When is a backup aspiration needed?

hCG and ultrasound for verification of

successful expulsion

Christian Fiala

Gynmed Ambulatorium

Vienna, Austria

Karolinska Institute

Department of Woman and Child Health

Stockholm/Sweden

www.fiapac.org

International Association of Abortion and Contraception Associates

Abortion, Contraception and Women’s Health

International Seminar of FIAPAC, RSOG, RC Ob/Gyn &P , 27/28 October 2005

hCG and US in medical abortion, C. Fiala

www.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

hCG and US in medical abortion, C. Fiala

1 2 3 4 5 6 7 8 9 10 11

5

10

15

12 13 14 15 16 17 18 19 20 21

20

22 23 24

Expulsion after Mifepristone and Misoprostol in %

(hours after misoprostol)

Time to expulsion of the sac in 1720 women with successfull termination of pregnancy. The women took mifeprostone on day 1 and misoprostol 48 hours later. Uncertain means expulsion at some point during 24 hours following misoprostol. Unknown means expulsion at some point later than 24 after misoprostol.

Source: The New England Journal of Medicine, 1998; 338 (18): 1244

Befor

e m

iso

Mor

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4 h

late

run

know

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rtain

hCG and US in medical abortion, C. Fiala

Day 1: hCG 269 mIU/ml Day 9: hCG 20

Treatment

hCG and US in medical abortion, C. Fiala

Day 7: hCG 7Day 3: GestationalSac

Day 1: Gestational sac 5 mmhCG 862

Treatment

hCG and US in medical abortion, C. Fiala

D 1: hCG 32.000 D 8: E 12 mmhCG 837

D 3: Gestationalsac

Treatment

hCG and US in medical abortion, C. Fiala

D 1: CRL 10 mmhCG 83.439

D 8: E 8 mmhCG 312

Treatment

hCG and US in medical abortion, C. Fiala

D 28: hCG 100D 10: E 20 mm, hCG 16.841

D 17: OC exD 21: Withdrawl-bleeding

D 1: CRL 6 mmhCG 104.900

D 3: Start OC

Treatment

hCG and US in medical abortion, C. Fiala

D 1: Gestational + yolk sachCG 13.300

D 3: Start OC

D 19: E 8 mmhCG 718

D 9: missed ABhCG 10.819

D 16: OC exD 18: Withdrawl-bleeding

Treatment

hCG and US in medical abortion, C. Fiala

Methods

– 217 women with

– an unwanted pregnancy

– <49 days of amenorrhea

– received:

• 600mg of Mifepristone orally

• 400µg of Misoprostol orally 2 days later

• hCG was performed at all visits

• US was performed before Mifepristone and at follow-up

hCG and US in medical abortion, C. Fiala

Results

• Curettage:– 1 continued pregnancy– 1 missed abortion– 1 haemorrhage

• One missed abortion was expelled after withdrawal bleeding

hCG and US in medical abortion, C. Fiala

Mean 3,8% (0,1-44); the size of the circles correlates with the number of patients. The smallest circles represent 1 patient; the biggest represent 25 patients3 cases of successful abortion (27,32 and 44%)2 cases of missed abortion (91 and 159%), 1 case of continued pregnancy (7,900 %)

0

5

10

15

20

0 2 4 6 8 10 12 14 16 18 20

%

days

Serum hCG at follow-up in % of the initial value

Fiala et al., 2003

hCG and US in medical abortion, C. Fiala

Mean 10mm (1-24mm); the size of the circles correlates with the number of patients. The smallest circles represent 1 patient; the biggest represent 10 patients

0

5

10

15

20

25

30

0 2 4 6 8 10 12 14 16 18 20

Days

mm

Endometrium thickness at follow-up

Fiala et al., 2003

hCG and US in medical abortion, C. Fiala

First trimester surgical abortion:

– Urinary test (cut off 1,000mIU/ml) at two weeks (Paul et al., 2000)

Medication abortion <9 weeks:

– Urinary test, cut off 500mIU/ml at 3 weeks

(Karolinska University Hospital, Sweden)

– Urinary test, cut off 1,000mIU/ml at >1 week

(Gynmed Clinic, Vienna)

– Decline in serum hCG at follow up in % of the initial value:

• 30% on day 10 (Jourdan and van den Bossche 1991)

• 40% at 1 week (Legarth et al. 1991)

• 60-70.5% 24 hours following misoprostol

• 99.4% on day 14 (Walker et al., 2001, Honkanen et al., 2002)

• 20% after day 6 (Fiala et al., 2003)

hCG for verification of expulsion

hCG and US in medical abortion, C. Fiala

Retained products of conception (RPC)

• Commonly present with sharp or crampy lower abdominal pain and bleeding

• No difference to haematomata

• Presence of sparse villi alone after successful surgical abortion is a normal finding and not diagnostic of RPC

• After abortion, small amounts of retained products may pass spontaneousely, avoiding the need for backup curettage

hCG and US in medical abortion, C. Fiala

Verification of expulsion

• Ultrasound

– Gives reliable results in most cases when the yolk sac or CRL can be visualised before treatment

– It is not reliable in very early pregnancy

– Endometrium is thick in many patients at follow up

• hCG

– Has to be used in early pregnancy

– Is very reliable in most cases > cut off at 20% of initial value after day 6

– Follow-up can be done at a different laboratory

hCG and US in medical abortion, C. Fiala

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