What investigations are required before performing a medical termination of pregnancy in a 7-week gestation patient with no known medical history of bleeding disorders, adrenal insufficiency, or medication allergies?

Investigations Required Before Medical Termination of Pregnancy at 7 Weeks

For a 7-week gestation patient with no known bleeding disorders, adrenal insufficiency, or medication allergies, the essential pre-procedure investigations include: pregnancy confirmation with ultrasound, hemoglobin/hematocrit, blood type and Rh status, and screening for sexually transmitted infections. 1

Mandatory Pre-Procedure Testing

Pregnancy Confirmation and Dating

• Ultrasound examination is essential to confirm intrauterine pregnancy, exclude ectopic pregnancy, and accurately date the gestation 2
• At 7 weeks, transvaginal ultrasound should visualize a gestational sac with fetal cardiac activity 2
• Accurate dating is critical because medical abortion efficacy decreases significantly after 7 weeks (92% success at ≤49 days vs 77% at 57-63 days) 3

Hematologic Assessment

• Complete blood count with hemoglobin and hematocrit to assess baseline anemia status 4
• This is particularly important as vaginal bleeding is an expected side effect, and baseline anemia increases risk of requiring transfusion 5

Blood Type and Rh Status

• Blood type and Rh antibody screen must be obtained 4
• Rh-negative women require anti-D immunoglobulin administration to prevent alloimmunization 1
• This should be given at the time of the procedure 1

Infectious Disease Screening

• Screen for Neisseria gonorrhoeae and Chlamydia trachomatis 4
• Consider screening for HIV, hepatitis B, hepatitis C, and syphilis based on risk factors and local guidelines 4
• Antibiotic prophylaxis is recommended regardless of screening results, as post-abortal endometritis occurs in 5-20% of women not given antibiotics 4, 1

Additional Considerations for Specific Populations

When Bleeding Disorder Screening IS Indicated

Although your patient has no known bleeding disorder history, screening should be considered if:

• Personal history of other bleeding symptoms (easy bruising, prolonged bleeding from minor cuts, epistaxis) 6
• Family history of bleeding disorders 6
• History of menorrhagia (10-20% of women with menorrhagia have von Willebrand disease) 6

If screening is indicated, obtain: PT/INR, aPTT, factor VIII, von Willebrand factor antigen, and von Willebrand factor functional assay 6

Laboratory Tests NOT Routinely Required

• Serum beta-hCG is not mandatory if ultrasound confirms intrauterine pregnancy 2
• Comprehensive metabolic panel is not routinely needed in healthy patients 1
• Thyroid function tests are only indicated if there is clinical suspicion of thyroid disease 4

Critical Contraindications to Assess

Absolute Contraindications to Medical Abortion

• Confirmed or suspected ectopic pregnancy (must be excluded by ultrasound) 5
• Known allergy to mifepristone or misoprostol 5
• Chronic adrenal failure or current corticosteroid therapy 5
• Inherited porphyria 5
• Severe cardiovascular disease, particularly pulmonary arterial hypertension (these patients require surgical termination in centers with cardiac surgery capabilities) 4, 1

Relative Contraindications Requiring Caution

• Hemorrhagic disorder or anticoagulant therapy (increased bleeding risk with prostaglandins) 5, 6
• Severe anemia (hemoglobin <9.5 g/dL) may warrant correction before procedure 6
• History of unexplained vaginal bleeding or endometrial hyperplasia 5

Procedure Setting Requirements

Medical termination at 7 weeks can be performed in an outpatient setting for low-risk patients, but high-risk patients should be managed in hospital settings with emergency support services available 4, 1

Common Pitfalls to Avoid

• Do not proceed without ultrasound confirmation of intrauterine pregnancy—ectopic pregnancy is an absolute contraindication and can be life-threatening 5, 2
• Do not forget Rh status determination—failure to give RhoGAM to Rh-negative women can cause alloimmunization affecting future pregnancies 1
• Do not skip antibiotic prophylaxis—this significantly reduces post-abortal endometritis from 5-20% to <1% 4, 1
• Do not perform medical abortion if gestational age cannot be accurately determined, as efficacy decreases significantly beyond 7 weeks 3