Controversies in family planning: pregnancy termination in women with uterine anatomic abnormalities

      A 35-year-old G3P2002 woman presented to our clinic for elective termination of her first trimester pregnancy. She had a history of one prior uncomplicated vaginal delivery at term, followed by an uncomplicated cesarean delivery at term for breech. Initial transvaginal ultrasound showed a single intrauterine pregnancy with a crown-rump length of 0.38 cm consistent with 6 weeks 1 day gestational age. The resident started the dilation but with some difficulty. The fellow took over and was able to adequately dilate and pass the 7-mm cannula but then noted no tissue return with the manual vacuum aspirator (MVA). The attending then performed transabdominal ultrasound guidance which showed that the cannula did not appear to be in the same cavity as the pregnancy; however, it did not appear extrauterine. We removed all instruments and performed a transvaginal ultrasound which showed two uterine cavities, with a thin endometrial stripe on the right and the intrauterine pregnancy on the left. At this point, the speculum was replaced, a second sterile prep was done and the attending attempted unsuccessfully to pass instruments into the left cavity under ultrasound guidance. We decided to proceed with a medication abortion using mifepristone and misoprostol. Two days later, the patient called the clinic reporting that after taking the misoprostol she had cramping but no bleeding. Our team is planning to repeat the misoprostol. Any additional thoughts if this attempt is still not successful?


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