Purpose: To practice management of challenging situations that can arise at the time of aspiration abortion procedures.

  1. You are performing an abortion for an anxious 20-year-old G1P0 patient at six weeks gestation. You complete the cervical block and have the tenaculum in place. As you attempt to introduce the smallest dilator, you are unable to advance the dilator through the internal os. After readjusting the speculum and the tenaculum, you again find that there is severe resistance as you attempt to advance the dilator into the cervical canal; it feels dry, gritty, and tight, and does not have the “normal” feel of the dilator tip advancing through the cervical canal.
    1. What is the differential diagnosis?
    2. What would you do next? 
  2. You have just completed an aspiration abortion for a 19-year-old patient at six weeks gestation. They had reported intermittent episodes of vaginal bleeding on three occasions during the past week, but did not have any severe cramping or clotting. Their pre-procedure ultrasound was performed one week ago, with a 5 mm gestational sac identified, but no yolk sac or embryonic pole. Their pregnancy test was positive. Dilation was not difficult and you were able to use a 6 mm flexible cannula. The tissue specimen is very scant and you are not certain whether you see sac or villi.
    1. What is the differential diagnosis?
    2. What would you do next?
  3. You are performing an abortion on a nulliparous 16-year-old patient at seven weeks gestation. You notice that their cervix is very small and it is hard to choose a site for the tenaculum. As you put traction on the tenaculum and try to insert the dilator, the tenaculum pulls off, tearing the cervix. There is minimal bleeding, so you reapply the tenaculum at a slightly different site, although it is difficult because the cervix is so small. This time, the cervix tears after inserting the third dilator, and there is substantial bleeding.
    1. What should you do now?
  4. You are inserting the cannula for a procedure on a patient at 9 weeks gestation with a retroflexed uterus. Although the dilation was easy, you feel the cannula slide in easily but at a different angle and much further than you sounded with one of the dilators. You don’t feel any “stopping point.” The patient feels something sharp.
    1. What is the differential diagnosis?
    2. What should you do now?
    3. How might you have anticipated and prevented this problem?
  5. A G3P2 patient at 8w5d presents for termination, with a history of one previous cesarean and a post-partum hemorrhage not requiring transfusion. The aspirator quickly fills with blood when suction applied. You empty it, recharge, and it again fills with blood. You have seen some tissue come through. You ask your assistant to prepare another MVA but it promptly fills with blood when attached to the cannula. Given the patient’s risk factors, what additional preparations would you consider beyond normal precautions? (Review in Managing Immediate Complications Table ).
    1. What do you suspect?
    2. What can you do now?

Teaching Points




Purpose: To practice managing challenges that may occur after uterine aspiration.

  1. The nurse consults with you about a possible problem phone call regarding a patient who had an abortion at the clinic five days ago. The patient complains of severe cramping and rectal pressure, has had minimal bleeding, and has a mild fever.
    1. What is the differential diagnosis?
    2. Which exam and ultrasound findings would support your diagnosis?
    3. What are your management recommendations?
    4. If these symptoms developed immediately after an abortion, what would you do?
  2. A 21-year-old patient comes to your office for follow-up after an 8-week abortion two weeks ago at another facility, and still has some symptoms of pregnancy including breast tenderness and abdominal bloating. Medications include birth control pills. The patient has had intercourse regularly for the past six days. The patient is afebrile, with normal vital signs. Pelvic exam is normal except for an 8-week size uterus. A high sensitivity urine pregnancy test is positive.
    1. What is the differential diagnosis?
    2. How can you rule in or out any of your diagnoses?
    3. How might your approach differ if the ultrasound showed moderate amount of heterogeneous contents?
    4. If the patient is not pregnant, how can you explain their positive urine pregnancy test and breast tenderness?

Teaching Points