Pregnancy Termination

First Trimester Abortion

History

  • Circumstances of pregnancy

  • Symptoms of pregnancy/complications (vaginal bleeding)

  • Menstrual history

  • Obstetrical history

  • Gynecologic history (LMP, contraception, STI, partner)

    • Determine gestational age

  • PMH (disease), medications, allergies

  • Social history

Physical Exam

  • Vitals

  • Pelvic examination

    • Uterus size

      • 12w rises out of pelvis

      • 15-16w midpoint between symphysis pubis and umbilicus

      • 20w umbilicus

Investigations

  • Pelvic ultrasound (gestational age, r/o ectopic)

  • Hemoglobin, hematocrit

  • Rh(D) status

  • Consider STI screening (Gono/Chlam, HIV, Syphilis, Hep B/C)

  • Baseline bhCG

Treatment

  • Abortion method (medical vs. surgical)

    • Explain experience (pain, bleeding) as well as potential complications (infections, bleeding, hospitalization, surgery)

      • Ensure has access to (or can phone) emergency medical care if soaking two full heavy pads per hour for 2 consecutive hours, Fever with T>38C or >24h after Misoprostol, severe pain, nausea, etc...

  • Mifepristone 200mg PO then followed 24-48h later by Misoprostol 800mcg vaginal or buccal (between cheeks and gums and swallowed after 30mins) up to 63d post LMP

    • May consider prophylactic antibiotics (doxycycline 100mg PO BID x7d starting with mifepristone), but NNT >5000 to prevent a serious infection

    • Contraindicated in ectopic pregnancy, IUD in place, chronic adrenal failure, longterm corticosteroid therapy, bleeding disorder, lack of access to emergent care

  • Rh Ig controversial in first trimester abortion due to lack of evidence, cost and availability

    • Consider in Rh neg patients (especially if gestation >8-10w)

  • Surgical dilation and curettage up to 14w gestation

  • Contraception should be considered after abortion (ovulation may occur 8d post abortion)

  • Analgesia (Acetaminophen, Ibuprofen, +/- Opioids PRN)

Follow-up at 7-14d

  • Confirm history (cramps decreased after tissues passed)

    • If abnormal bleeding/cramping (light or excessive/prolonged) consider ongoing pregnancy or ectopic

  • Pelvic examination (decreased and firm uterus)

  • Repeat ultrasound examination

  • Serial bhCG (decrease >80%) at 7-14d suggests completed medical abortion

  • May consider repeat Misoprostol dose or surgical evacuation at first follow-up visit

    • If >2-3w post medical abortion, offer surgical uterine evacuation

Missed/Incomplete Abortions

  • Expectant - 56% success

    • May wait up to 2-8 weeks unless excessive bleeding

  • Medical - 81% success

    • Misoprostol 800mcg orally or vaginally with repeat dose up to 7d later if no response

      • Consider Mifepristone 200mg PO 24h prior to misoprostol

  • Surgical management - 96% success

    • Consider surgical management for women who do not want to wait, or avoid the experience of pain/bleeding