EXERCISES: PRE-ABORTION EVALUATION

EXERCISE 3.1

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

  1.  A 25-year-old G1P0 patient calls your office for a telehealth visit about options for an undesired pregnancy, following a positive home pregnancy test.
    1. What history should you obtain to appropriately triage the patient?
    2. How will you determine the patient’s pregnancy dating?
    3. What additional diagnostic data would you consider obtaining?

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EXERCISE 3.2

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

  1. A 20-year-old G2P1 patient at 4 weeks 2 days by LMP comes to your office requesting pregnancy confirmation and to discuss options.

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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. A quantitative hCG is 1000, 48 hours later it is 1400.
    1. What is the differential diagnosis?
    2. Would your approach to care differ with a desired vs. undesired pregnancy

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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 has been sexually active since the uterine aspiration.

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EXERCISE 3.3

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

What is the differential diagnosis of the following ultrasound findings? What steps would you take to clarify the diagnosis?

    1. A 36-year-old G4P2 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.
    2. Embryonic pole length 8 mm with no visible cardiac activity.
    3. A 24-year-old G2P1 patient 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.
    4. A 30-year-old G3P0 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”.

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EXERCISE 3.4

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

  1. A 41-year-old G4P4 patient presents for uterine aspiration at 5 weeks by 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.

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  1. A 17-year-old G1P0 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.

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  1. A 40-year-old G4P3 patient at 7w4d presents for an abortion procedure. They have a BMI of 35 and a history of 3 previous cesareans.

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  1. A 29-year-old G5P2 patient presents for uterine aspiration at 7 weeks gestation, with history of venous thromboembolism, now anticoagulated on warfarin; INR is in therapeutic range.

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  1. A 38-year-old G3P2 patient presents for a uterine aspiration at 6 weeks gestation, with a blood pressure of 170/110 and a headache.

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  1. A 26-year-old G2P1 patient with a history of insulin-dependent diabetes presents for a uterine aspiration at 8 weeks gestation. A pre-operative glucose level is 520 mg/dL.

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