EXERCISES: PRE-ABORTION EVALUATION
Purpose: To review key steps in early pregnancy evaluation and pregnancy dating.
- A 25-year-old G1P0 patient calls your office for a telehealth visit about options for an undesired pregnancy, following a positive home pregnancy test.
- How will you establish the patient’s pregnancy dating?
- What additional diagnostic data would you consider obtaining?
Purpose: To review appropriate uses for different types of pregnancy tests, indicate whether you would use clinical assessment alone, a high sensitivity urine pregnancy test (HSPT), or a serum quantitative hCG test and why; or answer related questions.
- A 20-year-old G2P1 patient at 4 weeks 2 days by LMP comes to your office requesting pregnancy confirmation and to discuss options.
- A 27-year-old G3 P2 patient is 6 weeks by LMP with a pregnancy of unknown location (transvaginal US examination shows no intrauterine gestational sac and no ectopic pregnancy). The patient has been spotting intermittently but is otherwise asymptomatic. A quantitative hCG is 1000, 48 hours later it is 1400.
- What is the differential diagnosis?
- Would your approach to care differ with a desired vs. undesired pregnancy?
- A 32-year-old G2P0 patient returns for a follow-up visit 5 weeks after a first-trimester aspiration because of intermittent bleeding since their procedure, and has been sexually active since the aspiration.
Purpose: To review key information about ultrasound in early pregnancy.
What is the differential diagnosis of the following US findings? What steps would you take to clarify the diagnosis?
- A 36-year-old G4P2 patient at 5 weeks by LMP. In the longitudinal view of the uterus, a gestational sac is elliptical, fundal and eccentric to the midline. Mean sac diameter is 18 mm with no yolk sac or embryo visible.
- Embryonic pole length 8 mm with no visible cardiac activity.
- A 24-year-old G2P1 patient at 5 weeks and 3 days by LMP reports having intermittent right-sided pelvic pain and cramping. On US, you visualize a small 3 mm x 3 mm intrauterine fluid collection in the endometrial canal. The shape of the collection is triangular and there is no double decidual sign.
- A 30-year-old G3P0 patient reports they are 10 weeks by LMP and having intermittent spotting. On US, there is a flattened gestational sac without embryo or yolk sac, with cystic changes in the decidua present resembling “swiss cheese”.
Purpose: To consider management of case scenarios prior to an abortion. Not all material is covered in the Chapter.
- A 41-year-old G4P4 patient presents for uterine aspiration at 5 weeks by LMP. Pelvic examination reveals an irregular uterus that is 17 weeks in size. Ultrasound examination shows a 5-week intrauterine gestation and multiple uterine fibroids.
- A 17-year-old G1P0 patient who is 5 weeks pregnant presents for uterine aspiration. As you insert the speculum, the cervix looks inflamed and friable and has pus at the os.
- A 40-year-old G4P3 patient at 7w4d presents for an abortion procedure. They have a BMI of 35 and a history of 3 previous cesareans.
- A 29-year-old G5P2 patient presents for uterine aspiration, with history of venous thromboembolism, now anticoagulated on warfarin; last INR was in therapeutic range. How would your management change if 10 wk vs. >14 wk EGA.
- A 26-year-old G2P1 patient with a history of insulin-dependent diabetes presents for a uterine aspiration at 8 weeks gestation. A pre-procedure glucose level is 520 mg/dL.