Module 4: Point of care ultrasound in first trimester abortion (POCUS)

1. Introduction

In the case of first trimester scanning for abortion providers, the following clinical questions are relevant:

• The first, point of care ultrasound (POCUS) is a limited scan using an abdominal handheld ultrasound scanner, undertaken by health practitioners, using an abdominal scan to answer a simple clinical question, such as gestational age
• The second is a formal comprehensive scan using transvaginal or abdominal probes, undertaken by a trained sonographer, to provide a comprehensive review of the anatomy

This training module describes the theoretical knowledge required to provide point of care ultrasound for people seeking abortion. Provision of point of care ultrasound (POCUS) by an abortion provider was supported by the 2018 New Zealand Standards in Abortion Care. Whilst this recommendation is not continued in the 2021 New Zealand Aotearoa Abortion Guideline, the potential benefits referred to in the standards document remain unchanged.

Point of care ultrasound is not the equivalent of a formal diagnostic scan. Where a diagnostic scan reviews the available anatomy/function and reports on the findings, point of care ultrasound is performed by a health professional with the aim of answering simple clinical questions. As such pathologies outside of the clinical question may be missed with a point of care scan, and this tool is only valuable in answering the clinical question posed.

This module is aimed at providing the theory elements for using a simple, handheld device for the following:

1. Identifying the uterus
2. Identifying what is in the uterus, such as blood, foetus, sac, retained products of conception
3. Differentiating between proven intrauterine pregnancy (IUP) and pregnancy of unknown location
4. Gestation measurements in the context of establishing upper limit for early medical abortion (EMA)
5. Identifying that the uterus has been evacuated following vacuum aspiration

After completion of these theory elements, it will be necessary to undertake a practical assessment for accreditation.

In the case of first trimester scanning for abortion providers, the following clinical questions are relevant:

• Is there an intrauterine pregnancy?
• What is the gestational age of the intra- uterine pregnancy?
• Is the uterus empty?
• Is there a twin pregnancy?
• Are there retained products of conception?

Other tools available to clinicians in making their assessment are:

• Medical history, date of last menstrual period (LMP) and ectopic risk assessment
• Urine βhCG pregnancy tests, which are available at differing levels of sensitivity
• Serum βhCG analysis (a single value or movement in values)
• Physical examination
• A detailed ultrasound scan by a sonographer

These other tools are considered in more detail in Module 1 – Consultation.