RHEDI
Ultrasound-as-Needed Protocol for Medication Abortioncenter0NAF 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.” “Gestational age must be verified to be within the limits of the facility medical abortion protocol.” -NAF, Clinical Policy Guidelines for Abortion Care, 2020020000NAF 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.” “Gestational age must be verified to be within the limits of the facility medical abortion protocol.” -NAF, Clinical Policy Guidelines for Abortion Care, 2020Medication abortion can be performed without routine use of ultrasound. Ultrasound is a tool that, in consideration of patient history, exam findings, and personal preferences, can sometimes be useful in caring for patients who seek abortion care. Although most patients do not need an ultrasound prior to medication abortion, many practices have routinized ultrasonography for a variety of reasons. Requiring routine sonography can limit access due to:Financial cost to medical office of purchasing/maintaining an ultrasound machineDifficulty obtaining necessary training on limited use ultrasound and/or cost of paying technicianFinancial cost to patients obtaining these sonograms (especially if paying out of pocket)Delays in care Provider discomfort offering medication abortion WITHOUT ultrasound if training was only with ultrasoundWhen might ultrasound be indicated in medication abortion care?To determine gestational ageThe gestational age can usually be estimated using a combination of patient history, LMP, and exam. But ultrasound may be needed when:Gestational age is determined to be > 77 days (>11 weeks) by patient LMPIf ultrasound is available on-site: if LMP >77 days ago, perform sono FIRST to determine GAIf ultrasound is off-site: if LMP >77 days ago, consider performing bimanual exam FIRST and if exam is consistent with pregnancy <11 weeks, proceed with MAB. If exam suggests pregnancy >11 weeks, refer out for sono/abortionPatient had no menses and it has been more than 77 days since delivery or abortionPregnancy occurs while patient is amenorrheic from using long-acting progestin contraceptive (i.e., Depo, implant)Provider uncertainty with bimanual examTo assess for ectopic riskMost patients do not need an ultrasound to rule out ectopic pregnancy. Certain risk factors can be assessed through history that would indicate a greater need for ultrasound evaluation, including:History of previous ectopic pregnancyPatient became pregnant with an IUD in placeVaginal bleeding Unilateral pelvic pain Adnexal mass on examIf low-suspicion of ectopic, discuss ease, comfort, and cost of sono vs. initiating medication abortion with close (3 day) follow upIf high-suspicion of ectopic, refer for definitive care as appropriateTo confirm that abortion is completeThe abortion can usually be determined to be complete using a combination of patient history and urine or serum HCG. However, ultrasound my be indicated when:History not consistent with successful medication (no bleeding or cramping)Patient reports still feeling pregnant 1 week after taking misoSerum HCG has not declined by 60% in 2-3 days or by 90% in 1 weekNo initial HCG was drawn and urine HCG is still positive more than 3 weeks later ................
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