CHAPTER 3 EXERCISES: PRE-ABORTION EVALUATION

EXERCISE 3.1

Purpose: To review key steps in early pregnancy evaluation and dating.

1. A person calls your office for a telehealth visit about options for an undesired pregnancy, following a positive home pregnancy test.
   1. How will you establish their pregnancy duration?
   2. What additional diagnostic data would you consider obtaining?

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EXERCISE 3.2

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.

1. A person at 5 weeks by LMP comes to your office requesting pregnancy confirmation and to discuss options.

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2. A person is 6 weeks from their LMP with a pregnancy of unknown location (transvaginal US examination shows no intrauterine gestational sac and no ectopic pregnancy). They have been spotting intermittently but are otherwise asymptomatic. A quantitative hCG is 1000, 48 hours later it is 1400.
   1. What is the differential diagnosis?
   2. Would your approach to care differ if they desire to terminate vs continue the pregnancy?

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3. A person returns for a follow-up visit 5 weeks after a first-trimester procedural abortion because of intermittent bleeding since their procedure, and has been sexually active since the aspiration.

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EXERCISE 3.3

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?

1. 1. A person 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.
   2. Embryonic pole length 8 mm with no visible cardiac activity.
   3. A person at 5 weeks 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.
   4. A person at 10 weeks by LMP with intermittent spotting. On US, there is a flattened gestational sac without embryo or yolk sac, with cystic changes in the decidua resembling “swiss cheese”.

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EXERCISE 3.4

Purpose: To consider evaluation and management prior to an abortion. Not all material is covered in this Chapter.

1. A person 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. What further evaluation and management would you recommend?

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2. A person 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.

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3. A person 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 weeks vs. >14 weeks EGD?

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4. A person at 8 weeks gestation with a history of insulin-dependent diabetes presents for a uterine aspiration. A pre-procedure glucose level is 520 mg/dL.

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