Expectant Management
Expectant management is generally limited to this trimester; beyond it, incomplete expulsion and hemorrhage risk make active management preferred.
Answer: What is the first trimester?
This is the FDA-approved gestational age limit (in days) for the mifepristone–misoprostol regimen.
Answer: What is 70 days (10 weeks)?
This is the customary type of anesthesia for office vacuum aspiration in the U.S., associated with fewer complications than general anesthesia.
Answer: What is local anesthesia (paracervical block, usually lidocaine)?
The maximum dose of lidocaine without epinephrine for a paracervical block should not exceed 4.5 mg/kg or 300 mg total) (ACOG Clinical Consensus, Pain Management for In-Office Uterine and Cervical Procedures, 2025)
This is the preferred and most commonly used surgical method for second-trimester abortion, generally used beyond the ~15–16 week limit of simple vacuum aspiration.
Answer: What is dilation and evacuation (D&E)?
This is the heavy-bleeding threshold clinicians teach patients to watch for after a medication abortion (the point at which they should call or seek urgent care).
Answer: What is soaking more than 2 maxi pads per hour for 2 consecutive hours?
Overall <1% need emergency intervention for bleeding, and transfusion is rare (≤0.1%).
Follow-up to confirm complete passage after expectant or medical management can use ultrasound, or this serial laboratory test in settings where ultrasonography is unavailable.
Answer: What is serial serum beta-hCG? (ACOG Practice Bulletin 200, 2018)
This is the standard combined regimen and route for medication abortion.
Answer: mifepristone 200 mg orally followed misoprostal vaginally or buccally 24–48 hours later
What is the usual gestational-age range in which vacuum aspiration is used for procedural abortion?
Answer: Before 14 weeks' gestation.
This is the single antibiotic and dose the Society of Family Planning recommends started ~1 hour before uterine aspiration — chosen because it is cheap, equally effective PO or IV, and rarely allergenic.
Answer: What is doxycycline 200 mg?
Recommended for ALL patients undergoing D&E to reduce post-procedure infection, this is a Level A ACOG recommendation.
After a second-trimester abortion or pregnancy loss, this long-acting dopamine D2-receptor agonist — given as a single 1 mg oral dose — is the most effective drug for preventing bothersome breast engorgement and milk leakage.
Answer: What is Cabergoline?
Given after uterine evacuation at 18+ weeks
These three clinical conditions are absolute reasons ACOG says expectant management should NOT be offered, favoring prompt surgical evacuation instead. (Name at least TWO).
What are infection, hemorrhage, and/or hemodynamic instability?
Mifepristone works primarily by antagonizing which hormone's receptor?
Answer: Progesterone - Mifepristone is a selective progesterone receptor modulator with antiprogestin activity.
This tactile endpoint signals an empty uterine cavity during aspiration.
Answer: What is the gritty sensation of the empty cavity?
These cervical dilators are made from seaweed and gradually expand by absorbing moisture. What are they called?
Answer: Laminaria.
Two types of osmotic dilators: laminaria and dilipan
Laminaria absorb cervical interstitial fluid and reach maximal cervical dilation about 24 hours after placement in contrast with the synthetic Dilapan-S, which maxes out in about 6 hours.
This is the maximum window, in hours after a potentially sensitizing event such as an abortion or miscarriage, within which anti-D immune globulin should ideally be administered.
Answer: What is 72 hours?
If missed, some protective benefit may persist up to ~28 days, so it should still be given as soon as the need is recognized.
Whereas ACOG recommends offering Rh Ig for induced or spontaneous abortion before 12 weeks, the national family-planning society and the WHO recommend AGAINST routine RhD testing and RhIg for abortion at less than 12 weeks.
This is the approximate percentage of patients who achieve complete expulsion with expectant management of early pregnancy loss when given adequate time (up to 8 weeks).
Answer: What is ~80%? (ACOG; more than 80% expel within 2 weeks per JAMA.)
Name three of the absolute contraindications to medication abortion listed by ACOG.
What are confirmed/suspected ectopic pregnancy, IUD in place, chronic long-term systemic corticosteroid therapy, chronic adrenal failure, known coagulopathy or anticoagulant therapy, inherited porphyria, or allergy to mifepristone/misoprostol?) (ACOG Practice Bulletin 225, 2020)
Immediately after aspiration, the tissue is examined for these two structures whose visual identification (especially before 7 week) confirms an intrauterine pregnancy and helps rule out ectopic.
Answer: What are the gestational sac/membranes and placental (villous) tissue?
Confirmation of a completed abortion relies on immediate gross examination of the aspirate for products of conception
As with aspiration, D&E completeness is confirmed intra-procedurally by inspection of fetal parts and placenta
Name the ACOG first-line uterotonic for postabortion hemorrhage, AND the single key contraindication that would make you avoid it.
Answer: What is Methergine — avoided in hypertension? (ACOG Practice Bulletin No. 135, 2013)
What is the most common procedural injury during D&E?
Answer: cervical laceration (3.3% of cases) - most common injury
Most common serious complication of D&E is hemorrhage, occurring most often via uterine atony and requiring transfusion in about 0.1–0.6% of cases
A commonly used ultrasound criterion for complete expulsion is absence of a ______ plus an endometrial thickness less than this measurement (____mm).
Answer: What is absence of a gestational sac and < 30 mm? (Note: surgery is NOT required in asymptomatic women with a thicker stripe.)
When serum hCG is used to confirm a successful medication abortion, at least this percentage decline over 6–7 days is considered confirmatory.
Answer: What is ≥80%?
When follow-up is medically indicated or patient-preferred, it can be done by history, exam, serum hCG, or ultrasonography. A serum hCG decline of ≥80% over 6–7 days confirms success.
If ultrasound is used, its sole purpose is to determine presence/absence of the gestational sac — endometrial stripe thickness and Doppler flow do NOT predict need for aspiration and should not trigger intervention.
Remote follow-up (symptom checklist plus a confirmatory urine pregnancy test at ~4 weeks) is as effective as in-person visits for detecting ongoing pregnancy and is often patient-preferred.
In a randomized trial, MVA showed six-fold fewer complications than D&C and, unlike D&C, was associated with essentially no cases of this intrauterine adhesive complication.
Answer: What is Asherman's syndrome? (Kakinuma et al., BMC Pregnancy Childbirth, 2020)
A patient develops heavy bleeding during a D&E. Name the four major categories of causes of post-abortion hemorrhage.
Answer:
The 4 T's:
Tone — uterine atony
Trauma — cervical laceration, uterine perforation
Tissue — retained products
Thrombin — coagulopathy
For same-day cervical prep before D&E, these two approaches let providers avoid an overnight osmotic dilator visit.
Answer: What are misoprostol alone (single or serial dosing) or 4 hours of dilipan?