EXERCISES: EVALUATION PRIOR TO UTERINE ASPIRATION

EXERCISE 3.1

Purpose: To distinguish appropriate uses for choosing different types of pregnancy tests. For the following scenarios, indicate whether you would use a high sensitivity urine pregnancy test (HSPT) or a serum quantitative hCG test, the reasons why. Address related questions.

  1. A patient comes to your office requesting pregnancy confirmation and to discuss her options. She is 4 weeks 2 days LMP.
  2. A 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 you draw comes back at 1000, and another 48 hours later comes back at 1400.
    • What is the differential diagnosis?
    • Would your approach to care differ with a desired vs. undesired pregnancy?
  3. A patient returns for a follow-up visit 3 weeks after a first-trimester aspiration because of intermittent bleeding since. The patient started taking oral contraceptive pills the day following the abortion, and has been sexual active since the uterine aspiration.

Teaching Points

 

 

 

EXERCISE 3.2

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. Mean gestational sac diameter 18 mm with no yolk sac or embryo visible.
    2. Embryonic pole length 5 mm with no visible cardiac activity.
    3. 3 mm x 3 mm central anechoic sac in pregnant patient 5w3d by LMP with history of intermittent right lower quadrant cramping.
    4. Embryonic pole length 8 mm with no visible cardiac activity.
    5. Irregular, flattened gestational sac without embryo, with cystic changes present resembling “swiss cheese” pattern in patient who is 8 weeks LMP.

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EXERCISE 3.3

Purpose: To identify conditions prior to uterine aspiration that may warrant special management, consider how you would manage the following case scenarios. Not all material is covered in the Chapter.

  1. A 41-year-old patient presents for uterine aspiration at 5 weeks LMP. Pelvic examination reveals an irregular uterus that is 17 weeks in size. Ultrasound examination shows an intrauterine sac in the fundus consistent with 5 weeks gestation and multiple submucosal uterine fibroids.
  2. A 26-year-old patient presents to your office at 7 weeks gestation. They had a chest x-ray and abdominal series after a motor vehicle accident 2 weeks ago and decided to have an abortion because of concerns about the effects of the radiation on the fetus.
  3. You are preparing to perform a uterine aspiration for a patient who is 5 weeks pregnant. When you insert the speculum, you note that the cervix looks inflamed and friable and has pus at the os.
  4. A 40-year-old G4P3 patient at 7w4d presents for uterine aspiration. She has a BMI of 35 and a history of 3 previous cesareans.
  5. A 29-year-old patient presents for uterine aspiration at 7 weeks gestation. They have a prior history of venous thromboembolism and is currently anticoagulated on warfarin; the INR is in the therapeutic range.
  6. A 38-year-old patient presents for a uterine aspiration at 6 weeks gestation, with a blood pressure of 170/110 and a headache.
  7. A 26-year-old patient with a history of diabetes presents for a uterine aspiration at 8 weeks gestation. A pre-operative glucose level is 520 mg/dL.

Teaching Points