/benefit discussion should guide management of anticoagulation. The benefit of holding the morning dose of warfarin or low-molecular-weight heparin prior to an aspiration abortion is unclear.

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  1. A 38-year-old G3 P2 patient presents for an aspiration at 6 weeks gestation, with a blood pressure is 170/110 and a headache.
    • Mild to moderate hypertension is not a contraindication for an outpatient procedure, but requires subsequent referral for treatment of hypertension.
    • Confirm the blood pressure with appropriate cuff size; check if patient has a history of hypertension and if so, any anti-hypertensive medication and if taken today. Consider encouraging patient to take their anti-hypertensive medication if they have it, or relax for a while and recheck. Sedation will also reduce the pressure.
    • For severe hypertension (i.e. >160/110) in a patient who is symptomatic – with new onset headache or neurologic changes and pressures concerning for malignant hypertension.  The patient should be treated prior to the procedure or referred for additional management.

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  1. A 26-year-old G2 P1 patient with a history of insulin-dependent diabetes presents for an aspiration at 8 weeks gestation. A pre-operative glucose level is 520 mg/dL.
    • For patients with insulin-dependent diabetes, check blood sugar, and if > 400, take history for diabetic control medications and whether taken today, trends, A1c, and history of recent care.
    • Mild hyperglycemia (200-400 mg/dL) is not a contraindication for uterine aspiration.
    • Above 400, assess for ketoacidosis (including urine dip for ketones and assess volume status); if + ketones or poor volume status, stabilize or refer prior to the procedure.
    • Hypoglycemia (<70 mg/dL) warrants a patient to be given dextrose or food prior to a procedure.

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EARLY ABORTION TRAINING CURRICULUM Copyright © 2020 by UCSF Bixby Center for Global Reproductive Health. All Rights Reserved.