Elective Abortion Workup

Preabortion workup includes the following:

• Pregnancy tests are used to confirm the presence of a pregnancy, and home tests are reliable enough that their results can be accepted in some cases.

• Hemoglobin (Hb) or hematocrit (Hct) levels are always assessed. A full CBC count is optional but may be indicated if abnormal findings are detected with the Hb or Hct test.

• Rh typing is always performed. ABO typing is optional.

• STI screening typically includes a gonorrheal culture (GC) or chlamydial test (CT), and targeting those aged 25 years and younger is considered appropriate. Screening for other STIs, such as syphilis or HIV disease, is usually prohibitively expensive; however, patients with positive results from the GC or CT should be offered these tests.

• Vaginal wet preparations, pH testing, and/or urine dipstick analysis are usually performed for standard indications.

• If a woman has vaginitis, she can have the procedure as planned and be treated with outpatient therapy

• If a woman has suspected infection with chlamydia and/or gonorrhea, these infections can increase the risk of endometritis.She should be treated with oral azithromycin 1 gram for suspected chlamydia and both ceftriaxone 150mg injection and oral azithromycin for suspected gonorrhea.There is no data to support delaying the procedure for treatment.

Additional testing is dictated by findings on history and physical examination, including the following:

• Coagulation studies are indicated in patients with a history of bruising, abnormal bleeding, hemorrhage with previous surgical procedures, or petechiae on physical examination.

• Liver function tests are indicated in patients with ethyl alcohol abuse, hepatitis, hepatomegaly, or jaundice.

• Renal function tests are indicated in patients with a history of renal disease or dialysis.

Use of human chorionic gonadotropin titers include the following:

• Human chorionic gonadotropin (hCG) titers are helpful in performing very early terminations, to establish the completeness of an abortion postoperatively in cases of persistent positive results from a urinary pregnancy test, or to establish the presence of an ectopic pregnancy. Prior to a medical abortion, ruling out ectopic pregnancy is mandatory. In medical abortion protocols, they can also be used to establish the arrest of viability of a pregnancy or to establish the completeness of a medical abortion.

• Titer resolution is different between surgical and medical abortions. The titer should decrease to approximately 64% of its preabortion value within 24 hours of misoprostol being administered in medical abortion protocols. By 2 weeks, the titers should have dropped 99%.

• If an abortion is being performed prior to 5 weeks from the LMP, obtaining titer values preoperatively can be very useful. Managing most abortion procedures without obtaining an hCG titer is within the standard of care.

Ultrasonography is invaluable but not always used in first-trimester terminations. The standard of care demands that second-trimester terminations be evaluated preoperatively with sonography. Documenting uterine abnormalities is important because failed terminations can occur in patients with double uterus or ectopic pregnancies. It is also important to document any abnormal appearance such as suspected molar pregnancy.  Pregnancies of unknown location must be followed to resolution.

First-trimester sonography

The results of the examination are what is typically expected for a first-trimester screening examination. The focus is on fetal number, the size and nature of the gestational sac, the placental location, the uterus, and the ovaries. Document the presence and nature of a yolk sac.

Second- and third-trimester sonography

For second- or third-trimester abortions, performing an ultrasound preoperatively is the standard of care. Conduct these examinations like other second-trimester screening examinations. It is important to document placental location, particularly in patients with prior cesarean sections, as the risk of a placenta accreta is increased.  If an accreta is suspected on ultrasound or if the patient has a placenta previa and a prior uterine incision, further testing may be warranted prior to a procedure.  If anomalies are detected, women should be offered a referral for targeted examinations that can delineate specific fetal disease conditions. Not unusually, women decline further investigation if their abortion decision does not hinge on the specific findings.

Papanicolaou tests (Pap smears) are optional specifically prior to the procedure, but patients should be informed of their need for Pap smears as part of their postabortion contraceptive care.

Genetic testing of an abnormal first-trimester pregnancy may be done either preoperatively or at the time of the abortion procedure. At the time of the procedure, either the fetus or the placenta may be tested, but these tests have to be prearranged and may be expensive.

Autopsy should be considered for all second-trimester anomalies. The combination of genetic sampling (either by amniocentesis or cytogenetic specimen from the fetus and placenta) and autopsy should be offered to these patients to provide as much diagnostic information for the patient to facilitate counseling for future pregnancies.

Pathologic analysis of tissue is typically performed for documentation purposes, but visual inspection of the products of conception postprocedure is mandatory. Washing the blood clots off the tissue obtained prior to visual inspection is helpful, and the presence of villi can be detected more reliably after back-lighting the specimen. In cases in which very little tissue is obtained, the use of colposcopy may reveal villi.

Placental analysis typically reveals products of conception consistent with gestational age. Preoperative ultrasound typically reveals placental abnormalities, such as a molar gestation or choriocarcinoma, when present. However, results from the histologic analysis that reveal the presence of a partial molar pregnancy or an incomplete molar pregnancy are not uncommon. See Medscape Drugs & Diseases article Hydatidiform Mole.

Requirements for pathological examination of products of conception (POC) after surgical abortion are also determined by state regulations. Many states require examination of fetal tissue after abortion. Request pathological examination of tissue in the following circumstances, even if no state requirement exists:

• Tissue obtained is less than expected based on gestational age.

• Ectopic pregnancy is suspected.

• Sac, placental, or fetal tissue is not identifiable on gross examination in a first-trimester abortion.

• Placental and/or fetal tissue is not identifiable on gross examination in a second-trimester abortion.

• Tissue inconsistent with POC is identified in the specimen (eg, fat).

• Tissue is abnormal in appearance (eg, grapelike appearance consistent with molar pregnancy)

Many fetal anomalies can be detected upon anatomic inspection of the fetus.Well-trained pathologists can identify anomalies in both intact and D&E specimens.

Further workup with ultrasound or beta hcg levels is warranted in the following cases:

• Scant tissue is obtained. Pathologic confirmation should be available within 24 hours if an ectopic pregnancy is suggested or within a week to 10 days if no pathology is suggested.

• Ectopic pregnancy is suspected.

• Sac, placental, or fetal tissue is not identifiable on gross examination in a first-trimester abortion.

• Placental and/or fetal tissue is not identifiable on gross examination in a second-trimester abortion.

• Tissue inconsistent with POC is identified in the specimen (eg, fat).