Developed by RHEDI, this protocol provides guidance on performing aspiration abortion without sonography. A print-ready/PDF version of the protocol is also available.

Ultrasound-as-Needed Protocol
for Aspiration Abortion

NAF guidelines state:

“The use of ultrasound is not a requirement for the provision of first trimester abortion care. Proper use of ultrasound may inform clinical decision-making in abortion care.”

“Pregnancy must be confirmed, and gestational age must be assessed. . . . When gestational age cannot be reasonably determined by other means, ultrasonography should be used.”

-NAF, Clinical Policy Guidelines for Abortion Care, 2018

Most practices have routinized ultrasonography as a part of aspiration abortion for a variety of reasons. However, requiring sonography can limit access due to:
  • Financial cost to medical office of purchasing/maintaining an ultrasound machine
  • Difficulty obtaining necessary training on limited use ultrasound and/or cost of paying technician
  • Financial cost to patients obtaining these sonograms (especially if paying out of pocket)
  • Delays in care
  • Provider discomfort offering aspiration abortion WITHOUT ultrasound if training was only with ultrasound

Gestational age can be estimated using a combination of patient history, LMPConstant D, et al. Accuracy of gestational age estimation from last menstrual period among women seeking abortion in South Africa, with a view to task sharing: a mixed methods study. Reprod Health. 2017 Aug 22;14(1):100. doi: 10.1186/s12978-017-0365-7. Schonberg D, et al. The accuracy of using last menstrual period to determine gestational age for first trimester medication abortion: a systematic review. Contraception. 2014 Nov;90(5):480-7. doi: 10.1016/j.contraception.2014.07.004. Epub 2014 Jul 18., and bimanual exam.

So when is ultrasound indicated in aspiration abortion care?

Before the abortion
  • To determine/confirm gestational age
    1. Patient amenorrheic since delivery or abortion, or from using long-acting progestin contraceptive (i.e., Depo, implant)
    2. Provider uncertainty with bimanual exam
  • To identify structural details that may impact the procedure
    1. Twin/multiple gestation
    2. Bicornate or septate uterus
    3. Fibroids
  • To assess for ectopic riskMVA abortion is not effective at ending an ectopic pregnancy but it will not hasten a rupture or further complicate an ectopic pregnancy. Identifying villi or sac on tissue exam after aspiration can confirm intrauterine pregnancy in early pregnancy of unknown location.
    1. History of previous ectopic pregnancy
    2. Becoming pregnant with an IUD in place
    3. Adnexal mass on exam
      1. If low suspicion of ectopic, discuss ease, comfort, and cost of sono vs. initiating aspiration abortion with evaluation of tissue
      2. If high suspicion of ectopic, refer for definitive care as appropriate
During or after the abortion
  1. For assistance in managing difficult cases or complications
  2. For determining need for re-aspiration if insufficient tissue identified
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