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Pregnancy termination

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of pregnancy termination are prepared by our editorial team based on guidelines from the American College of Obstetricians and Gynecologists (ACOG 2021,2020,2013), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2016), and the Society of Family Planning (SFP 2014,2013,2012). ...
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Diagnostic investigations

Determination of gestational age: as per ACOG 2020 guidelines, confirm the pregnancy and determine gestational age before medication abortion.
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  • Pre-abortion evaluation

  • Evaluation for placenta accreta

Diagnostic procedures

Pathological examination: as per SFP 2013 guidelines, avoid obtaining routine pathological assessment of tissue aspirates as they add little diagnostic value in settings where gross or microscopic examination of pregnancy tissue is routinely carried out by well-trained and experienced staff members, and where local or regional laws mandating outside pathologic examination do not supervene.
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Medical management

Medication abortion, setting: as per ACOG 2020 guidelines, consider providing medication abortion by any clinician with the skills to screen patients for eligibility for medication abortion and to provide appropriate follow-up.
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  • Medication abortion (regimens)

  • Medication abortion (contraindications)

  • Pain management

  • Anti-D immunoglobulin

  • Antibiotic prophylaxis

  • Methylergonovine maleate prophylaxis

Surgical interventions

Surgical abortion, indications
As per SFP 2013 guidelines:
Recognize that surgical abortion can be performed successfully and safely as early as 3 weeks from the last menstrual period if a protocol exists including sensitive pregnancy testing, immediate and meticulous examination of the aspirate, and follow-up of questionable specimens to rule out an ectopic pregnancy or continuing gestation.
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Recognize that early surgical abortion carries lower morbidity and mortality than procedures performed later in gestation, and early aspiration may expedite the diagnosis of ectopic pregnancy, resulting in less invasive treatment.
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  • Surgical abortion (cervical preparation)

  • Surgical abortion (procedures)

  • Surgical abortion (paracervical vasopressin)

  • Surgical abortion (intraoperative ultrasound)

  • Surgical abortion (outcomes)

Specific circumstances

Patients with pregnancy of unknown location: as per SOGC 2016 guidelines, provide abortion care without delay in females with a pregnancy of unknown location and requesting medical abortion, provided that they have no clinical symptoms of ectopic pregnancy.
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Patient education

Pre-abortion counseling: as per ACOG 2020 guidelines, counsel patients that medication abortion failure rates, especially continuing pregnancy rates, increase as gestational age approaches 10 weeks.
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Follow-up and surveillance

Follow-up assessment
As per ACOG 2020 guidelines:
Do not obtain routine in-person follow-up after uncomplicated medication abortion. Offer the choice of self-assessment or clinical follow-up evaluation to assess medication abortion success. Consider obtaining follow-up evaluation by medical history, clinical examination, serum hCG testing, or ultrasound when medically indicated or preferred by the patient.
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Determine whether the gestational sac is present as the sole purpose if an ultrasound is obtained at follow-up after medication abortion. Recognize that the measurements of endometrial thickness or other findings do not predict the need for subsequent uterine aspiration.
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More topics in this section

  • Management of post-abortion bleeding

  • Management of ongoing pregnancy

  • Post-abortion contraception

Quality improvement

Health professional training: as per ACOG 2020 guidelines, train clinicians wishing to provide medication abortion services in performing uterine evacuation procedures or to ensure they are able to refer patients to a clinician having this training.
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