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HEALTH EVALUATION PRIOR TO UTERINE ASPIRATION

People seeking abortion care are impacted by numerous external factors which may impact their access to abortion care as well as various components of evaluation such as US, labs, physical examination, and more. Many people live in restricted settings and not all of the following may be available to everyone before or after their abortions. Clinicians should use shared decision making and center patient safety and preferences when determining appropriate care in a given setting. See Chapter 1 for more discussion on the Reproductive Justice framework in this context.

History and Physical

  • Review pertinent health history, obstetric history (cesareans/ectopics), surgical history (gynecologic surgery), medications, substance use, and allergies. A screening tool can ensure a thorough history is obtained (Raymond 2020).
  • Review information for the following medical conditions (Guiahi 2012):
    • Cardiovascular (hypertension, valvular disease, arrhythmias)
    • Pulmonary (asthma, active respiratory infection)
    • Hematologic (bleeding and clotting disorders, anticoagulants, severe anemia)
    • Hemorrhage risk factors (see below)
    • Endocrine (diabetes, hyperthyroidism)
    • Renal and hepatic disease (affecting drug metabolism and clearance)
    • Neurologic (seizure disorder)
    • Psychiatric (severe depression, anxiety, PTSD, substance use disorder)
  • Abortion is an essential and urgent service. Minimize delays, especially in people with significant health problems, as risk increases with advancing gestational duration.
  • Certain health conditions warrant management or referral prior to abortion (see Table below), although referrals may necessitate travel in restricted access settings.
  • Physical exam as indicated by history and/or symptoms (e.g. bleeding).
  • Pelvic exam is not necessary for medication abortion with reliable LMP (WHO 2022).
  • Bimanual and speculum exams may be performed immediately prior to a procedural abortion.
    • Bimanual if indicated for cervix and uterine size/position (see limitations above)
    • Speculum exam can assess cervicitis warranting testing/treatment.
  • Higher weight or larger body size does not increase risk of abortion complications and should not be used in isolation to transfer or delay care (Benson 2016, McMahon 2025).

Lab Tests, If Indicated

No routine pre-abortion lab testing is required for people without underlying conditions. Some labs are indicated by history, exam or EGD. Lack of testing should not be a barrier to access.

  • Rh testing standards are evolving: Rh testing must be offered to people with unknown Rh status > 12 weeks gestation and RhIG offered to those > 12 weeks who are Rh negative (NAF 2024, SFP 2022, WHO 2022; See Ch 5 Rh Isoimmunization).
    • May forgo Rh testing if the patient wants no future children or declines testing.
    • Document informed consent if >12 weeks and Rh testing and/or RhIG declined.
    • To document Rh status: use chart record, self-report, or lab.
  • Hemoglobin (fingerstick ok): If pertinent history (e.g. blood transfusion, anemia symptoms) (see hemorrhage risk assessment below).
  • Chlamydia (CT)/Gonorrhea (GC): recommended for symptomatic people and offer for asymptomatic individuals at increased risk (e.g. ≤ 25 not recently tested, new or multiple sexual partners in last year, previous or coexisting STI, etc. per CDC screening guidelines (CDC 2021, SFP 2025a).
    • If cervicitis on exam: test (GC/CT), treat empirically, proceed with abortion care
    • See Ch 5: Antibiotic Prophylaxis.
  • Tests may be considered for pertinent to underlying conditions based on clinical judgment and individual patient factors (ex: may consider glucose for patients with uncontrolled IDDM, INR for people taking Warfarin > 12 weeks, etc.)

Some people may receive US or other services at Crisis Pregnancy Centers (CPCs) where non-evidence based, unethical, and coercive practices may be utilized to attempt to deter people from abortion care or even contraceptive options (Bryant 2018). CPCs may be hard for people to identify and may be mistaken for health centers providing reproductive health care. For more information see ACOG Issue Brief 2022.

Selected Health Condition Considerations and Management in First Trimester Aspiration Abortion

Adapted from Ipas 2023 and Guiahi 2012
Health Condition Considerations
Hypertension (HTN)
  • Well controlled HTN is not contraindication.
  • Symptomatic and/or severe HTN (>160/110): treat prior to procedure or refer for additional management.
  • Methylergonovine (Methergine); avoid in people with chronic HTN.
Seizure Disorder
  • Anti-seizure medications: continue as prescribed.
  • May receive procedural benzodiazepines or opiates without dose adjustment.
  • Uncontrolled seizure disorder or generalized seizure within 2 weeks may benefit from higher level care.
Anemia
  • See hemorrhage risk assessment below. If current or recent sx / hx, or transfusion hx, check pre-procedure Hgb.
Anticoagulant use
  • Anticoagulation can be continued with relatively low risk of additional blood loss <14 weeks gestation (Lee 2021).
Bleeding Disorders
  • Outpatient uterine aspiration can be performed with appropriate preparation (i.e. IV access, uterotonics).
  • Aspiration may be preferred over MAB, but may individualize decisions using shared decision making.
  • Tailor NSAID use for pain management by risks/benefits for bleeding or anticoagulant interaction (SFP 2021).
Insulin-Dependent Diabetes (IDDM)
  • No changes in diet or medications are recommended for uterine aspiration, but consider scheduling early in the day to avoid hypoglycemia.
  • Low glucose levels (<70) require dextrose or food prior to procedure.
  • High glucose levels (200-400) are not a contraindication, but levels >400 warrant evaluation for DKA; if identified, treat prior to procedure or referral.
Heart Disease
  • If severe disease or symptomatic underlying disease, aspiration may be performed with monitoring by anesthetist or anesthesiologist.
Asthma
  • People with mild asthma may have routine procedural abortion. Advise bringing meds to the clinic, and taking routine asthma meds before procedure.
  • With acute asthma exacerbation, consider delaying abortion care until controlled or receive a higher level of care.
  • Misoprostol is safe for those with asthma; hemabate is contraindicated.
Active respiratory infection
  • Consider risk/benefit of abortion vs. delay during acute illness, particularly with severe symptoms.
  • Follow appropriate respiratory precautions based on setting and local context.
Uterine Fibroids
  • Significant fibroids may impact ability to complete procedural abortion depending on size/location in relation to pregnancy. Recommend US guidance; cervical preparation with misoprostol may be a helpful adjunct.
  • Consider MAB or referral as needed.
Previous Cesarean Delivery
Congenital Uterine Anomalies
  • Occurs in 0.5% of people with a uterus
  • Procedure possible if pregnancy is located in uterine horn communicating with the cervix (based on US and exam). Consider US guidance and convert to MAB if unable to aspirate.
  • If pregnancy in non-communicating horn, consider MAB or refer (Goldthwaite 2014).
Alcohol or substance use disorders
  • Alcohol use disorder may need higher benzodiazepine doses due to tolerance.
  • Opioid use disorder: may need higher opioid doses due to tolerance.
  • See Chapter 5 for management details

Hemorrhage Risk Assessment, Prevention and Preparation Measures for Abortion

(Adapted from SFP; Kerns 2024)
Hemorrhage Risk Group Prevention and Preparation Measures

Low Risk

  • No prior cesarean deliveries
  • < 2 prior cesarean sections and no previa or placenta accreta spectrum
  • No bleeding disorder
  • No history of obstetric hemorrhage

Measures for All

  • Preoperative hemoglobin or hematocrit levels < 14 weeks if symptoms or history of significant anemia or blood transfusion; consider routine > 14 weeks
  • Ultrasound for gestational duration
  • Cervical preparation
    • Misoprostol or dilators if > 13 weeks
    • Dilators if > 20 weeks
  • Consider vasopressin in paracervical block

Moderate Risk

  • ≥2 cesarean deliveries
  • Prior cesarean delivery and previa
  • Bleeding disorder
  • History of obstetric hemorrhage
  • Increasing maternal age
  • Gestational duration > 20 weeks
  • Fibroids (depending on size, location)
  • Fetal Demise

All of the above, and consider…

  • Uterotonic medications readily accessible
  • Intraoperative ultrasound guidance
  • Transfusion consent
  • Cervical preparation with dilators if >20 weeks

High Risk

  • Placenta accreta spectrum diagnosis or concern
  • Any of the moderate risk categories may be considered ‘high risk,’ per discretion of the clinician

All of the above, and consider…

  • Refer to center with transfusion capability, anesthesia, and interventional radiology
  • Transfusion and possible hysterectomy consents
  • Preoperative creatinine, coagulation panel
  • Type and cross >2 units

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TEACH Abortion Training Curriculum 8th Edition Copyright © by The TEACH Program. All Rights Reserved.

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