History and Physical

  • Review medical history, sexual and reproductive history, meds, 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 Chapter 5: Managing Complications Table
    • Endocrine (diabetes, hyperthyroidism)
    • Renal and hepatic disease (affecting drug metabolism and clearance)
    • Neurologic (seizure disorder) or psychiatric (severe depression or anxiety)
  • Abortion is an essential and urgent service. Minimize delays, especially in people with significant medical problems, as risk increases with advancing gestational age. Medical conditions warrant management or referral prior to abortion.
  • Physical exam as indicated by history and patient symptoms
  • Pelvic exam is not necessary for medication abortion with sure LMP (WHO 2022).
  • Bimanual and speculum exam may be performed immediately prior to an aspiration.
    • Bimanual for uterine size / position (see Limitations in Table above)
    • Speculum exam can assess cervicitis warranting testing / treatment

Lab Tests if Indicated

No routine pre-abortion lab testing is needed in patients without underlying conditions. Some labs are indicated by history, exam or dating. Lack of testing should not be a barrier to access.

  • Tests pertinent to underlying conditions:
    • Glucose for patients with IDDM
    • INR for patients on certain anti-coagulants (Warfarin) > 12 weeks
  • Rh (D) testing standards are evolving: < 12 weeks from LMP, may forego Rh testing and Rh-D IG for MAB (NAF May 2022; WHO 2022) (See Ch 5 Rh Isoimmunization)
    • May forgo Rh testing if patient wants no future children or declines testing.
    • Document Rh status or informed waiver if declining Rh testing
    • If Rh negative, can use donor card, chart, patient report, or lab.
  • Hemoglobin: If history / symptoms of anemia (fingerstick; not complete CBC).
  • Chlamydia (CT) / Gonorrhea (GC): asymptomatic patients ≤ 25 or at increased risk (i.e. new or multiple sexual partners in last year). May refer for testing if not at your facility.
    • If cervicitis on exam, test (GC/CT), and treat empirically
    • Universal antibiotic prophylaxis is evidence-based for aspiration abortion (Low 2012; Achilles 2011); unclear for EPL aspiration (Lissauer 2019). See Chap 5.

Selected Health Condition Considerations and Management in First Trimester Aspiration Abortion

Adapted from Ipas 2016

Health Condition Considerations
Hypertension (HTN)
  • 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.
Seizure Disorder
  • 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.
Clotting disorders
  • Anticoagulation medications can be continued with relatively low risk of additional blood loss throughout the first trimester (Lee 2021).
Bleeding Disorders
  • 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).
Insulin-Dependent Diabetes
  • 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.
Heart Disease
  • 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
Active respiratory infection
  • 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.
Uterine Fibroids
  • 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.
Previous Cesarean Delivery
  • 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).
Congenital Uterine Anomalies
  • 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 or substance use disorders
  • 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


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