Developed by RHEDI, this protocol provides guidance on performing aspiration abortion without sonography. A print-ready/PDF version of the protocol is also available.
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
- 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?
- To determine/confirm gestational age
- Patient amenorrheic since delivery or abortion, or from using long-acting progestin contraceptive (i.e., Depo, implant)
- Provider uncertainty with bimanual exam
- To identify structural details that may impact the procedure
- Twin/multiple gestation
- Bicornate or septate uterus
- 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.
- History of previous ectopic pregnancy
- Becoming pregnant with an IUD in place
- Adnexal mass on exam
- If low suspicion of ectopic, discuss ease, comfort, and cost of sono vs. initiating aspiration abortion with evaluation of tissue
- If high suspicion of ectopic, refer for definitive care as appropriate
- For assistance in managing difficult cases or complications
- For determining need for re-aspiration if insufficient tissue identified