CHAPTER 6 TEACHING POINTS: UTERINE ASPIRATION 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.
   1. What is the differential diagnosis?
      • Acute flexion or tortuosity of the cervix
      • Congenital or acquired uterine abnormalities:
        1. Abdominal scarring due to prior (especially multiple) cesarean sections, which often limit adequate traction.
        2. Cervical stenosis
        3. Müllerian anomaly
        4. Fibroid in the lower uterine segment
      • Error in assessment of uterine position (e.g possible sharply anteverted uterus with high cervix that may appear retroverted by visual exam without a thorough bimanual).
      • False passage of the cannula due to any of the above
      • Cervical scarring from prior procedures (colposcopy, LEEP)
   2. What would you do next?
      • See dilation tips from Steps for Uterine Aspiration above.
      • Ask for ultrasound guidance.
      • If unsuccessful, consider additional analgesia, misoprostol for 2–4 hours, delaying the procedure for a week to allow for more cervical ripening
      • Consider having a more experienced provider assist with dilation or finish the procedure–(may require returning another day).
      • Convert to medication abortion.
   3. How might you respond to the patient’s request for a break due to pain?

• • • As much as possible, give the person control and keep them informed.
    • If someone asks to stop, then stop.
    • Check in about whether they want additional pain management or whether there is something else you can add or optimize.
    • Ask if they want physical or emotional support during the procedure.
    • Consider adding “Let me know when you are ready to proceed.”
    • Keep them informed if you need to consider additional steps for safety, including a discussion of risks if procedure can not be completed today.

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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?
      • Failed or incomplete aspiration abortion
      • Completed aspiration abortion with POC too small to visualize
      • Ectopic pregnancy
   2. What do you do next?

• • • Recheck POC, MVA, EVA bottles, tubing, cannula, and strainer (if used).
    • Use a magnifier and backlighting if available.
    • Repeat US and re-aspirate if tissue is still visible..
    • Consider using a different cannula, such as rigid, curved cannula to follow flexion.
    • Rule out an ectopic pregnancy in any case without definitive POC:
      1. Draw serial hCGs and give ectopic precautions.
      2. An hCG decrease of 50% within 48 hours suggests successful abortion (and is more reliable than US or pathology).
    • If free-floating villi are seen without any membranes present, consider the possibility of retained gestational sac, and repeat US.
    • If no villi are seen, you may send the specimen to pathology. “Villi” on a pathology report confirms a pregnancy but not completion. Provider POC exam reduces the risk of failed or incomplete abortion. Routine histologic exam by a pathologist confers no incremental clinical benefit, and adds cost (Paul 2002).

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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?

• • Before applying tenaculum to a small or flat cervix, try injecting several mls of anesthetic to add bulk and facilitate placement (deeper in cervix, not in bleb).
  • Add a second tenaculum elsewhere on the cervix to broaden the base of support, then re-attempt dilation.
  • If bleeding, apply cervical pressure (direct pressure or clamp cervix with ring forceps). Inject dilute vasopressin (4-6 units in 5-10 cc sterile saline intra-cervically), Monsel’s solution, or silver nitrate; sutures are rarely required.
  • Offer medication abortion, if eligible.

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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 person feels something sharp.
   1. What is the differential diagnosis?
      • A probable uterine perforation vs. a creation of false passage.
   2. What should you do now?
      • Immediately stop suction.
      • Apply transabdominal ultrasound to locate instruments (in this case, cannula) and whether they are present in the uterus or if a perforation has occurred.
      • Gently remove cannula.
      • Evaluate for sharp or localized pain, vital signs, and bleeding.
      • US may identify fluid collection in the cul-de-sac, but < 14 weeks it is rare to be able to identify abdominal contents in the uterus, or uterine contents in the abdomen.
      • If the cervical canal and uterine cavity can be visualized on US, an experienced clinician may choose to finish the procedure under US guidance.
      • If vacuum has been applied, look for evidence of intra-abdominal contents (i.e. omental fat) in the aspirate. If seen, this confirms perforation. Any evidence of intra- abdominal contents necessitates transfer to a higher level of care.
      • If the patient remains asymptomatic for pain or bleeding, consider observation for two hours.
      • Asses with repeat US before discharge to assess for fluid in the cul-de-sac.
      • Give precautions before discharge
      • Consider uterotonics if bleeding is significant.
      • Hospitalization is indicated if:
        • The patient is hemodynamically unstable. Place IVs and initiate IV fluid.
        • The patient has significant pain.
        • There is evidence of large perforation, laceration, expanding hematoma, fetal parts in abdomen, free fluid in abdomen, or any viscera / omentum in uterus or aspirate.
        • You are unable to complete procedure after the pregnancy has been disrupted, particularly after 13 weeks
   3. How might you have anticipated and prevented this problem?
      • Use gentle steady pressure during dilation until beyond the internal os.
      • Traction on the tenaculum helps straighten uterine flexion. Consider posterior placement for a retroflexed uterus to help straighten the angle.
      • Passing a flexible uterine sound or os finder may help to find the correct path, although use caution as a smaller instrument may increase perforation risk.
      • If your dilator passes easily but the cannula does not, consider using a smaller cannula or dilating one size higher.
      • Do not hesitate to re-check your pelvic exam.
      • Use US guidance, if available.
      • Consider a rigid curved cannula to maneuver the angle better.
      • Cervical ripening with misoprostol can be helpful.

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5. A parous person at 9 weeks presents for an abortion, with a history of a 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. 1. Given their risk factors, what additional preparations would you consider beyond normal precautions?

      This person is in the moderate risk category for hemorrhage (Kerns 2024). In addition to what you would do for a low risk patient (see Managing Immediate Complications Table), the following should also be considered:

      • Have uterotonic medications readily accessible.
      • Consider ultrasound guidance.
      • Consider obtaining consent for transfusion, if in a setting with transfusion capabilities.
      • With additional risk factors, if possible, you might also consider referring to a center with transfusion capability, anesthesia, and interventional radiology.
   2. What do you suspect?
      • The patient has already bled about 200 cc (each MVA has a capacity of 60cc) and is at risk for hemorrhage (defined as 500 cc EBL).
      • Consider some causes of hemorrhage with 4T’s mnemonic: Tissue (incomplete aspiration), Tone (atony), Trauma (cervical laceration or perforation), or Thrombin (a rare underlying bleeding disorder). Also consider ectopic pregnancy, such as cesarean scar ectopic pregnancy.c. What can you do now?

As a memory tool, practice 2 primary steps for each of the 6T mnemonic of management:

• • Tissue: Assure uterus is empty
    • Estimate EBL
    • Reaspiration (with US guidance) via EVA for rapid evacuation; check that products of conception are adequate. Use US guidance as needed.
  • Tone:
    • Uterine massage
    • Medications (methergine, misoprostol, dilute vasopressin, tranexamic acid)
  • Trauma: Assess source
    • “Cannula test” (watching return as you slowly withdraw cannula from fundus to external os, to identify bleeding zone)
    • Walk or clamp cervix with ring forceps
  • Thrombin:
    • Review bleeding history
    • Consider additional tests as indicated (clot test, coagulation tests, CBC)
  • Treatment
    • IV fluid bolus
    • Uterine tamponade with Foley catheter or Bakri balloon (inflate bulb)
  • Transfer
    • Vitals every 5 minutes
    • Initiate transfer

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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?
   1. With everyone, but especially those with a trauma history, start up-front with counseling about all pain management options, including what the person can do (breathing, distraction, alternative positioning), non-pharmacologic support, sedation options including anxiolytics, oral NSAIDs, and topical anesthetics. Offer to have a chosen support person in the room.
   2. Stop and remove the speculum, getting this person in a more comfortable position to go over how the procedure may bring back memories of previous difficult experiences and discuss the benefits of additional sedation dosing or modalities that have not yet been added. Check if they want to proceed.
      You might say, “I’m sorry this is uncomfortable. Would any of these options help? How would you feel about inserting the speculum yourself or raising the head of the exam table?”
   3. You might offer to practice pushing their hips downward, or visualize softening or melting of muscles downward during the exam. Reinforce that they are in control of their own body, and give suggestions about what they can focus on to help keep the procedure safe.
   4. Have them tell you when they are ready for each step of the procedure. For example, ask them to tell you when to tell you when they are ready for the speculum insertion and when to advance the speculum beyond the introitus. Consider using a pediatric speculum.
   5. If they continue to have discomfort, consider a referral out for deep sedation
   6. Familiarize yourself with the mandated reporting laws in your state. Most states require reporting for any minor (<18 years old) who reports sexual abuse or if the partner is significantly older than the minor. For state laws: https://aspe.hhs.gov/reports/state-laws

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EXERCISE 6.2

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?
      • This person may have developed a hematometra, or accumulation of blood in the uterus following the procedure.
      • Undetected perforation with possible bowel injury
      • Endometritis
   2. Which exam and ultrasound findings would support your diagnosis?
      • Hematometra
        • Physical examination reveals a large, tense, and tender uterus.
        • US shows an expanded uterine cavity with heterogeneous echo complex, consistent with clots in the uterus.
        • Perforation with possible bowel injury:
          • Exam may reveal uterine tenderness and cervical motion tenderness (CMT)
          • US (particularly transvaginal ultrasound) may reveal free fluid
      • Endometritis:
        • Uterine tenderness on exam (ranging from mild to exquisite, with or without CMT)
        • US may appear normal, or may reveal retained tissue or clot
   3. What are your management recommendations?
      • Hematometra: While small collections of clots may pass spontaneously or with uterotonics if the patient’s pain is tolerable, aspiration is usually required for larger clots, with or without intraoperative uterotonics.
      • Perforation: If bowel injury suspected or significant free fluid present, patient will require transfer and evaluation for surgical evaluation.
      • Endometritis: If any retained tissue present, should be re-aspirated as it is a nidus of infection, and the patient should be treated with outpatient PID regimen if stable.
   4. If these symptoms developed immediately after abortion, what would you do?
      • Hematometra: Immediate re-aspiration with or without uterotonics may prevent an ED visit.
      • Perforation: Evaluate with ultrasound for presence of free fluid, and monitor for 1.5-2 hours. If meeting criteria for transfer such as suspected bowel injury, the patient would be transferred to the emergency department.
      • Endometritis: N/A, endometritis typically occurs > 24+ hours post-procedure.

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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?
      • A completed abortion in someone with hormonal contraceptive side effects
      • A failed attempted abortion with an ongoing pregnancy
      • Retained POC / asymptomatic hematometra
      • Uterine fibroids causing enlarged uterine size
      • Ectopic pregnancy or heterotopic pregnancy with continuing ectopic
      • Hydatidiform mole
   2. How can you rule in or out any of your diagnoses?
      • Home pregnancy tests are high sensitivity pregnancy tests (HSPT; positive at 20-25 mIU/mL) and can remain positive 4 – 6 weeks after abortion so a positive HSPT 2 weeks later may be positive for any of the differential diagnoses in this example.
      • Assess whether POC, post-abortion US, or an hCG were checked after the abortion; but a quantitative hCG is an important baseline for further testing.
      • Is serial serum hCG rising or falling, and at what rate? See Chapter 3. An US can help identify an ongoing pregnancy, remaining clots, or an ectopic pregnancy. However, a negative US is inconclusive and cannot definitively rule out an ectopic.
      • Exam may be helpful to evaluate uterine size, bogginess, or adnexal masses.
      • Re-aspiration determines uterine contents: presence of POC or pathologic changes.
      • Breast tenderness could be from hormonal contraceptives.
      • 8-week size could be due to fibroids, retained clots, or inter-examiner variability.
   3. How might your approach differ if the ultrasound showed a moderate amount of heterogeneous contents?
      • This suggests retained tissue, decidua and/or clotted blood. Uterine re-aspiration may show evidence of chorionic villi, or membranes.
   4. If they are not pregnant, how can you explain their positive urine pregnancy test and breast tenderness?
      • A high sensitivity pregnancy test may still be positive for up to 4 – 6 weeks following an abortion.
      • After an abortion, breast tenderness can take 10-14 days to fully resolve. Breast tenderness may also be secondary to the initiation of hormonal contraceptives.

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EXERCISE 6.3

Purpose: To review routine follow-up after uterine aspiration, please answer these questions.

1. An individual has had nausea and vomiting throughout pregnancy. How long will it take for them to feel better after the abortion?
2. 1. • Nausea is one of the first pregnancy symptoms to subside after an abortion, generally within 24 hours. Nausea may be induced by CHC use.
      • If it persists beyond a week, rule out ongoing pregnancy or retained tissue.
      • Breast tenderness subsides in 1-2 weeks, but may be influenced by CHCs.

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2. Clinicians typically advise people to call if they have certain “warning signs” following uterine aspiration. What “warning signs” would you include and why?
3. • Persistent severe pain or cramping:
     • May indicate hematometra, infection, uterine trauma, or ectopic.
   • Pelvic / rectal pain with little or no bleeding:
     • Suggests hematometra.
   • Heavy bleeding (saturating >2 pads per hour for >2 hours) or orthostatic symptoms:
     • Suggests the need for intervention.
   • Peritoneal signs (pain with cough, palpation, or sudden movement):
     • May suggest perforation or infection and warrant reevaluation.
   • Sustained fever (greater than 100.4°F / 38°C ):
     • Raises concern about pelvic infection.
   • Foul-smelling vaginal discharge
     • Raises concern about a pelvic infection.

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3. After an aspiration, how long would you advise someone to wait before resuming exercise, heavy lifting, tampon use and/or vaginal intercourse? What is the rationale for your recommendations?
4. • Resuming exercise or heavy lifting: Many clinicians empirically discourage strenuous exercise and intercourse for 1-2 weeks after abortion, to prevent exacerbation of bleeding or cramping, or avoid infection, although there is no evidence that this makes any difference.
   • They may resume normal activity when they feel ready. This can be as soon as a few hours after their abortion, or more typically within 24 hours. Generally the best advice is to “listen to your body,” enjoy the activities that make them feel better, and avoid activities that make them worse.
   • Tampon use and/or resuming vaginal intercourse: no data suggest increased infection with intercourse after an abortion, so advice may be liberalized. Encourage them to trust their body and resume intercourse when they feel ready. As ovulation can occur within 7-10 days, encourage the person to initiate their chosen method of contraception promptly after abortion if they do not want to become pregnant at this time.