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McLaren H, Hennessey C. First-trimester Procedural Abortion. Clin Obstet Gynecol 2023; 66:676-684. [PMID: 37750678 DOI: 10.1097/grf.0000000000000808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
First-trimester abortion is a common and safe procedure. A focused history and physical examination are essential for providing this care. Laboratory assessment can include Rh typing, hemoglobin, and cervicitis testing as indicated by a patient's risk factors. Procedural abortion in the first trimester includes cervical dilation with or without cervical preparation, and uterine evacuation utilizing a manual vacuum aspirator or electric vacuum aspirator. Complications occur rarely and are often easily managed at the time of diagnosis.
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Affiliation(s)
- Hillary McLaren
- Department of Obstetrics and Gynecology, Section of Complex Family Planning, University of Chicago, Chicago, Illinois
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van den Berg J, Hamel CC, Snijders MP, Coppus SF, Vandenbussche FP. Mifepristone and misoprostol versus misoprostol alone for uterine evacuation after early pregnancy failure: study protocol for a randomized double blinded placebo-controlled comparison (Triple M Trial). BMC Pregnancy Childbirth 2019; 19:443. [PMID: 31775677 PMCID: PMC6880504 DOI: 10.1186/s12884-019-2497-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/09/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Early pregnancy failure (EPF) is a common complication of pregnancy. If women do not abort spontaneously, they will undergo medical or surgical treatment in order to remove the products of conception from the uterus. Curettage, although highly effective, is associated with a risk of complications; medical treatment with misoprostol is a safe and less expensive alternative. Unfortunately, after 1 week of expectant management in case of EPF, medical treatment with misoprostol has a complete evacuation rate of approximately 50%. Misoprostol treatment results may be improved by pre-treatment with mifepristone; its effectiveness has already been proven for other indications of pregnancy termination. This study will test the hypothesis that, in EPF, the sequential combination of mifepristone with misoprostol is superior to the use of misoprostol alone in terms of complete evacuation (primary outcome), patient satisfaction, complications, side effects and costs (secondary outcomes). METHODS The trial will be performed multi-centred, prospectively, two-armed, randomised, double-blinded and placebo-controlled. Women with confirmed EPF by ultrasonography (6-14 weeks), managed expectantly for at least 1 week, can be included and randomised to pre-treatment with oral mifepristone (600 mg) or oral placebo (identical in appearance). Randomisation will take place after receiving written consent to participate. In both arms pre-treatment will be followed by oral misoprostol, which will start 36-48 h later consisting of two doses 400 μg (4 hrs apart), repeated after 24 h if no tissue is lost. Four hundred sixty-four women will be randomised in a 1:1 ratio, stratified by centre. Ultrasonography 2 weeks after treatment will determine short term treatment effect. When the gestational sac is expulsed, expectant management is advised until 6 weeks after treatment when the definitive primary endpoint, complete or incomplete evacuation, will be determined. A sonographic endometrial thickness < 15 mm using only the allocated therapy by randomisation is considered as successful treatment. Secondary outcome measures (patient satisfaction, complications, side effects and costs) will be registered using a case report form, patient diary and validated questionnaires (Short Form 36, EuroQol-VAS, Client Satisfaction Questionnaire, iMTA Productivity Cost Questionnaire). DISCUSSION This trial will answer the question if, in case of EPF, after at least 1 week of expectant management, sequential treatment with mifepristone and misoprostol is more effective than misoprostol alone to achieve complete evacuation of the products of conception. TRIAL REGISTRATION Clinicaltrials.gov (d.d. 02-07-2017): NCT03212352. Trialregister.nl (d.d. 03-07-2017): NTR6550. EudraCT number (d.d. 07-08-2017): 2017-002694-19. File number Commisie Mensgebonden Onderzoek (d.d. 07-08-2017): NL 62449.091.17.
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Affiliation(s)
- Joyce van den Berg
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Postbus 9015, Nijmegen, GS 6500 The Netherlands
| | - Charlotte C. Hamel
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Postbus 9015, Nijmegen, GS 6500 The Netherlands
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, GA 6525 The Netherlands
| | - Marcus P. Snijders
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Postbus 9015, Nijmegen, GS 6500 The Netherlands
| | - Sjors F. Coppus
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, De Run 4600, Veldhoven, DB 5504 The Netherlands
| | - Frank P. Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, GA 6525 The Netherlands
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Amin T, Saridogan E, Dooley M, Jurkovic D. Morphological appearance of uterine cavity on ultrasound prior to development of intrauterine adhesions. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:142-143. [PMID: 28236322 DOI: 10.1002/uog.17444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 02/14/2017] [Accepted: 02/17/2017] [Indexed: 06/06/2023]
Affiliation(s)
- T Amin
- Institute for Women's Health, University College Hospital, London, UK
| | - E Saridogan
- Institute for Women's Health, University College Hospital, London, UK
| | - M Dooley
- The Poundbury Clinic, King Edward VII's Hospital, London, UK
| | - D Jurkovic
- Institute for Women's Health, University College Hospital, London, UK
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Wylomanski S, Winer N. [Role of ultrasound in elective abortions]. ACTA ACUST UNITED AC 2016; 45:1477-1489. [PMID: 27814980 DOI: 10.1016/j.jgyn.2016.09.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/27/2016] [Accepted: 09/27/2016] [Indexed: 11/15/2022]
Abstract
Ultrasound plays a fundamental role in the management of elective abortions. Although it can improve the quality of post-abortion care, it must not be an obstacle to abortion access. We thus studied the role of ultrasound in pregnancy dating and possible alternatives and analyzed the literature to determine the role of ultrasound in post-abortion follow-up. During an ultrasound scan, the date of conception is estimated by measurement of the crown-rump length (CRL), defined by Robinson, or of the biparietal diameter (BPD), as defined by the French Center for Fetal Ultrasound (CFEF) after 11 weeks of gestation (Robinson and CFEF curves) (grade B). Updated curves have been developed in the INTERGROWTH study. In the context of abortion, the literature recommends the application of a safety margin of 5 days, especially when the CRL and/or BPD measurement indicates a term close to 14 weeks (that is equal or below 80 and 27mm, respectively) (best practice agreement). Accordingly, with the ultrasound measurement reliable to±5 days when its performance meets the relevant criteria, an abortion can take place when the CRL measurement is less than 90mm or the BPD less than 30mm (INTERGROWTH curves) (best practice agreement). While a dating ultrasound should be encouraged, its absence is not an obstacle to scheduling an abortion for women who report that they know the date of their last menstrual period and/or of the at-risk sexual relations and for whom a clinical examination by a healthcare professional is possible (best practice agreement). In cases of intrauterine pregnancy of uncertain viability or of a pregnancy of unknown location, without any particular symptoms, the patient must be able to have a transvaginal ultrasound to increase the precision of the diagnosis (grade B). Various reviews of the literature on post-abortion follow-up indicate that the routine use of ultrasound during instrumental abortions should be avoided (best practice agreement). If it becomes clear immediately after the procedure that the endometrial thickness exceeds 8mm, immediate reaspiration is necessary. Ultrasound examination of the endometrium several days after an instrumental elective abortion does not appear to be relevant (grade B). An analysis of the literature similarly shows that routine ultrasound scans after medical abortions should be avoided. If a transvaginal ultrasound is performed after a medical abortion, it should take place at least two weeks afterwards (best practice agreement). The only aim of an ultrasound examination during follow-up should be to determine whether a gestational sac is present (best practice agreement). Finally, if an ultrasound is performed at any point during pre- or post-abortion care, a report should be drafted, specifying any potential gynecologic abnormalities found, but its absence must not delay the scheduling of the abortion (best practice agreement).
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Affiliation(s)
- S Wylomanski
- Service de gynécologie-obstétrique, CHU de Nantes, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France.
| | - N Winer
- Service de gynécologie-obstétrique, CHU de Nantes, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
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Lemmers M, Verschoor M, Oude Rengerink K, Naaktgeboren C, Opmeer B, Bossuyt P, Huirne J, Janssen C, Radder C, Klinkert E, Langenveld J, Catshoek R, Van der Voet L, Siemens F, Geomini P, Van Hooff M, Van der Ploeg J, Coppus S, Ankum W, Mol B. MisoREST: surgical versus expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage: a randomized controlled trial. Hum Reprod 2016; 31:2421-2427. [DOI: 10.1093/humrep/dew221] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 05/25/2016] [Accepted: 06/14/2016] [Indexed: 11/12/2022] Open
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Tohma YA, Dilbaz B, Evliyaoğlu Ö, Çoşkun B, Çolak E, Dilbaz S. Is ultrasonographic evaluation essential for diagnosis of retained products of conception after surgical abortion? J Obstet Gynaecol Res 2016; 42:489-95. [DOI: 10.1111/jog.12944] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 10/22/2015] [Accepted: 12/07/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Yusuf Aytaç Tohma
- Başkent University, Department of Obstetric and Gynecology; Konya Turkey
| | - Berna Dilbaz
- Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital; Ankara Turkey
| | - Özlem Evliyaoğlu
- Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital; Ankara Turkey
| | - Bora Çoşkun
- Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital; Ankara Turkey
| | - Eser Çolak
- Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital; Ankara Turkey
| | - Serdar Dilbaz
- Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital; Ankara Turkey
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Cheung KW, Ngu SF, Cheung VYT. Sonographic characteristics of the uterus in asymptomatic women after second-trimester medical termination of pregnancy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:611-616. [PMID: 25792576 DOI: 10.7863/ultra.34.4.611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the sonographic characteristics of the uterus after apparently uncomplicated second-trimester medical termination of pregnancy and to follow the evolution of these findings until the return of menstruation. METHODS Twenty-three women who requested termination of pregnancy at gestational ages between 14 and 20 weeks were recruited. Uterine characteristics were measured by 2- and 3-dimensional transvaginal with or without transabdominal sonography. The uterine anteroposterior diameter, length, and width, endometrial thickness, presence of an endometrial mass, intrauterine vascularity, and endometrial volume were measured within 24 hours, 1, 2, 4, 6, and 8 weeks after termination, and during the postmenstrual phase. RESULTS The mean uterine anteroposterior diameter, uterine length, uterine width, endometrial thickness, and endometrial volume ± SD deceased gradually from 66.1 ± 9.7 to 40.9 ± 5.3 mm, 131.4 ± 14.7 to 81.3 ± 13.8 mm, 84.6 ± 10.3 to 54.2 ± 7.6 mm, 25.6 ± 8.1 to 4.5 ± 2.6 mm, and 39.4 ± 22.6 to 2.5 ± 2.1 mL, respectively, from within 24 hours after termination to the postmenstrual phase. Endometrial masses were identified in 8 women (34.8%) within 4 weeks after termination, which could persist for up to 8 weeks. However, all endometrial masses resolved after menstruation. Minimal and moderate endometrial vascularity was detectable in up to 21.7% after termination; none was detectable in any women after menstruation. CONCLUSIONS This study provides information on the normal sonographic parameters of the uterus after second-trimester medical termination of pregnancy, which has been lacking in the literature. Also, our findings suggest that all endometrial masses regress with time; therefore, asymptomatic women with an incidental finding of an endometrial mass can be followed without the need for an immediate intervention.
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Affiliation(s)
- Ka Wang Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong.
| | - Siew-Fei Ngu
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Vincent Y T Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong
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Napolitano R, Ghosh M, Gillott DJ, Ojha K. Three-dimensional Doppler sonography in asymptomatic and symptomatic women after medical termination of pregnancy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:847-852. [PMID: 24764340 DOI: 10.7863/ultra.33.5.847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To characterize the 3D Doppler sonographic appearance of the uterine cavity in asymptomatic and symptomatic women after administration of mifepristone and misoprostol for medical termination of pregnancy. METHODS A prospective observational study was performed. Women admitted for medical termination of pregnancy underwent transvaginal sonography 15 days after the procedure. Volumes were acquired, and offline analyses of the 3D vascularization indices were performed. Outcomes were collected at the follow-up scan and by telephone after the termination. Women were subclassified as asymptomatic or symptomatic according to the presence/absence of fever, vaginal bleeding, abdominal/pelvic pain, and infections. Spotting was defined as any episodic vaginal bleeding that was less than an expected menstruation and not regarded as a symptom. RESULTS A total of 104 women who underwent medical termination of pregnancy between 6 and 9 weeks' gestation were enrolled in the study. The termination procedure was successful in 98% of cases; among them, 9 women (8.6%) were symptomatic due to bleeding. Two asymptomatic women required surgery; 1 had sonographic evidence of suspected retained products of conception (endometrial thickness ≥ 15 mm or power Doppler vascularization presence). Fifty-seven women (55%) presented with retained products of conception. All the women with suspected retained products regained normal menses; of these, 3 symptomatic women with retained products (2.9%) underwent a 1-month sonographic follow-up. The symptomatic status was not associated with endometrial thickness, 3D intrauterine mass volume, or 2-dimensional (2D) and 3D power Doppler appearances. CONCLUSIONS The necessity of surgery after medical termination of pregnancy cannot be predicted by sonography. In cases with sonographic evidence of suspected retained products of conception, endometrial thickness, 2D Doppler findings, and the 3D vascularization indices correlated poorly with bleeding symptoms. Long-term follow-up should be considered in symptomatic women, and it can avoid any unnecessary surgical intervention.
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Affiliation(s)
- Raffaele Napolitano
- Pregnancy Advisory Center, St George's University of London, Cranmer Terrace, London SW17 0RE, England.
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Tzeng CR, Hwang JL, Au HK, Chien LW. Sonographic patterns of the endometrium in assessment of medical abortion outcomes. Contraception 2013; 88:153-9. [DOI: 10.1016/j.contraception.2012.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 09/02/2012] [Accepted: 09/24/2012] [Indexed: 10/27/2022]
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Hassan R, Bhal K, Joseph B. The need for repeat evacuation of retained products of conception: how common is it? J OBSTET GYNAECOL 2012; 33:75-6. [PMID: 23259885 DOI: 10.3109/01443615.2012.731451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Evacuation of retained products of conception with suction curettage is a widely used method for the management of missed miscarriage, incomplete miscarriage and termination of pregnancy. This procedure carries a risk of incomplete evacuation, which may lead to a further repeat evacuation. There are limited data on the incidence of repeat evacuation for suspected retained products. We undertook a retrospective audit on patients who underwent suction curettage for retained products of conception between January 2006 and February 2008, in order to evaluate the rate of repeat evacuation. Our study showed 3.1% (17 of 541) of patients underwent a repeat evacuation for suspected retained products. Suction curettage remains a safe and common procedure, however, it is important to minimise the recurrence of repeat evacuations through the use of medical management, improved training and local guidelines. This in turn should lower the risk of further complications associated with a surgical procedure.
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Affiliation(s)
- R Hassan
- Department of Obstetrics and Gynaecology, 1 University Hospital of Wales, Cardiff , UK.
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Huang YT, Horng SG, Lee FK, Tseng YT. Management of anembryonic pregnancy loss: an observational study. J Chin Med Assoc 2010; 73:150-5. [PMID: 20231000 DOI: 10.1016/s1726-4901(10)70030-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Accepted: 12/23/2009] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND This study was undertaken to determine if expectant management with a longer waiting period is an effective and safe option for women with anembryonic pregnancy. METHODS Women with an ultrasound diagnosis of anembryonic pregnancy were offered the option of expectant management with a 3-week waiting period or surgical evacuation according to their preference. RESULTS A total of 121 women with anembryonic pregnancies participated in the study; 45 of them elected expectant management. The overall success rate was 83.3% in the expectant group and 97.3% in the surgical group. No significant complications were noted in either group. CONCLUSION Expectant management with a 3-week waiting period is an efficacious and safe option with a low risk of infection and hemorrhage. However, it is difficult to predict the exact time period before spontaneous abortion.
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Affiliation(s)
- Ying-Ti Huang
- Division of Obstetrics and Gynecology, Hsinchu Cathay General Hospital, Hsinchu, Taiwan, R.O.C
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McEwing RL, Anderson NG, Meates JBA, Allen RB, Phillipson GTM, Wells JE. Sonographic appearances of the endometrium after termination of pregnancy in asymptomatic versus symptomatic women. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2009; 28:579-586. [PMID: 19389896 DOI: 10.7863/jum.2009.28.5.579] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE The purpose of this study was to describe normal sonographic appearances of the endometrium in asymptomatic women after elective termination of pregnancy (TOP) and to determine whether sonographic findings are discriminatory in symptomatic women after TOP. METHODS Sonographic parameters were compared in prospectively recruited women after elective TOP. The first 38 were asymptomatic. In a later group, 105 had symptoms suggestive of retained products of conception (RPOC). Endometrial thickness, cavity irregularity, echogenicity of cavity contents, color Doppler flow, and resistive indices (RIs) were assessed. In the symptomatic group, sonographic findings were correlated with symptoms and histologic results. RESULTS There was a marked overlap in sonographic appearances between the groups. The endometrial cavity is commonly irregular and thickened and may show prominent color Doppler flow in women with an uneventful course as well as in women with histologically proven RPOC. Differences between asymptomatic and symptomatic women were only seen for: endometrial thickness (10.8 mm [range, 1-29 mm] versus 15.3 mm [range, 1.8-34 mm]; P = .0005), and cavity irregularity was greater in symptomatic women (P = .001). Color Doppler flow mean RIs were similar. Symptoms were similar in women proceeding to curettage versus no curettage; no significant relationship was found between individual symptoms and sonographic parameters. Chorionic villi were seen in 47 of 56 women (84%) with positive histologic results. CONCLUSIONS Sonographic appearances and symptoms correlate poorly with each other and with histologic results. Sonography has limited benefits in triaging women with suspected RPOC after TOP in the first trimester. Our findings support a more conservative approach to suspected RPOC after TOP.
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Affiliation(s)
- Rachael L McEwing
- Department of Radiology, Christchurch Women's Hospital, Christchurch, New Zealand.
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