By Siripanth Nippita, MD, MS and Maureen Paul, MD, MPH

Many people know they’re pregnant early. For some, if a pregnancy is unwanted, they seek abortion care right away. But what if I don’t see a gestational sac with a yolk sac on an ultrasound?

Drs. Siripanth Nippita and Maureen Paul respond: You can still provide abortion care! It is still important to consider the risk of ectopic pregnancy (EP), though this risk is lower among
individuals seeking abortion compared with the general population.

If a transvaginal ultrasound does not demonstrate an intrauterine or extrauterine pregnancy, and the pregnancy test is positive, this is a pregnancy of unknown location (PUL).

If you see a gestational sac (round or oval, with a hyperechoic rim) without a yolk sac or any type of fluid collection in the uterus, this is a probable intrauterine pregnancy, and the risk of EP is much lower.

Question: Can I provide mifepristone and misoprostol in these situations?

Answer: Yes, after assessing risk for ectopic pregnancy!

It is safe to start medication management for a patient with PUL or a probable intrauterine pregnancy after assessing an individual’s risk of EP based on risk factors and current symptoms. You do not have to wait to see a definite intrauterine pregnancy (gestational sac with a yolk sac, implanted in a normal location) to initiate treatment.

You should also give ectopic pregnancy precautions to all patients choosing immediate treatment.

Question: How do I make sure the medication worked?

Answer: Serum hCG follow-up is recommended for individuals with PUL. You should get a baseline hCG level at the initial visit. Schedule a follow-up hCG either 48-72 hours after misoprostol (which should drop by at least 50%) or if not feasible, 5-10 days after misoprostol (which should drop by at least 80%).

Individuals with a probable intrauterine pregnancy can also have hCG follow up to confirm pregnancy resolution. If this is not possible, use an alternative approach such as a home urine pregnancy test 14 days after mifepristone.

Question: What if the patient wants a procedure?

Answer: Procedural management with confirmation of pregnancy resolution is safe for individuals with PUL or probable IUP. If you see both a gestational sac and villi (which is not expected in individuals with PUL), no further follow-up is needed. If no sac is seen, draw a serum hCG on the day of procedure with a plan to repeat it in 24-72 hours. Levels should drop by at least 50% after 24 hours, 70% after 48 hours, and 80% after 72 hours.

Want more?

Read more about early and medication abortion in the authors’ chapter on Abortion in Contraceptive Technology, 22nd edition.