12VAC5-412-240.C. Medical Testing and Laboratory Services

The National Abortion Federation’s basic standard of care regarding the identification of products of conception following an abortion states, “Termination of pregnancy must be confirmed prior to the woman leaving the facility or further evaluation must be initiated.” One Board of Health member who is a doctor stated in the September 2015 BOH meeting, the proposed language of the amended regulations “falls short of the standard of care.” Asking a patient if they want further evaluation based on their ability to pay is simply malpractice.

The rationale given by Commissioner Levine and VDH for eliminating further evaluation was that it “removes mandatory additional testing and makes the testing permissive, allowing the physician and patient to discuss and determine the need for additional testing,” leading to “improved patient care.” Removing basic standards of care will not lead to improved patient care, but raise the risk that further complications or serious harm will occur, if the regulations are left as proposed by VDH.

Based on abortion care “consensus, rigorous review of relevant medical literature, and known patient outcomes,” if the termination of the pregnancy cannot be confirmed, further evaluation must be initiated, and must not wait for the result of a doctor patient discussion regarding the cost of further evaluation. These are “evidence-based guidelines” from within the abortion care community. And quite frankly, just good healthcare.

The World Health Organization’s “Safe Abortion” describes in a section titled, “Tissue examination following surgical abortion,”

After surgical methods of abortion, immediate examination of the products of conception is important to exclude the possibility of ectopic pregnancy and assess whether the abortion is likely to be complete…If the aspirate does not contain products of conception, ectopic pregnancy should be suspected and the woman should undergo further evaluation.

The WHO’s “Safe Abortion” continues in a section titled, “Ectopic Pregnancy”

If ectopic pregnancy is suspected, it is essential to confirm the diagnosis immediately and to initiate treatment or transfer the woman as soon as possible to a facility that has the capacity to confirm diagnosis and provide treatment. The inspection of aspirated tissue following a surgical abortion procedure can nearly eliminate the risk of an ectopic pregnancy going undetected.

In the absence of evidence-based guidelines from the Commissioner or VDH, the non-prescriptive guidelines presented by the National Abortion Federation will suffice. Therefore I recommend amending 12VAC5-412-420.C. in the following way:

C.  All tissues removed resulting from the abortion procedure shall be examined to verify that villi or fetal parts are present; if villi or fetal parts cannot be identified with certainty, the patient must be reevaluated and the tissue specimen shall be sent for further pathologic examination and the patient alerted to the possibility of an ectopic pregnancy., and referred appropriately.  Patient follow-up must continue until one of the following has been documented

1.      The diagnosis of ectopic pregnancy has been excluded;

 2.      Clinical resolution of a possible ectopic pregnancy has been ensured; or

3.      Transfer of care to an appropriate provider has been made.

Resolution of the pregnancy must be verified and documented. The facility shall track and log any specimens sent for further pathologic examination.