CHAPTER 6 EXERCISES: ASPIRATION ABORTION PROCEDURE

EXERCISE 6.1

Purpose: To practice management of challenging situations that can arise at the time of aspiration abortion procedures.

1. While performing a procedural abortion for a person at 6 weeks gestation, you complete the cervical block and have the tenaculum in place. As you attempt to introduce the smallest dilator, you are unable to advance the dilator through the internal os. After readjusting the speculum and the tenaculum, you again find that there is severe resistance as you attempt to advance the dilator into the cervical canal; it feels dry, gritty, and tight, and does not have the “normal” feel of the dilator tip advancing through the cervical canal. through the cervical canal.
   1. What is the differential diagnosis?
   2. What would you do next?
   3. How might you respond to the patient’s request for a break due to pain?

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2. You have just completed an aspiration abortion for a person at 6 weeks gestation. Their pre-procedure ultrasound shows a 5 mm fluid collection, but no yolk sac or embryonic pole. Their pregnancy test was positive. Dilation was not difficult and you were able to use a 6 mm flexible cannula. The tissue specimen is very scant and you are not certain whether you see sac or villi.
   1. What is the differential diagnosis?
   2. What would you do next?

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3. You are performing an abortion for a nulliparous person at 9 weeks gestation. You notice that their cervix is very small and it is hard to choose a site for the tenaculum. As you put traction on the tenaculum and try to insert the dilator, the tenaculum pulls off, tearing the cervix. There is minimal bleeding, so you reapply the tenaculum at a slightly different site, although it is difficult because the cervix is small. This time, the cervix tears after inserting the third dilator, with substantial bleeding.
   1. What should you do now?

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4. You are inserting the cannula for a procedure for a person at 9 weeks gestation with a retroflexed uterus. Although the dilation was easy, you feel the cannula slide in easily but at a different angle and much further than you sounded with one of the dilators. You don’t feel any “stopping point.” The patient feels something sharp.
   1. What is the differential diagnosis?
   2. What should you do now?
   3. How might you have anticipated and prevented this problem?

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5. A parous person at 9 weeks presents for an abortion, with a history of one previous cesarean and a postpartum hemorrhage not requiring transfusion. The aspirator quickly fills with blood when suction is applied. You empty it, recharge, and it again fills with blood. You have seen some tissue come through. You ask your assistant to prepare another MVA but it promptly fills with blood when attached to the cannula.
   1. Given their risk factors, what additional preparations would you consider beyond normal precautions? (Review in Managing Immediate Complications Table).
   2. What do you suspect?
   3. What can you do now?

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6. You are providing care for a 14-year-old who has experienced sexual trauma and is 7 weeks pregnant. You have provided conscious sedation. Every time you attempt to insert the speculum, they raise their hips off the table. What do you do?

Purpose: To practice managing challenges that may occur after uterine aspiration.

1. The nurse consults with you about a phone call regarding someone who had an abortion at the health center five days ago. They complain of severe cramping and rectal pressure, have had minimal bleeding, and have a mild fever.
   1. What is the differential diagnosis?
   2. Which exam and ultrasound findings would support your diagnosis?
   3. What are your management recommendations?
   4. If these symptoms developed immediately after an abortion, what would you do?

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2. A person comes to your office for follow-up after an 8-week abortion two weeks ago and still has some symptoms of pregnancy including breast tenderness and abdominal bloating. Medications include birth control pills. They have had intercourse regularly for the past six days. They are afebrile, with normal vital signs. Pelvic exam is normal except for an 8-week size uterus. A high sensitivity urine pregnancy test is positive.
   1. What is the differential diagnosis?
   2. How can you rule in or out any of your diagnoses?
   3. How might your approach differ if the ultrasound shows moderate amount of heterogeneous contents?
   4. If they are not pregnant, how can you explain their positive urine pregnancy test and breast tenderness?

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