What is the diagnosis for a patient who underwent a medical termination of pregnancy (MTP) without ultrasound (USG) guidance from an outside source?

Diagnosis for Patient Who Underwent MTP Without Ultrasound Guidance

The diagnosis should be documented as "Status post medical termination of pregnancy (MTP), pregnancy location and completion status unconfirmed" or "Post-MTP with pregnancy of unknown location." This reflects the critical safety concern that without pre-procedure ultrasound, you cannot confirm whether an intrauterine pregnancy was terminated versus a potentially missed ectopic pregnancy 1.

Critical Diagnostic Considerations

Why Ultrasound Confirmation Matters

• Pre-procedure ultrasound is essential to confirm intrauterine pregnancy location before MTP, as proceeding without this confirmation creates significant risk of undiagnosed ectopic pregnancy 1, 2.
• Studies show that 11% of women requesting MTP had ectopic, unviable, or multiple pregnancies diagnosed on pre-procedure ultrasound that would have been missed without imaging 2.
• The primary concern is not whether the MTP "worked" but whether an ectopic pregnancy was missed, which could lead to life-threatening rupture 1.

Immediate Risk Assessment Required

This patient requires urgent evaluation with the following protocol:

• Obtain quantitative serum β-hCG immediately to establish baseline, as this is essential for determining whether pregnancy tissue remains and for serial monitoring 3.
• Perform transvaginal ultrasound regardless of β-hCG level to evaluate for:
  • Any remaining intrauterine pregnancy tissue 4
  • Adnexal masses suggesting ectopic pregnancy 5
  • Free fluid in pelvis indicating possible rupture 5
• Assess hemodynamic stability and peritoneal signs, as these indicate potential ruptured ectopic requiring immediate surgical intervention 6.

Diagnostic Algorithm Based on Findings

If β-hCG is detectable (>5 mIU/mL):

• Repeat β-hCG in exactly 48 hours to assess trajectory 3:
  • Declining β-hCG (>15% drop) suggests successful termination of intrauterine pregnancy; continue monitoring until <5 mIU/mL 3
  • Rising or plateauing β-hCG raises concern for ectopic pregnancy or failed MTP requiring urgent gynecology consultation 3, 6
• Approximately 22% of ectopic pregnancies present with β-hCG <1,000 mIU/mL, so low levels do not exclude this diagnosis 3.

If ultrasound shows:

• Empty uterus with adnexal mass: High suspicion for ectopic pregnancy (positive likelihood ratio 111); obtain immediate gynecology consultation 3.
• Retained products of conception: Document as "incomplete MTP" but recognize that 59% of women with ultrasound evidence of retained tissue do not require surgical intervention 4.
• No intrauterine or extrauterine findings: Document as "pregnancy of unknown location post-MTP"; 7-20% of these cases ultimately prove to be ectopic 3.

Appropriate Documentation

The medical record should include:

• "Status post medical termination of pregnancy performed at outside facility without pre-procedure ultrasound confirmation of intrauterine pregnancy location"
• Current β-hCG level and ultrasound findings
• Explicit documentation that ectopic pregnancy has not been excluded 1
• Plan for serial β-hCG monitoring every 48 hours until diagnosis established 3, 6

Critical Safety Points

• Never assume successful intrauterine pregnancy termination without ultrasound confirmation of pre-procedure intrauterine location 1, 2.
• The risk of ectopic pregnancy is 10-13% in early pregnancy presentations with bleeding or pain 5.
• Patients must be counseled to return immediately for severe abdominal pain, shoulder pain, syncope, or hemodynamic instability suggesting ruptured ectopic 6.
• Studies demonstrate that medical abortion performed before confirmed intrauterine pregnancy has similar efficacy (98.2% vs 97.1%) but carries the critical risk of missed ectopic pregnancy 1.

Follow-Up Protocol

• Serial β-hCG every 48 hours until either:
  • Levels decline to <5 mIU/mL confirming complete termination 3
  • Abnormal rise/plateau pattern triggers gynecology consultation for suspected ectopic 3, 6
• Repeat transvaginal ultrasound in 7-10 days if β-hCG remains detectable but declining 3.
• Admission criteria include: hemodynamic instability, peritoneal signs, β-hCG >3,000 mIU/mL without intrauterine pregnancy, or adnexal mass with free fluid 6.