Outpatients undergoing early uterine evacuations in your office require a safe environment and a clinician with a thorough knowledge of the medical and surgical techniques. This practical review provides protocols for medical abortion and early pregnancy failures and guides you through the manual vacuum aspiration procedure.
Few situations are more devastating than when a patient, excited about her pregnancy, comes to your office and is diagnosed with an early pregnancy failure (EPF). As clinicians know, however, this is a common scenario. In fact, approximately 15% of clinically recognized pregnancies are not viable, with the incidence increasing to 50% in women over age 45.1 Also prevalent are elective terminations of pregnancy: 49% of all pregnancies in this country are unintended and half of these end in pregnancy termination with roughly 43% of women having at least one abortion by the age of 45.2 This means that most likely, every practitioner will encounter a patient in this predicament at least once. Given the emotional and psychological distress that often accompanies both EPF and termination of pregnancies, knowing the proper techniques to safely evacuate an early pregnant uterus in the office setting enables a clinician to offer prompt continuity of care in a more private and supportive environment.
Our goal here is to briefly summarize the different approaches for first-trimester uterine evacuation in the office setting, including medical and surgical techniques. Patients presenting with either EPF or termination of pregnancy benefit from: comprehensive options counseling (parenting, adoption, termination); accurate diagnosis of gestational age and location of pregnancy; contraception counseling, and further psychological therapy as needed on an individual basis.
Medical terminations In helping a patient decide between a surgical or medical route, keep in mind that a medical abortion is usually more appropriate for a woman who can answer yes to most of the following questions: "Do I want privacy and to control the process? Can I cope with the often heavy, severe bleeding and cramping? Can I complete all steps of the regimen? Am I in a hurry or can I wait up to a few weeks for abortion to take place? Will I be able to return for follow-up? If necessary, can I identify problems and seek care? If the medical treatment is unsuccessful, am I willing to undergo surgery?"
In September 2000, the FDA approved mifepristone and misoprostol for medical abortions. Up until then, some practitioners had been using methotrexate/misoprostol for early first-trimester abortions. Both regimens are effective, with the mifepristone and misoprostol combination having slightly higher success rates and quicker times to completion, especially in earlier gestations.5,6
All patients undergoing medical termination should have a physical exam that includes height, weight, blood pressure, pulse, a pelvic exam, and in our clinic, an ultrasound for correct dating of the gestation and to rule out an ectopic pregnancy. Laboratory evaluation should include hemoglobin, hematocrit, and Rh typing. If a woman is Rh negative, administer Rho (D) immune globulin on day 1 or no more than 72 hours after giving misoprostol or the first bleeding episode.