MEDICAL EVALUATION PRIOR TO ASPIRATION

Selected Health Condition Considerations and Management in First Trimester Aspiration Abortion

^{Adapted from Ipas 2016}

• Mild – moderate is not contraindication; referral for treatment as needed.
• Symptomatic and / or severe HTN (>160/110) should be treated prior to procedure or referred for additional management.
• Methylergonavine (Methergine) should be avoided for patients with chronic HTN.

• Anti-seizure medications should be taken as prescribed on the day of uterine aspiration, and continued as usual following the procedure
• Not a contraindication to receiving procedural benzodiazepines or opiates
• Uncontrolled seizure disorder or generalized tonic clonic seizure in last 2 weeks is a contraindication to in-clinic abortion.

• If recent sx / hx, check pre-procedure Hgb. If significantly low, be prepared to manage potential bleeding appropriately or refer.

• Anticoagulation medications can be continued with relatively low risk of additional blood loss throughout the first trimester (Lee 2021).

• Aspiration generally prefered over medication abortion, but decision should be individualized using shared decision making.
• Aspiration can be performed in outpatient setting with appropriate preparation (i.e. IV access, available uterotonics).
• Use of NSAIDs for post-abortion pain management should be tailored to the risks/benefits for bleeding or interaction with anticoagulants (SFP 2021).

• No changes in diet or medications are recommended for vacuum 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; require treatment or referral prior to procedure.

• If symptomatic of underlying heart disease, or severe disease, aspiration may be performed with monitoring by anesthesiologist or anesthetist.

• Patients with mild asthma may have routine procedural abortion. Advise taking routine asthma meds before procedure and bringing meds to the clinic.
• Patients with an acute exacerbation or poorly controlled asthma may need to delay abortion care until better controlled.
• Misoprostol is safe for use in patients with asthma

• Consider risk/benefits of continuing pregnancy vs abortion during acute illness.
• In context of COVID-19 community transmission, recommend PPE that assumes infection if status is unknown for patient & staff.

• Significant fibroids may impact ability to complete procedural abortion depending on size/location in relation to pregnancy. US guidance may be a helpful adjunct.
• Consider referral to a higher level of care with an experienced provider.
• Medication abortion may be considered as an alternative.

• Patients may be at increased risk of hemorrhage given placental location and risk of placental adherence. Ensure uterotonic medications are readily accessible. Consider performing aspiration under US guidance.
• Additional rare risk of uterine scar pregnancy if multiple previous cesarean deliveries; consider US &/or referral to higher-level facility (Timor-Tritsch 2015).

• Found in 0.5% of general population with a uterus
• Procedure possible if pregnancy is located in uterine cavity communicating with the cervix (based on US and exam). Convert to medication abortion if unable to aspirate.
• If pregnancy in non-communicating horn, consider MAB or refer (Goldthwaite 2014).

• Alcohol use disorder: may need larger benzodiazepine doses due to tolerance.
• Opiate use disorder: may need larger opiate doses due to tolerance.
• See Chapter 5 for more information