Abortion and Contraception Medical Procedures

Abortion Care

• Labs to perform:
  • H and H (if > 10 weeks or history of anemia)
  • Rh status
  • Quantitative Beta hCG
• Determine if ultrasound is required:
  • Concern for ectopic pregnancy
  • Uncertain LMP
  • Irregular menses
  • Vaginal bleeding
  • Size/date discrepancy
• Initiating contraception:
  • Implant can be inserted at the time of mifepristone
  • Pills, patch, and ring can be started the day after mifepristone
  • IUD can be inserted at the follow-up visit after confirming completion

Assessing Completion of Abortion

• In-office or phone visit within 1-2 weeks
• Hx of abortion completion:
  • Appropriate bleeding after misoprostol
  • No further pregnancy symptoms
• Declining quantitative Beta hCG:
  • 80% decline in Beta hCG after 1 week
• Ultrasound:
  • Verify prior gestation sac is no longer present
• Negative home UPT:
  • 4 weeks after mifepristone
  • If positive UPT, need evaluation for ongoing pregnancy and possible aspiration abortion

Aspiration Abortion

• Takes minutes, no follow-up needed
• Can be performed up to 14 weeks safely
• Multiple anesthesia options
• Shorter bleeding period
• Disadvantages:
  • Requires pelvic instrumentation
  • Less patient control
  • Potential medication adverse effects
• Analgesia and anxiolytic options:
  • NSAIDs
  • Local anesthesia
  • Moderate or deep sedation
• Additional comfort measures:
  • Heat packs
  • Music
  • Patient-centered language vs. triggering language
• Procedure lasts about 5-10 minutes
• IUD can be inserted immediately after the procedure

Cervical Cancer Screening Guidelines

• High-risk HPV necessary but not sufficient for the development of squamous cervical neoplasia
• HPV infection:
  • Transient or persistent
  • HPV 16 and 18 responsible for most types of HPV
• Factors in persistence:
  • Genotype of HPV
  • Cigarette smoking
  • Compromised immune system
  • HIV
  • Age > 30 years at the time of infection
• Risk factors for cervical CA:
  • Age: coitarche < 25 years old
  • Gynecologic health history
  • Menstrual history
  • Sexual health
  • Contraceptive use
  • Pregnancy history
  • History of vaginal and sexually transmitted infections
  • Genital and breast hygiene
  • Gynecologic procedures and surgeries
  • Urologic and rectal health
  • Cervical cancer screening

Physical Exam for Gynecologic Visit

• General physical exam:
  • Height
  • Weight
  • Blood pressure
  • Pulse
  • Temperature
  • BMI
• General appearance:
  • Posture
  • Emotional state
  • Appropriateness of dress
  • Speech pattern
  • Social interaction
• Eyes, ears, nose, throat
• Neck
• Thyroid
• Chest and lungs
• Spine
• Kidneys (checking for CVA tenderness)
• Reflexes
• Peripheral circulation and varicosities (inspect the legs and feet)
• Abdomen exam
• Breasts and axillary lymph nodes
• Breast exam starts with the patient in a sitting position

Reproductive Goals/Intentions: PATH Questions

• PA: do you think you might like to have (more) children at some point?

Cervical CA Screening Guidelines

• Reflex HPV will test for hrHPV if the cytology is ASCUS (but only order this hrHPV in women > 25 years old)
• Conventional (slide-based) cannot order HPV testing
• Co-test Pap: only liquid-based; does cytology and HPV high-risk are both performed
• Reflex to 16, 18/45 will test for genotypes if hrHPV is positive
• Primary hrHPV test:
  • Only 2 FDA-approved primary tests
  • Same collection procedure as liquid Pap
  • Tests for genotypes 16 and 18 and twelve other hrHPV types
  • If positive, reflex to cytology is preferred
  • If 16/18 positive and unable to reflex from the same sample, colposcopy plus cytology are acceptable

Screening Special Populations

• HIV-infected and immunocompromised:
  • Start cytology alone within 1 year of onset of sexual activity or within 1st year of HIV diagnosis, no later than 21
• Under 30 years old:
  • Need to repeat cytology in 1 year after normal Pap; after 3 consecutive normal annual Paps, then can screen every 3 years
• Over 30 years old:
  • Need to do cytology alone or co-testing; co-testing can go to every 3 years after 1 negative co-test