Ultrasound Evaluation of the Endometrium After Medical Termination of Pregnancy

Self-managed Medication Abortion in the United States

Self-managed abortion (SMA) is ending a pregnancy without medical supervision, either by obtaining medications (known as self-managed medication abortion) or through other means. Many factors influence a person's decision to pursue self-managed abortion, such as time constraints, financial considerations, and local availability of abortion services. We present on the prevalence, methods and best practices for clinicians in the United States who may interface with individuals undergoing self-managed medication abortion at any point in the process through a harm reduction approach.

Ultrasonographic features of the endometrium following successful medical termination of early pregnancy

OBJECTIVE

Ultrasonographic features of the endometrium are often assessed when deciding the necessity of surgical intervention following early medical abortion. Knowledge is therefore needed on the ultrasonographic appearance of the endometrium following successful medical abortion in order to avoid unnecessary surgical interventions. We aimed to assess endometrial thickness and echogenicity at multiple time points following successful early medical abortion.

STUDY DESIGN

We conducted a retrospective study in the largest office-based abortion providing clinic in Denmark. Using archived ultrasonographic images, we assessed endometrial thickness and echogenicity following all early medical abortions that did not need surgical intervention or repeated medication for completion during the years 2014-2017.

RESULTS

Ultrasonographic endometrial features were assessed 1854 times following 1074 early medical abortions. Median endometrial thickness in the 1st week from induction was 13 milimeters (mm; lower-upper quartile 11-17 mm). For the 2nd, 3rd, 4th, and >4th week, the median endometrial thickness was found to be 11 mm (9-15 mm), 11 mm (8-14 mm), 12 mm (9-16 mm), and 11 mm (8-14 mm), respectively. Of the ultrasonographic examinations performed in the 1st week from medical induction, 24.7 % showed a heterogenous endometrium. For 2nd, 3rd, 4th, >4th week, the frequency of heterogeneity was 23.9 %, 16.3 %, 21.3 %, 18.9 %, respectively. A total of 151 abortions (14.1 %) were each examined three times, median time of examination being day 7, 15, and 26 following induction. Among these abortions, the three most common patterns of change in endometrial thickness were "decreasing" (37.7 %), "increasing-decreasing" (23.2 %), and "decreasing-increasing" (21.9 %). Further, 49.7 % of the 151 abortions showed a homogenous endometrium at all three examinations, 17.2 % showed a heterogenous endometrium at first examination and a homogenous endometrium the following two examinations, and 9.9 % showed a heterogenous endometrium at the first two examinations followed by a homogenous endometrium.

CONCLUSION

In early medical abortions completed without secondary intervention, endometrial thickness and echogenicity varied clinically significantly for weeks following the medical induction. Every possible pattern of change in endometrial thickness and echogenicity was observed.

Post-abortion Complications: A Narrative Review for Emergency Clinicians

An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally “safe” (performed in a safe, clean environment with experienced providers and no legal restrictions) or “unsafe” (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.

Expectant versus medical management for retained products of conception after medical termination of pregnancy: A randomized controlled study

BACKGROUND

Despite the rise of medical treatments for the termination of pregnancy, to-date no prospective trial has evaluated the efficacy of misoprostol in treating retained products of conception after induced termination of pregnancy.

OBJECTIVE

To compare medical management with misoprostol with expectant management for retained products of conception after first trimester medical termination of pregnancy.

STUDY DESIGN

An open-label randomized controlled trial conducted at a university-affiliated tertiary medical center. Consenting consecutive women who underwent a routine 3-week follow-up evaluation after medical termination of pregnancy and had a sonographic suspicion of retained products of conception, defined as sonographic evidence of intra-uterine remnant (>12 mm) with a positive Doppler flow, were recruited. The participants were randomized into a medical treatment group (800 mcg of sublingually administered misoprostol) or expectant management. They all underwent repeat ultrasound scans every 2 weeks until a maximum of 6 weeks, and those suspected for persistent retained products of conception were referred to operative hysteroscopy. The primary endpoint was successful treatment defined as no need for surgical intervention due to persistent retained products of conception within 8 weeks from pregnancy termination.

RESULTS

There were no significant differences in demographic characteristics between the study groups. The median sonographically demonstrated retained product length was 20 mm (interquartile range, [IQR] 17-25) in the medically managed group compared with 20 mm (IQR 17-26) in the expectantly managed group (P=.733). Treatment succeeded in 42/68 (61.8%) women in the medically managed group compared with 36/63 (57.1%) women in the expectantly managed group (relative risk [RR] = 1.12, 95% confidence interval [CI] 0.74-1.70; P=.590). There was no difference in adverse outcomes between the 2 groups.

CONCLUSION

There is no clinically meaningful advantage for medical treatment with misoprostol compared with expectant management after first trimester medical termination of pregnancy in women with suspected retained products of conception. Surgical intervention can be avoided in up to 60% of women who are managed expectantly over 8 weeks of follow-up.

[Evaluation of the success of medical abortion by a plasma hCG control threshold]

OBJECTIVES

In France, monitoring of the success of medical abortion is recommended 2 to 3 weeks after the procedure. However, there is no clear consensus on the modalities of this monitoring. The main objective of this study is to identify a threshold of serum hCG (human chorionic gonadotropin) control for medical abortions ≤7 weeks of gestation below which success can be confirmed without recourse to pelvic ultrasound.

METHODS

This is a retrospective multicenter study conducted over a 14-month period. The serum hCG level, measured between the 15th and 25th day following the abortion, was compared with the results of the pelvic ultrasound performed at the follow-up visit. Ultrasound failure was defined as retention or persistent pregnancy.

RESULTS

Among the 624 women included, the failure rate was 22.3%, including 86.3% of retentions, 8.6% of pregnancies stopped and 5% of pregnancies progressed. Using a ROC curve, the threshold value of hCG found to exclude failure at 95% was 253 IU/l (AUC=0.9202, sensitivity=84.17%, specificity=85.95% and positive predictive value [PPV]=63%).

CONCLUSIONS

A serum hCG level ≤253 IU/l is sufficient to affirm the efficacy of medical abortion. However, since PPV is only 63% for this threshold, ultrasound should be reserved for women with high hCG levels.

Management of Postabortion Complications for the Emergency Medicine Clinician

Although induced abortion is generally a safe outpatient procedure, many patients subsequently present to the emergency department, concerned about a postabortion complication. It is helpful for emergency physicians to understand the medications and procedures used in abortion care in the United States to effectively and efficiently triage and treat women presenting with potential complications from an abortion. Furthermore, because many states are experiencing increased abortion restrictions that limit access to care, emergency medicine physicians may encounter more patients presenting after self-managed abortions, which presents additional challenges. This article reviews the epidemiology and background of abortion care, including the range of symptoms and adverse effects that are within the scope of an uncomplicated procedure. This review also offers a comprehensive overview of management of abortion complications, including algorithms for more common complications and descriptions of less common but more severe adverse events. The article concludes with a recognition of the social stigma and legal regulations unique to abortion care.

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.

Sonographic characteristics of the uterus in asymptomatic women after second-trimester medical termination of pregnancy

OBJECTIVES

The purpose of this study was to evaluate the sonographic characteristics of the uterus after apparently uncomplicated second-trimester medical termination of pregnancy and to follow the evolution of these findings until the return of menstruation.

METHODS

Twenty-three women who requested termination of pregnancy at gestational ages between 14 and 20 weeks were recruited. Uterine characteristics were measured by 2- and 3-dimensional transvaginal with or without transabdominal sonography. The uterine anteroposterior diameter, length, and width, endometrial thickness, presence of an endometrial mass, intrauterine vascularity, and endometrial volume were measured within 24 hours, 1, 2, 4, 6, and 8 weeks after termination, and during the postmenstrual phase.

RESULTS

The mean uterine anteroposterior diameter, uterine length, uterine width, endometrial thickness, and endometrial volume ± SD deceased gradually from 66.1 ± 9.7 to 40.9 ± 5.3 mm, 131.4 ± 14.7 to 81.3 ± 13.8 mm, 84.6 ± 10.3 to 54.2 ± 7.6 mm, 25.6 ± 8.1 to 4.5 ± 2.6 mm, and 39.4 ± 22.6 to 2.5 ± 2.1 mL, respectively, from within 24 hours after termination to the postmenstrual phase. Endometrial masses were identified in 8 women (34.8%) within 4 weeks after termination, which could persist for up to 8 weeks. However, all endometrial masses resolved after menstruation. Minimal and moderate endometrial vascularity was detectable in up to 21.7% after termination; none was detectable in any women after menstruation.

CONCLUSIONS

This study provides information on the normal sonographic parameters of the uterus after second-trimester medical termination of pregnancy, which has been lacking in the literature. Also, our findings suggest that all endometrial masses regress with time; therefore, asymptomatic women with an incidental finding of an endometrial mass can be followed without the need for an immediate intervention.

Three-dimensional Doppler sonography in asymptomatic and symptomatic women after medical termination of pregnancy

OBJECTIVES

To characterize the 3D Doppler sonographic appearance of the uterine cavity in asymptomatic and symptomatic women after administration of mifepristone and misoprostol for medical termination of pregnancy.

METHODS

A prospective observational study was performed. Women admitted for medical termination of pregnancy underwent transvaginal sonography 15 days after the procedure. Volumes were acquired, and offline analyses of the 3D vascularization indices were performed. Outcomes were collected at the follow-up scan and by telephone after the termination. Women were subclassified as asymptomatic or symptomatic according to the presence/absence of fever, vaginal bleeding, abdominal/pelvic pain, and infections. Spotting was defined as any episodic vaginal bleeding that was less than an expected menstruation and not regarded as a symptom.

RESULTS

A total of 104 women who underwent medical termination of pregnancy between 6 and 9 weeks' gestation were enrolled in the study. The termination procedure was successful in 98% of cases; among them, 9 women (8.6%) were symptomatic due to bleeding. Two asymptomatic women required surgery; 1 had sonographic evidence of suspected retained products of conception (endometrial thickness ≥ 15 mm or power Doppler vascularization presence). Fifty-seven women (55%) presented with retained products of conception. All the women with suspected retained products regained normal menses; of these, 3 symptomatic women with retained products (2.9%) underwent a 1-month sonographic follow-up. The symptomatic status was not associated with endometrial thickness, 3D intrauterine mass volume, or 2-dimensional (2D) and 3D power Doppler appearances.

CONCLUSIONS

The necessity of surgery after medical termination of pregnancy cannot be predicted by sonography. In cases with sonographic evidence of suspected retained products of conception, endometrial thickness, 2D Doppler findings, and the 3D vascularization indices correlated poorly with bleeding symptoms. Long-term follow-up should be considered in symptomatic women, and it can avoid any unnecessary surgical intervention.

Medical abortion follow-up with serum human chorionic gonadotropin compared with ultrasonography: a randomized controlled trial

OBJECTIVE

To estimate whether follow-up with serum human chorionic gonadotropin (hCG) results in fewer unplanned visits and interventions than follow-up with ultrasonography.

METHODS

Women were randomized to either in-clinic serum hCG or ultrasound follow-up after medical abortion. The primary outcome, unplanned interventions and visits, was measured as a composite binary outcome including: additional clinic or emergency room visits, repeat dosing of misoprostol, and surgical evacuation of the uterus. Surveys were administered at initial follow-up and again 1 month after abortion to inquire about unscheduled visits, interventions, and patient satisfaction. Medical records were reviewed for evidence of additional interventions and visits.

RESULTS

A total of 376 patients was randomized. Most participants were white (56%), single (83%), nulliparous (63%), and had completed high school (96%). Average participant age was 26±6 years and average gestational age was 46±6 days. Within 2 weeks of abortion, there was no significant difference in the rate of unplanned interventions and visits between arms, 8.2% (13/159) in the serum hCG arm compared with 6.6% (10/151) in the ultrasound arm (relative risk 1.23, 95% confidence interval [CI] 0.56-2.73, P=.60). By 4 weeks postabortion, 4.4% (6/135) in the ultrasound arm and 1.4% (2/142) in the hCG arm had undergone surgical evacuation (relative risk 0.32, 95% CI 0.07-1.54, P=.16). The majority in both the serum hCG (88%) and ultrasound (95%) arms was satisfied with their assigned follow-up method.

CONCLUSION

Medical abortion follow-up with serum hCG does not reduce the rate of unplanned interventions and visits compared with ultrasonography. Overall, the number of unplanned interventions is low and both methods of follow-up are acceptable to women.

Medication abortion

Medical methods for pregnancy termination in early gestation offer women an alternative to surgical evacuation and have the potential to improve access globally to safe abortion. Several drug regimens are used with varying efficacy including mifepristone plus misoprostol, misoprostol alone, and methotrexate plus misoprostol. Where available, a mifepristone plus misoprostol regimen is most frequently used and is highly effective for early abortion. We review these drug regimens along with clinical practice recommendations including patient counseling and selection, regimen administration location, expected side effects, and follow-up procedures. Overall, women who choose medical abortion report high levels of satisfaction.

Medical abortion in the first trimester: The use of serum hCG and endometrial thickness as markers of completeness

OBJECTIVE

The combination of mifepristone and misoprostol is an established method for induction of early first trimester abortion, but there is no consensus about the best evaluation of treatment outcome. We assessed endometrial thickness, determined by ultrasound and serum-human chorionic gonadotropin (s-hCG) as markers of successful management.

METHODS

Prospective trial involving 255 women, with a gestation of 62 days or less, who were to undergo medical abortion. In addition to our established routines of performing clinical and ultrasound examinations, we also determined the s-hCG level prior to treatment and at follow-up.

RESULTS

Of the 255 subjects treated during the study, 20 (7.8%) were lost to follow-up. The overall complete abortion rate was 94.0%. Fourteen subjects required vacuum aspiration, nine of them prior to the scheduled follow-up and five thereafter. None of the pregnancies were ongoing. A decrease of 99% in s-hCG levels was noted in 99% of the women, when levels determined prior to mifepristone intake and those measured 15-71 days post-abortion were compared.

CONCLUSION

This study confirms that s-hCG levels drop sharply after medical abortion. To assess the completeness of medical abortion, we recommend that clinical examination to be combined with determination of s-hCG. Ultrasonography should be carried out only when indicated.

Endometrial thickness following medical abortion is not predictive of subsequent surgical intervention

OBJECTIVES

To evaluate the ability of endometrial thickness after medical abortion to predict the need for subsequent dilatation and curettage (D&C).

METHODS

We pooled data from two multicenter medical abortion trials involving 2208 women who received mifepristone orally followed by misoprostol vaginally. Women returned for transvaginal ultrasonography approximately 7 days later. The endometrial thickness was measured if no gestational sac was present. Final status was confirmed by a phone interview at 5 weeks. The area under the receiver-operating characteristics (ROC) curve was calculated to assess the overall ability of endometrial thickness to predict the need for subsequent D&C. Endometrial thickness was dichotomized using threshold values at 5-mm increments from 10 to 30 mm. The sensitivity, specificity, negative predictive value and positive predictive value were calculated to evaluate the ability of each endometrial thickness threshold value to predict subsequent D&C. Multivariable regression analysis was performed to adjust endometrial thickness values for study, treatment group, and study site.

RESULTS

At 7 days after misoprostol treatment, 1870 women (84.7%) had endometrial thickness assessed. Thirty of these women (1.6%) subsequently underwent D&C. The mean endometrial thickness was 14.5 mm for women who underwent D&C and 10.9 mm for those who did not (difference 3.5 mm (95% CI, 1.8-5.3 mm)). Endometrial thickness was poorly predictive of the need for D&C, with an area under the ROC curve of 0.65. All endometrial thickness thresholds had positive predictive values of 25% or less. The results were unchanged by adjustment of endometrial thickness values by multivariable modeling.

CONCLUSIONS

Although endometrial thickness following successful expulsion of the gestational sac is thicker in women who will eventually require surgical intervention after medical abortion, endometrial thickness is not a clinically useful predictor of the subsequent need for D&C.

Endometrial Thickness- a Practical Prospective Marker for the Risk of Surgical Intervention after RU486 Induced Abortion

Background

Medical termination of pregnancy [TOP] during the early first trimester is commonly used. However, treatment failure which warrants surgical intervention occurs in small proportion of patients. Our objective was to examine the effectiveness and predictive value of sonographic measurement of endometrial thickness during a follow up visit after medical abortion as an accurate predictor of the necessity of curettage for completion of pregnancy termination.

Methods

Women who opted for medical TOP where treated by single dose of RU486 followed by a single dose of misoprostol. Endometrial thickness was evaluated by transvaginal U.S. at 14 days after misoprostol tretament. The data was collected prospectively for this cohort study which includes all the women undergoing medical abortion in the first seven weeks of gestation.

Results

In 34.7% of the patients the endometrial width was > 11 mm on the follow-up visit. Surgical intervention was performed in 18% of these patients, for a failure rate of the medical termination of pregnancy [TOP] of 6.25%, as compared with no failure rate in those with endometrium < 11 mm, P < 0.001. In the patients where the endometrium was 11-12 mm on follow-up, the failure rate was 5%, and if > 12 mm the failure was 5.9%. In cases where the endometrium was 12-13 mm the failure rate was 27.3%, and if >13 mm the failure was 18.9%. When the endometrium was 13-14 mm the failure rate was 10%, and when >14 mm the failure was 23.7%. Half of the 18 patients who had undergone dilatation and curettage [D&C] for completion of the TOP, had endometrium > 14 mm, one to two weeks after the medical abortion.

Conclusion

Measurement of endometrial width after medical TOP is beneficial in segregating patient to low or high risk for surgical treatment of retained product of conception [POC]. Using a cutoff of 11 mm during the follow-up visit after medical TOP, 18% of the patients may need dilatation and curettage to complete the pregnancy termination, and if it is >14 mm, half of them may need surgical intervention. There is no difference between 11 and 14 mm regarding the risk of surgical intervention after medical TOP.

Ultrasonographic endometrial thickness after medical and surgical management of early pregnancy failure

OBJECTIVE

We sought to compare endometrial thickness after misoprostol or dilation and curettage (D&C) for early pregnancy failure and to assess the predictive value of endometrial thickness for subsequent D&C after misoprostol treatment.

METHODS

In a randomized trial of early pregnancy failure management, 491 women were treated with misoprostol vaginally, and 161 were treated with D&C. Transvaginal ultrasonography was planned for 2 and 14 days after misoprostol treatment, and 14 days after D&C.

RESULTS

The mean endometrial thickness 14 days after treatment was 9.0 mm for the misoprostol group and 6.9 mm for the D&C group, (difference 2.1 mm, 95% confidence interval [CI] 1.0-3.2). After the ultrasonograms 2 and 14 days after misoprostol, 13 (3.8%) and 12 (3.2%) women, respectively, subsequently underwent D&C. Women requiring D&C after successful expulsion had significantly greater endometrial thickness than those who did not at 2 days (mean difference 5.2 mm, 95% CI 1.6-8.8) and 14 days (mean difference 5.5 mm, 95% CI 2.3-8.8) after misoprostol. However, endometrial thickness was a poor predictor of subsequent D&C. The areas under the receiver operating characteristic curves for endometrial thickness at 2 and 14 days were 0.71 and 0.73, respectively. Regardless of cutoff values used for predicting subsequent D&C, endometrial thickness had a positive predictive value of 40% or less.

CONCLUSION

The difference in endometrial thickness between misoprostol treatment and D&C for early pregnancy failure is not clinically significant. Endometrial thickness is not a useful predictor of subsequent surgical intervention after successful expulsion of the gestational sac after misoprostol for early pregnancy failure.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov,www.clinicaltrials.gov, NCT00177333

LEVEL OF EVIDENCE

I.

Role of transvaginal sonography in the diagnosis of retained products of conception

INTRODUCTION

The aim of this study was to evaluate the criteria of endometrial thickness to detect retained products of conception following first trimester spontaneous abortion or elective pregnancy termination.

METHODS

This was a retrospective study on 116 patients who underwent uterine re-evacuation with a diagnosis of retained products of conception based on clinical and sonographic findings. Pathologic reports of samples obtained during re-evacuation were reviewed for the presence of gestational tissue. Endometrial thickness determined by transvaginal sonography and certain clinical features (gestational age and interval between initial curettage and re-evacuation, which may affect presence or absence of gestational tissue, parity, indication for initial curettage) were noted. The sensitivity and specificity of sonographic measurement of endometrial thickness for detecting retained products of conception were assessed.

RESULTS

Histopathologic reports confirmed the diagnosis of retained products of conception in 66 of 116 patients (56.9%). Percentage of nulliparity and the time elapsed between initial curettage and re-evacuation were significantly high in patients with retained products of conception. The sensitivity and specificity of endometrial thickness greater than 13 mm for detecting retained products of conception were 85 and 64%, respectively.

CONCLUSION

An endometrial thickness of 13 mm or more, detected by transvaginal sonography, has the best diagnostic efficiency for detection of retained products of conception following first trimester spontaneous abortion or elective pregnancy termination.

Contemporary management of early pregnancy failure

Early pregnancy failure is a common pregnancy complication. This paper reviews the terminology, diagnosis, and treatment of early pregnancy failure. Although surgical curettage has been the standard of care for more than 50 years, additional treatment options exist which appear to be satisfactory to patients. Manual vacuum curettage in the office is an effective alternative to electric vacuum curettage in an operating room. Nonsurgical treatments, including expectant and medical management, are reasonable alternatives depending on the clinical situation and the patient's desires. Clinicians need to understand how these options compare to provide appropriate counseling to patients.

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.

Frequently asked questions about medical abortion

The development of methods of inducing abortion medically (nonsurgically) has created alternative options to make abortion available to women in a variety of health-care settings. Medical abortion is induced with a regimen of mifepristone followed by a prostaglandin analogue. Since its first introduction in the late 1980s, the regimen has undergone some modifications based on research evidence, and, in many countries, clinicians are using regimens that may differ from the one that has been licensed. This causes confusion among providers, also because only a few countries have developed national guidelines for the provision of medical abortion. We approached health care personnel providing abortion services in various countries and asked them to send us questions that they, or their colleagues, might have concerning the clinical practice of medical abortion in the early first trimester (up to 63 days since the first day of the last menstrual period). These questions were sent to experts representing the fields of biomedical and clinical research, clinical practice and family planning, who conducted literature reviews so that, whenever possible, the answers could be based on existing evidence. A consensus meeting was held in Bellagio, Italy, between November 1 and 5, 2004, to review the questions and to discuss the answers. The aim of this article is to provide a brief overview of some of the questions asked and the answers discussed.

Sonographic appearance of the uterine cavity following administration of mifepristone and misoprostol for termination of pregnancy

PURPOSE

To describe the sonographic appearance of the uterine cavity in women after administration of mifepristone and misoprostol for termination of pregnancy.

METHODS

Thirty-six women treated with mifepristone 600 mg followed by misoprostol 400 mug 2 days later for termination of pregnancy were the subjects of the study. Gestational age as calculated from the last menstrual period was < or =49 days. Pretreatment sonographic parameters, including gestational sac size and crown-rump length, were measured. The sonographic appearance of the uterine cavity was recorded and documented 6 hours (T-1) and 14 days (T-2) after administration of misoprostol.

RESULTS

The mean menstrual age of the patients was 42 days (range 31-49 days). The mean gestational age according to crown-rump length was 43 days (range 40-48 days). Sonographic examination performed atT-1 revealed 23 patients (62.9%) with a well-defined echogenic mass located in the uterine cavity, 2 patients (5.5%) with an intrauterine sac containing a nonviable embryo, and 11 patients (30.5%) with an endometrium thickness of 7-14 mm with no evidence of intrauterine contents. Doppler flow signals were detected in 15 of the 23 patients (65.2%) with an echogenic intrauterine mass. Sonographic examination performed at T-2 revealed 19 patients (52.8%) with a persistent echogenic intrauterine mass; Doppler flow could be detected in 15 of these patients (78.9%). Dilatation and curettage was required in 2 patients (5.6%) due to failure of treatment; all others regained normal menses.

CONCLUSIONS

An intrauterine echogenic mass with well-defined borders, with or without Doppler flow signals, can be detected 2 weeks after administration of mifepristone and misoprostol for termination of pregnancy. Because most of the women in our study regained normal menses without further surgical intervention, this finding could indicate remnants of trophoblastic tissue evacuated spontaneously from the uterine cavity. Therefore, dilatation and curettage should be avoided in these cases, unless clinical symptoms or signs necessitate surgical intervention.

The role and applications of ultrasound in ambulatory gynaecology

Ultrasound has changed gynaecological practice and continues to do so. One of the earliest applications of abdominal scanning in gynaecology was for monitoring follicular development during fertility treatment with clomiphene citrate or gonadotrophins in the 1960s and 1970s. Subsequently, it was natural that with the introduction of in vitro fertilization, abdominal and transvaginal ultrasound played a key role in the development of oocyte retrieval techniques. These were truly the first interventional ultrasound-guided ambulatory procedures in gynaecology. In this chapter, the reader will be introduced to the roles that the various ultrasound modalities play in our current daily practice, and how they have changed the management of numerous gynaecological conditions in both diagnostic and therapeutic contexts. We will also outline the recent developments and the 'hot' research topics in this field.