The roles of clinical assessment, human chorionic gonadotropin assays, and ultrasonography in medical abortion practice

Telephone follow-up after early medical abortion using Australia's first low sensitivity urine pregnancy test

BACKGROUND

Follow-up after early medical abortion (EMA) in Australia often entails tracking serum human chorionic gonadotropin levels or performing ultrasonography in-clinic. In other countries, methods of follow-up such as using a low-sensitivity urine pregnancy test (LSUPT), telephone evaluation and a questionnaire have been demonstrated to be safe and acceptable.

AIMS

To evaluate the safety and efficacy of telephone follow-up after EMA using an LSUPT and questionnaire.

MATERIALS AND METHODS

A prospective observational cohort study of patients undergoing telephone follow-up after EMA using an LSUPT and questionnaire was conducted from March 26 to July 31, 2020. Outcomes of patients who returned to clinic because of a positive LSUPT were evaluated and adverse event rates were calculated. Routinely collected adverse event information was used to compare complication rates during the evaluation period with that prior to introduction of the LSUPT.

RESULTS

During the study period, 2223 patients underwent the new protocol. One hundred and ninety-seven patients had a positive LSUPT at their telephone follow-up. One hundred and thirty-two had an incomplete abortion, 11 had a continuing pregnancy, 53 had a complete abortion and one left the clinic before full assessment.

CONCLUSIONS

Introduction of telephone follow-up with an at-home LSUPT reduced the number of patients requiring unnecessary clinic appointments, with over 90% of patients completing their follow-up at home. Complication rates during the study period were found to be at least comparable with previously identified organisational adverse events.

Analysis of Complications and Management After Self-Administration of Medical Termination of Pregnancy Pills

Background Medical abortion up to seven weeks of pregnancy by using a combination of mifepristone and misoprostol with careful follow-up is approved by WHO guidelines. But due to the counter sale of medical termination of pregnancy (MTP) pills, in our country, pregnant women have easy access to use them landing upon serious complications. The present study aims to assess the outcome of self-medicated MTP pills in pregnant women. Method This prospective observational study includes pregnant women who presented to our hospital for medical assistance due to complications after using the counter of MTP pills without medical consultation. Findings of ultra-sonographic and physical examination were noted along with analysis of subsequent management. Results The major complaint at presentation was excessive bleeding (78%). Out of 100 patients, 66% of cases were diagnosed as incomplete abortion, 6% as missed abortion, and 6% as unaffected pregnancy. Ectopic pregnancy was detected in 12% of cases. Sixty patients of incomplete abortion were managed with suction and evacuation and six were supplemented with misoprostol. All patients with ectopic pregnancies were managed surgically. Conclusion The majority of the pregnant women who took MTP pills presented with serious complications in the form of bleeding, incomplete/missed abortion, and ectopic pregnancy. Restriction of the over-the-counter dispensation of abortion pills needs to be strictly implemented and knowledge of women regarding the unfavourable outcome of MTP pill intake without proper consultation needs to be improved.

Barriers and Facilitators to the Implementation of First Trimester Medical Abortion With Mifepristone in the Province of Québec: A Qualitative Investigation

OBJECTIVE

Mifepristone became available in Canada in January 2017, but provincial medical policy delayed its use for medical abortion (MA) in Québec for 1 year. The objective of this study was to identify barriers and facilitators experienced by physicians who could potentially provide this newer abortion practice in Québec.

METHODS

This study was part of the Canadian Contraception and Abortion Research Team-Mifepristone Implementation Study, an observational, prospective, mixed-methods study. Interviews were conducted with physicians representing all health regions of Québec. Using thematic analysis guided by diffusion of innovation theory, the study identified key barriers and facilitators to implementation.

RESULTS

From January 2017 to March 2018, study investigators interviewed 25 family physicians and 12 obstetrician-gynaecologists. Most were women (81%), over 40 years old (65%), with >20 years in practice since residency (49%). Less than half of the sample provided abortion services (41%), and only 8% provided MA with mifepristone. Key barriers to implementation were: (1) uncertainty or confusion about policies regarding MA, (2) lack of human resources or support from colleagues, (3) uncertainty about product distribution, (4) confusion about professional collaboration, and (5) lack of local infrastructure. Key facilitators were: (1) perception of support and influence from colleagues, (2) previous experience with provision of first trimester MA, (3) requests for first trimester MA by patients or other physicians, and (4) knowledge of research on mifepristone MA.

CONCLUSION

Despite Health Canada's approval of mifepristone in Canada and supportive federal policies for provision of MA in primary care, physicians in the province of Québec face onerous barriers to the practice of mifepristone MA.

Routine β-Human Chorionic Gonadotropin Monitoring for Single-Dose Methotrexate Treatment in Ectopic Pregnancy

STUDY OBJECTIVE

To evaluate an alternative monitoring protocol without day 4 β-human chorionic gonadotropin (β-hCG) measurement for predicting the need for a repeated methotrexate (MTX) dose in patients undergoing single-dose MTX therapy for ectopic pregnancy (EP).

DESIGN

Single-center retrospective study (Canadian Task Force classification II-3).

SETTING

University-affiliated hospital.

PATIENTS

Included in the study were 184 EP patients treated with MTX between January 2009 and December 2016.

INTERVENTIONS

Single-dose MTX treatment (50 mg/m²).

MEASUREMENTS AND MAIN RESULTS

The patients were treated with repeated doses of MTX every 7 days, if necessary, according to Stovall's protocol, or with laparoscopic surgery in cases of tubal rupture. The success of a single-dose of MTX according to the alternative measure was defined as a >50% decrease in the β-hCG level between days 1 and 7 in clinically stable patients. The sensitivity, specificity, false-negative rate, false-positive rate, and attributable risk of this new monitoring measure were calculated and compared with the traditional regimen. The new protocol had a sensitivity and specificity of 100% and 88.7%, respectively, for predicting a required second dose in patients whose day 1 β-hCG levels were <2000 mIU/mL. For patients with day 1 β-hCG level ≥2000 mIU/mL, both monitoring regimens had the same efficiency.

CONCLUSIONS

The new monitoring model without the day 4 β-hCG measurement may offer both patients and clinicians multiple options to monitor single-dose MTX therapy for selected EP patients, with a comparable clinical efficiency to Stovall's protocol and less expense and follow-up burden to patients.

Medical Abortion

OBJECTIVE

This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.

INTENDED USERS

Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.

TARGET POPULATION

Women with an unintended first trimester pregnancy.

EVIDENCE

Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).

BENEFITS, HARMS AND/OR COSTS

Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.

SUMMARY STATEMENTS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care

RECOMMENDATIONS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.

An overview of medical abortion for clinical practice

Medical abortion is a safe, convenient, and effective method for terminating an early unintended pregnancy. Medical abortion can be performed up to 63 days from the last menstrual period and may even be used up to 70 days for women who prefer medical abortion over surgical abortion. Counseling on the adverse effects and expectations for medical abortion is critical to success. Medical abortion can be performed in a clinic without special equipment, and it is perceived as more "natural" than a surgical abortion by many women. Follow-up for medical abortion can be simplified to include only serum human chorionic gonadotropin measurements when necessary, although obtaining an ultrasound remains the criterion standard. Pain associated with medical abortion is best treated with nonsteroidal anti-inflammatory medications, possibly in combination with opioid analgesics. Medical abortion can contribute to continuity of care for women who wish to remain with their primary care providers for management of their abortion.

Simplified medical abortion using a semi-quantitative pregnancy test for home-based follow-up

OBJECTIVE

To simplify follow-up after medical abortion by examining whether women could use a semi-quantitative pregnancy test at home to screen for ongoing pregnancy.

METHODS

Three hundred women seeking medical abortion at a tertiary hospital in Vietnam participated in the study. Participants used a semi-quantitative pregnancy test at the hospital to estimate baseline human chorionic gonadotropin (hCG) levels and administered another test at home 2 weeks later for comparison. Women interpreted the test result at home and then returned to hospital for follow-up care. At this visit, self-assessment was verified. To assess further the feasibility of the test as a follow-up tool in service delivery, 200 additional women completed a user comprehension survey.

RESULTS

The tests identified all 11 ongoing pregnancies among study participants (100% sensitivity; 89.7% specificity). Women reported that the test was easy to use (255/292 [87.3%]) and that provider instructions helped them to use the test (291/292 [99.7%]).

CONCLUSION

Semi-quantitative pregnancy tests offer high sensitivity and negative predictive value. If user instructions can be further simplified, the tests could be used in lieu of transvaginal ultrasound and/or serum hCG at clinic-based follow-up or by women themselves for home-based follow-up. Clinical trials.gov:NCT01150279.

Clinical diagnosis of completeness of medical abortion by nurses: a reliability study in Mozambique

BACKGROUND

The provision of medical abortion continues to rely on routine use of ultrasound to confirm expulsion of pregnancy. However, the absence of ultrasound in most of the health facilities in developing countries and the additional training required to enable providers to use ultrasound is often prohibitive. The purpose of this study was to compare clinical history and physical examination with ultrasound in confirming completion of abortion.

STUDY DESIGN

A total of 718 women consented for medical abortion with misoprostol and were assessed for pregnancy expulsion by nurses and gynecologists. Nurses used history and physical examination while gynecologists used ultrasound to establish their diagnoses.

RESULTS

Nurses' clinical diagnoses for complete abortion, incomplete abortion and ongoing pregnancy were 83% (SE 0.01), 15% (SE 0.01) and 2% (SE 0.01), respectively. When gynecologists used ultrasound, the diagnoses for complete abortion, incomplete abortion, an ongoing pregnancy were 80% (SE 0.01), 17% (SE 0.01) and 3% (SE 0.01), respectively. Overall, nurses agreed with gynecologist diagnoses in 84% of cases, with a κ coefficient of 0.49 (SE 0.06) and chance-corrected first-order agreement (AC(1)) of 0.81 (SE 0.02). Agreement was very high for the diagnosis of complete abortion (AC(1) 0.89; SE 0.02), while it was moderate for ongoing pregnancy (AC(1) 0.58; SE 0.22) and incomplete abortion (AC(1) 0.45; SE 0.08).

CONCLUSIONS

Clinical history and physical examination alone, without the use of ultrasonography, are effective for the determination of successful pregnancy expulsion. However, greater emphasis is required on the clinical identification of ongoing pregnancy during any training of providers.

Cornual ectopic pregnancy in a female with initial negative ultrasound

Cornual pregnancies are a rare form of ectopic pregnancy that can be misdiagnosed as an intrauterine pregnancy via ultrasound. We report a 16-year-old adolescent girl with a cornual ectopic pregnancy and subsequent rupture in the emergency department.

Value of "minimum menstrual age" in determining early pregnancy failure

OBJECTIVES

The purposes of this study were to assess a discriminatory "minimum menstrual age" (28 days + number of days elapsed between the first positive pregnancy test result and sonogram) for the diagnosis of early pregnancy failure when no embryonic/fetal heartbeat is seen and to compare minimum menstrual age dating with last menstrual period and sonographic dating.

METHODS

We conducted a retrospective study of 338 initial first-trimester sonographic examinations among women with suspected early pregnancy failure. A minimum menstrual age for each was calculated, and pregnancy outcomes were assessed. The predictive value of the minimum menstrual age for the pregnancy outcome was assessed at both 42 and 49 days and compared to that of dating by the last menstrual period and sonography.

RESULTS

Among a study cohort of 338 patients, the average gestational age calculated by the last menstrual period was 53 days; by sonography, it was 50 days; and by the minimum menstrual age, it was 35 days (P < .01). All cases in which there was no sonographically detectable embryonic heartbeat above a minimum menstrual age of 42 days resulted in pregnancy failure.

CONCLUSIONS

The minimum menstrual age is a conservative estimate of the gestational age, with an estimated positive predictive value of 100% for early pregnancy failure when no embryonic heartbeat is seen after 42 days. The minimum menstrual age can be combined with other existing diagnostic clues to predict early pregnancy failure with greater accuracy.

Comprehensive analysis of the use of pre-procedure ultrasound for first- and second-trimester abortion

BACKGROUND

The use of ultrasound (US) is common in some settings before an abortion procedure. However, its positive effect on the safety or efficacy (ability to complete abortion) of the procedure has not been established. Our aim was to determine whether the use of pre-procedure US improves safety and/or efficacy of the abortion procedure.

METHODS

We searched the following databases: Pubmed, Embase, Lilacs and Popline; reference lists of retrieved papers; and Google. We considered any controlled trial comparing women seeking abortion who received pre-procedure US to those who did not. Our outcome measures were efficacy of the abortion, complication rates and side effects.

RESULTS

We did not identify any controlled trials or systematic reviews comparing the use of pre-procedure US to no US prior to abortion.

CONCLUSIONS

Ultrasound is widely used in pregnancy to estimate gestational age and to detect any abnormalities of the pregnancy or uterus. The effect of its use among women undergoing abortion is unclear, and only indirect evidence is available.

Gestational trophoblastic tumor with liver metastasis after misoprostol abortion

BACKGROUND

Early elective medical abortion is performed frequently in different countries of the world. Serious complications like gestational trophoblastic neoplasia (GTN) are uncommon and mostly nonmetastatic. High risk metastatic GTN following medical abortion is a rare event which may occur coincidentally.

CASE

A 26 year-old-woman, gravida 2 para 1, 6 weeks after misoprostol abortion presented with sever nausea, vomiting, and right upper abdominal pain. Human chorionic gonadotropin (hCG) level was 2,500,000 mIU/ml and metastatic work up revealed multiple liver metastases. She totally received nine cycles of EMA-CO (ethoposide- methotrexate- actinomycin- cyclophosphamide, vincristine) regimen for treatment and consolidation. Six months after treatment she is in complete remission.

CONCLUSION

Follow up of patients after medical abortion by means of single serum hCG measurement is highly recommended for early diagnosis of complications including gestational trophoblastic tumor. EMA-CO regimen seems to be an effective and safe treatment for liver metastatic gestational trophoblastic neoplasia.

First-trimester ultrasound: current uses and applications

This article is aimed to aid the sonographer and medical care provider in better interpretation and clinical application of first-trimester ultrasound findings in early pregnancy. We review current uses, applications, and interpretations of first-trimester ultrasound. A discussion of basic embryology and normal as well as abnormal first-trimester sonographic findings are discussed. We also cover the utility of the first-trimester ultrasound in screening for fetal aneuploidy. Attention is also given to the role of the first-trimester ultrasound in the prediction of adverse perinatal and maternal outcomes.

Can mifepristone medical abortion be simplified? A review of the evidence and questions for future research

Mifepristone medical abortion has been a valuable addition to the reproductive health options of women. Aspects of its provision have however sometimes limited its accessibility and use. This article summarizes existing evidence for simplifying the provision of medical abortion and thus increasing its availability. We identify three ways through which medical abortion provision might be simplified based on existing evidence and suggest five additional simplifications that require further research to confirm their safety and efficacy.

Medication abortion employing routine sequential measurements of serum hCG and sonography only when indicated

OBJECTIVES

This study was designed to demonstrate the safety and efficacy of providing medication abortion in a primary care site without routine use of pre- and postprocedure transvaginal sonography.

METHODS

We performed a retrospective record review of 172 consecutive patients choosing medication abortion at our clinic. Our protocol used sonography only as needed for specific indications. All patients were intended to be followed up with serum human chorionic gonadotropin (hCG) testing pre- and posttreatment.

RESULTS

Of the 151 patients not lost to follow-up, 96 (63%) had pretreatment sonography according to protocol or physician preference and 55 did not. Ninety-nine percent (95/96) of those receiving initial sonography had a successful, and uneventful, medication abortion treatment, while 98.2% (54/55) of those not receiving an initial sonography did so. This difference was not statistically significant (.597 by one-sided Fisher's Exact Test). All 119 of the women who did not receive postabortion sonography aborted completely. Only 4 of the 91 women who had both pre- and postprocedure hCG measurements, all of whom aborted successfully, had follow-up-to-initial hCG ratios of greater than 0.2 (20%).

CONCLUSION

Using a clinical protocol that involves obtaining pre- and posttreatment serum hCG measurements, with sonograms only when indicated, has similar outcomes to a protocol that uses mandatory pre- and posttreatment sonograms.

Mifepristone-induced abortion in one horn and a growing fetus in another horn in a patient with a twin pregnancy in a bicornuate uterus

OBJECTIVE

To report a case of mifepristone-induced abortion in only one horn but a growing fetus in another horn for a twin pregnancy in a bicornuate uterus.

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Taiwan.

PATIENT(S)

A 31-year-old woman who conceived spontaneously presented with 37 days' gestation.

INTERVENTION(S)

Mifepristone 600 mg orally followed by misoprostol 400 mug orally 2 days later.

MAIN OUTCOME MEASURE(S)

Termination of pregnancy.

RESULT(S)

Induced abortion in only one horn but a growing fetus in another horn for a twin pregnancy in the bicornuate uterus detected by ultrasound. Surgical abortion with vacuum curettage was performed, and menstruation resumed 1 month later.

CONCLUSION(S)

As medical abortion with mifepristone and misoprostol becomes more prevalent, more studies are necessary to establish the dosage and regimens for multiple pregnancies associated with uterine anomalies.

Review of medical abortion using mifepristone in combination with a prostaglandin analogue

Induced abortion is still a major health problem in the world and the most frequently performed intervention in obstetrics and gynecology with an estimated total of 46 million worldwide each year. Medical abortion with mifepristone and prostaglandin was first introduced in 1988 and is now approved in 31 countries. This combination of drugs has recently been included in the List of Essential Medicines by the World Health Organisation. The present review summarizes the development, physiology and the development of the currently used regimens.

Monitoring Medical Abortion Using Mifepristone/Misoprostol Combination with Ultrasonogram and Serum Human Chorionic Gonadotropin

OBJECTIVE

The oral mifepristone/misoprostol combination (MMC) is safe for medical abortion in early pregnancy. The abortion status in MMC-treated pregnancies at Taipei Medical University-Wan Fang Medical Center was determined by ultrasonography, serum beta-human chorionic gonadotropin (beta-HCG), and histopathology.

METHODS

All women at less than 49 days since the last menstruation who asked for legal abortion were evaluated by ultrasonography. They then received 600 mg of oral mifepristone followed 48 hours later by 600 microg of misoprostol. Women who had vaginal spotting or bleeding after 14 days were included in this study and underwent transvaginal ultrasonography, serum beta-HCG measurement and vacuum aspiration or therapeutic dilatation and curettage (D&C) on day 14. Specimens were identified by histopathology. Abortion status was determined from linear regression of serum beta-HCG and endometrial thickness.

RESULTS

Of 35 women who underwent vacuum aspiration or therapeutic D&C, histopathology showed that 20 had decidual tissue and 15 had gestational tissue. Logistic regression showed that the distance measurement to the logistic regression line differed significantly between complete and incomplete abortion (p < 0.05).

CONCLUSION

In this study, serum beta-HCG assays in addition to ultrasonographic evaluation helped to discriminate abortion status after oral MMC.

Willing and able? Provision of medication for abortion by future internists

INTRODUCTION AND BACKGROUND

The development of medications such as mifepristone (RU486) has created the opportunity to introduce medication abortion as a component of office practice.

METHODS

Two hundred twelve residents training in internal medicine, family practice, and gynecology at 11 residency programs completed anonymous surveys assessing willingness to provide medication for abortion and perceived barriers to future provision of mifepristone.

RESULTS

Residents training in internal medicine knew less about mifepristone and preabortion screening than other primary care trainees. Forty-two percent of internists, 84% of family practitioners, and 83% of gynecologists were willing to prescribe mifepristone (p < .001). Many internists were concerned about lacking adequate "backup" access to vacuum aspiration services (84% of internists, 74% of family practitioners, 35% of gynecologists; p < .001). In multivariable analysis, the training-related factors most predictive of whether an internist was willing to provide medication for abortion were feeling that mifepristone is very safe, abortion services are needed by the patients served, knowing to check an ultrasound before inducing abortion, and having no concern of how to manage bleeding or of lacking adequate backup should vacuum aspiration be needed.

CONCLUSIONS AND DISCUSSION

Many (42%) future internists are willing to provide mifepristone, but most lack adequate knowledge of mifepristone and preabortion screening. As access to abortion services is limited in many U.S. counties, internists who are willing to provide mifepristone should be offered the necessary training to do so safely.

Ability of the clinician and patient to predict the outcome of mifepristone and misoprostol medical abortion

We performed this analysis to evaluate the ability of both women and their clinicians to predict pregnancy expulsion after using mifepristone and misoprostol for medical abortion up to 63 days gestation. Women who participated in a multicenter, randomized trial comparing misoprostol 6-8 h vs. 23-25 h after mifepristone attended a follow-up visit approximately 7 days after mifepristone treatment. Each subject was asked if she felt she had expelled the gestational sac. Clinicians also assessed if the sac had been expelled based on the woman's history. Vaginal ultrasonography was then performed to assess the uterine cavity. Of the 1080 women enrolled in the multicenter study, 931 (86.2%) who attended the first follow-up visit by study day 12 and did not have a uterine suction aspiration prior to this visit were included in this analysis. Vaginal ultrasonography at the first follow-up visit demonstrated expulsion in 915 [98.3%, 95% confidence interval (CI): 97.2-99.0] women. Overall, sensitivity, specificity, and positive and negative predictive values for subjects were 96.5%, 31.3%, 98.8% and 13.5%, respectively. When both the clinician and patient felt that the gestational sac had passed (n = 880 [94.5%, 95% CI: 92.9-95.9]), expulsion was confirmed by sonography in 99.1% (95% CI: 98.2-99.6) of cases. Women and clinicians are very accurate at determining expulsion of gestational sac during medical abortion with mifepristone and misoprostol without ultrasonography or a physical examination.

Routine follow-up visits after first-trimester induced abortion

Routine follow-up visits after abortion are intended to confirm that the abortion is complete and to diagnose and treat complications. Many clinicians also take advantage of the follow-up visit to provide general reproductive health care: discussing contraceptive plans and providing family planning services; diagnosing sexually transmitted infections; performing a Pap test or discussing abnormal Pap results. We reviewed the evidence related to the routine postabortion follow-up visit. Other than mifepristone medical abortion performed at 50 days of gestation or later and methotrexate medical abortion, we found little evidence that mandatory follow-up visits typically detect conditions that women themselves could not be taught to recognize. In addition, the natural history of the most severe complications after abortion-infection and unrecognized ectopic pregnancy-have time courses inconsistent with the usual timing of the follow-up visit. Costs associated with this visit can be great. These include travel expenses, lost wages, child-care expenses, privacy and emotional burdens for women, and scheduling disruptions and the related opportunity costs caused by "no-shows" for the provider. Follow-up appointments should be scheduled for those women likely to benefit from a physical examination. For the remainder of women, simple instructions and advice about detecting complications, possibly coupled with telephone follow-up, might suffice. Although arguably valuable in their own right, counseling, family planning services, or sexually transmitted infection diagnosis and treatment should not be so inflexibly bundled with postabortion care. Protocols that require in-person follow-up after abortion may not make the best use of a women's time or abilities, or of the medical system.

Role of routine ultrasonography in monitoring the outcome of medical abortion in a clinical setting

BACKGROUND

Clinical methods generally used to evaluate the completeness of medical abortion are not accurate. There are no published reports evaluating the role of routine ultrasonography in monitoring the outcome of medical abortion. The purpose of this study was to investigate whether routine transvaginal ultrasonography (TVS) at the follow-up visit after medical abortion can accurately identify women who will require surgical intervention.

DESIGN

Retrospective review of medical records and charts of all women undergoing medical abortion in the first trimester of pregnancy between January 1999 and December 2001.

METHODS

Medical abortion was performed using oral mifepristone and a vaginal prostaglandin analog before 63 days gestation. All women had an initial TVS to confirm intrauterine pregnancy and gestational age, and another TVS at the follow-up visit 2-3 weeks later to assess the completeness of abortion. Surgical evacuation of the uterus was allowed as indicated on clinical grounds but not on the basis of ultrasound findings only.

RESULTS

A total of 690 women consented to medical abortion during the study period. Eleven of these women were excluded from the study for various reasons. Of the remaining 679 cases, 95% (645/679) had a documented follow-up at the hospital. The pregnancy termination rate among these women was 99.2% (640/645) and TVS identified all five cases of continuing pregnancy at the follow-up. A total of 66 (10.2%) patients had complications. The uterine cavity was empty on TVS at the follow-up visit in 84.8% (547/645) of cases and only 3.1% (17/547) of them required surgical aspiration/curettage due to excessive or prolonged vaginal bleeding. In the remaining 15.2% (98/645) the uterine cavity was not empty, and 43.9% (43/98) of them had a curettage. The risk of requiring a surgical intervention was significantly higher [odds ratio (OR) 24.4; 95% confidence interval (95% CI) 14.9-39.7] when the uterine cavity was not demonstrated to be empty at the follow-up visit 2-3 weeks after medical abortion. However, 59.1% (55/93) of women did not require surgical intervention despite ultrasound evidence of thick endometrial echo-complex.

CONCLUSION

Routine TVS 2-3 weeks after medical abortion appears to be an efficient means of accurately identifying the cases of ongoing pregnancy and diagnosing a complete abortion. Although TVS could be used as an adjunct to clinical examination to diagnose an incomplete expulsion, it does not accurately differentiate those women who require surgical intervention from those who do not.

Accuracy of serum beta-human chorionic gonadotropin cutoff values at 42 and 49 days' gestation

OBJECTIVE

The accuracy of serum beta-human chorionic gonadotropin levels as cutoff values for estimating gestational age was studied.

MATERIAL AND METHODS

A database was created using information from previously performed research studies, which allowed entry of women both less than and greater than 49 days' gestation, involving medical abortion. Serum beta-human chorionic gonadotropin determinations and vaginal ultrasonography were performed in all studies before treatment. A total of 574 women had data available for analysis. A receiver operating characteristic curve was created to evaluate the predictive value of potential beta-human chorionic gonadotropin cutoff values for 42 and 49 days' gestation.

RESULTS

Appropriate serum beta-human chorionic gonadotropin cutoff values for 42 and 49 days' gestation were 23,745 mIU/mL (sensitivity, 96%; specificity, 91%; positive predictive value, 68%; negative predictive value, 99%) and 71,160 mIU/mL (sensitivity, 95%; specificity, 62%; positive predictive value, 76%; negative predictive value, 91%), respectively. Under 42 days' gestation, the serum beta-human chorionic gonadotropin-time relationship appears to be linear, with a greater diversity of individual values after 42 days.

CONCLUSION

Serum beta-human chorionic gonadotropin values can be used with reasonable accuracy to screen for a gestational age up to 49 days' gestation.