Which pre-operative examinations before abortion ?

1. Which pre-operative examinations before abortion ? Dr ANNE VEROUGSTRAETE César De Paepe Hospital Brussels (ULB) SJERP-VUB: Family Planning Center of the “Vrije Universiteit Brussel” CCNAC: Central Coordination of Flemish Abortion Centers

2. I checked for you the following guidelines concerning induced abortion • WHO • IPPF • United Kingdom: Royal College of Obstetrics and Gynaecologists: RCOG • The Netherlands: Nederlands Genootschap van Abortusartsen: NGvA • France: Agence Nationale d’Accréditation et d’Evaluation en Santé: ANAES • Board members of the European Society of Contraception: (ESC) coming from Spain, Turkey, The Netherlands, UK, Israel, Slovenia, Greece, Czech Republic, France, Hungary, Poland, Belgium and a gynaecologist from Romania gave their opinion at the ESC seminar in Warsaw (september 2005)

3. Medical history • Are you in good health? • Do you take any medicine? • Allergy? • Did you ever have problems with general or with local anesthesia? • Do you faint easily? • Smoking? • Bleeding disorders? heavy menses? bleeding after operations or after visit to the dentist? • Bloodtranfusions? ever had anemia? • Anemia or bleeding disorders in your family?

4. Medical history • How many children? • Normal birth? • Gynaecological operations? (ectopic pregnancy, miscariage, termination of pregnancy, caesarean section, cervical operation) • Ever had gynaecological infections? STI? • First day of last menstrual period? • Pregnancy test? who did the test? • Symptoms of early pregnancy? Pain? Spotting? • Were you using contraception? did something go wrong? • Which contraception do you want to use after the abortion?

5. Physical examination • Bloodpressure? • Anemia? • Bimanual pelvic examination: 1 finger is OK • Size of uterus corresponds with LMP? softening of cervical isthmus (6-8w) and uterus • Size smaller than expected: pregnancy can be younger or ectopic or missed abortion • Size bigger than expected: pregnancy more advanced or twins or fibroids or molar • Anteversion or retroversion ? • Sign of genital infection? of STI? • Vaginisme, pain, fear at pelvic examination?? • Same doctor before and during abortion procedure helps

6. Laboratory testing • ABO & Rhesus (Rh) bloodgroup: • IPPF, WHO: to be done if available in case of complications that might require bloodtransfusion • WHO: there is still no conclusive evidence about the need for passive immunisation of all Rh-negative women after first trimester abortion • The Netherlands (NGvA): no need for rhesus testing up to 8 w LMP: passive immunisation with anti-D at that early stage of pregnancy is not needed • France (ANAES), UK(RCOG), most board members ESC: bloodgroup test for all and anti-D for all Rh-negative women • Board member of Spain only checks Rh and of The Netherlands only Rh after 7 w

7. Laboratory testing • Red cell antibodies screening in all: RCOG • Haemoglobin: IPPF & WHO & ANAES & NGvA and board members of France, Belgium, Hungary, The Netherlands: if physical examination or history suggests anemia or in population with high prevalence of anemia • RCOG recommends Hb testing in all women as do board members of Spain, Czech Republic, Poland, Israel, UK, Turkey and Greece. • Board members of Slovenia and Romania test Hb in second trimester abortion & medical abortion

8. Laboratory testing • HCG: IPPF&WHO: pregnancy test is not required unless typical pregnancy signs are not present. Of the board members of ESC only Czech, French and Hungarian, check HCG routinely and our Romanian friend checks it routinely only in case of medical abortion. • The Polish & Czech board members of ESC routinely check for Syphilis, HIV, Hepatitis B&C. The others do not. • More general pre-operative tests are done by Polish, Czech, Romanian, Greek, Turkish, and Israelian board members; some in all situations, others for second trimester abortion or for late and sometimes early medical abortion. • RCOG would suggest testing for haemoglobinopathy, HIV, Hepatitis B&C in some situations

9. Prevention of Infection • IPPF: post-abortion infection is rare if abortion is performed properly • Detection of Chlamydia & other lower genital tract organisms ? • IPPF: screening can be proposed for STI (and HIV) • France (ANAES), Belgium, Poland, Hungary, Czech, Slovenia: screening if symptoms or positive history • UK RCOG: screening for lower genital tract organisms should normally be offered to all in women requesting abortion, but done with the woman’s consent • Systematic screening in some abortion centres in Belgium (prevalence chlamydia: 3,5- 4,8 % ) 21% of chlamydia would have been missed if criteria of The Netherlands would have been used (antibiotic prophylaxis <30 years) • WHO: Routine use of antibiotics at the time of the abortion reduces the risk of infection by half (Sawaya et al. 1996), but abortion should not be denied if antibiotics are not available • RCOG (UK): minimum standard = antibiotic prophylaxis • Metronidazole 1g + Doxycycline 100 mg 2x/d during 7d or • Metronidazole 1g + Azitromycine 1g • The Netherlands: antibiotic prophylaxis if < 30 years, unless.. • France: antibiotic prophylaxis if history of PID

10. Cervical Cytology • An abortion request may be an opportunity for assessing cervical cytology, especially in settings where there is a high prevalence of cervical cancer and STI, but it must never be a pre-condition for providing the abortion: IPPF, WHO, RCOG, ANAES

11. Ultrasound • WHO: ultrasound scanning is not necessary for the provision of early abortion • IPPF, WHO: where it is available, ultrasound is mainly usefull for the detection of ectopic pregnancy beyond 6 weeks LMP • UK (RCOG): all services must have access to ultrasound scanning (mainly when ectopic pregnancy is suspected), but ultrasound is not an essential pre-requisite of abortion in all cases • France (ANAES): all abortion units should have one ultrasound machine with a vaginal probe • Guidelines in The Netherlands & Belgium: all women seeking abortion should have an ultrasound scan • Most Board members of ESC would do an ultrasound scan; UK said they usually did a scan, only Poland did not.

12. Ultrasound • Abdominal ultrasound: 3 –4 weeks after conception, a gestational sac can usualy be seen • Vaginal ultrasound: 2,5 weeks after conception a tiny gestational sac appears, 3 weeks after conception it usualy can be seen (a-centric) • Molar pregnancy: first trimester: irregular image not yet typical image of later molar pregnancies • Living pregnancy? Twins? Any fetal anomaly? • Uterus bicornis • Ectopic pregnancy

13. Ectopic Pregnancy • Occurs in 0,5 - 1 % • beyond 6 weeks LMP ectopic pregnancy is suspected if no gestational sac is seen in the uterus • Cave! : pseudo-sac: fluid without chorionic crown • HCG: 1.000-2.000 => vaginal echo + sac • HCG: 6.000 => abdominal echo + sac • HCG x 2 every 48 h in Nl pregnancy - progesterone • heterotopic pregnancy: 1 in uterus - 1 ectopic • 1/ 30.000 intrauterine pregnancies: before • 1/ 7.000: now • ovulation induction, in vitro fertilization, embryo transfer => 1/ 900 or more

14. Risk factors for uterus perforation • Fixed uterus retroflection & anteflection • uterus bicornis, tight cervix • previous uterine surgery: termination of pregnancy, caesarean section, large loop excision of the cervix • > parity • > age of patient • > gestational age • general anesthesia

15. Medical problems not in outpatient facility • Anemia: Hb < 7 --- Hct < 30 • Bloodpressure 160/110 mmHg or more • Insulin-dependent diabetes • Grand-mal epilepsy • Bleeding disorders • Serious asthma • Acute cardiopulmonary disease • Massive fibroids with gross distortion of uterine cavity

16. Conclusion • To provide good abortion care it is essential to listen attentively to the medical history and current situation of the woman. • A conscientious physical examination will further help detect possible risky situations • No bloodtests can replace a carefull medical history and fysical examination by well trained practitioners • Most providers check ABO & Rhesus (Rh) bloodgroup in order to give anti-D to rhesus negative women. It remain unclear if it is usefull in very early pregnancy (< 7-8 w) • Haemoglobin test is usefull in some situations • Anti-infectious strategy with screening for lower genital tract organisms or prophylactic antibiotics seems good practice if available • Ultrasound scan is usefull but not mandatory in all cases