March 2022
An estimated 25 million unsafe abortions occur every year,
it is one of the leading causes of
maternal mortality and morbidity worldwide.
The two methods of abortion are:
- medical abortion: the use of medications to end a pregnancy; the most commonly used
medications are misoprostol alone or misoprostol in combination with mifepristone. - surgical abortion: the use of transcervical procedures to end a pregnancy, including manual
vacuum aspiration (MVA), electric vacuum aspiration (EVA) and dilatation and evacuation (D&E)
Information for individuals requesting an abortion
The following information should be provided, in a clear,
understandable, non-judgemental and respectful way:
- Abortion is a safe procedure for which major complications are rare at all
pregnancy durations. - The choice of abortion methods available.
- What will happen during and after the abortion (see Table 1).
- What pain management options are available.
- Side effects, risks and complications of abortion methods (see Table 2)
- How to be sure the pregnancy has ended for those having a medical abortion at home.
- How to identify the need to seek urgent medical attention during or after the abortion.
- The range of potential emotions experienced after an abortion.
- Other available services, such as sexually transmitted infection (STI) screening, counselling
for those who need it and support for those experiencing, for example, sexual coercion or
domestic violence and abuse. - What contraception options are available and how they can be accessed.
Contraindications and extra considerations
Medical abortion
There are few contraindications to medical abortion:
- known or suspected ectopic pregnancy
- previous allergic reaction to mifepristone or misoprostol
- severe uncontrolled asthma
- chronic adrenal failure
- inherited porphyria.
- Mifepristone should not be used as there is a theoretical risk of exacerbation of the underlying condition, but use of misoprostol alone could be considered.
Extra consideration and additional care planning might be necessary for those:
- on long-term steroid therapy – theoretically, since mifepristone is a glucocorticoid
receptor antagonist, it might inhibit the action of the steroid therapy and exacerbate the
underlying condition; seek specialist input on whether dose adjustments to a corticosteroid
regimen are required - on anticoagulant medication – anticoagulants may need to be stopped before abortion
medications are administered and then restarted after the abortion. - with a bleeding disorder, who may need care in a clinical setting rather than at home.
- with symptomatic anaemia, where the haemoglobin concentration should be measured
and who may need additional care in a hospital setting. - with an IUD in place – the IUD should ideally be removed in advance of treatment; if the
IUD cannot be retrieved, it is important to confirm that it is expelled during the procedure,
by using imaging such as an abdominal X-ray after the abortion.
Information for health workers providing abortions
Medical abortion
Before 12 weeks of pregnancy
can be safely managed by most people at home,
it is as safe and effective as infacility treatment, and
can be more convenient and private for people.
The most effective regimen is
mifepristone 200mg orally, followed
24–48 hours later by misoprostol
800 micrograms taken by the vaginal, buccal or sublingual route.
- If expulsion of the pregnancy has not occurred within 4 hours, a further 400 micrograms of
misoprostol should be taken by the vaginal, buccal or sublingual route. - If misoprostol is provided for use at home, additional doses should be provided in case they
are required. - consider pregnancy durations of over 9 weeks as the effectiveness of a single dose of 800 micrograms of misoprostol starts to decline from then onwards.
- If mifepristone is not available, use misoprostol 800 micrograms taken by the vaginal, buccal or sublingual route,
- followed by misoprostol 400 micrograms every 3 hours until the pregnancy has passed.
12–24 weeks of pregnancy
At 12 weeks or more, medical abortion is usually undertaken in a medical facility.
However, there is no evidence indicating that out-of-facility medical abortion is unsafe.
If mifepristone is available, it should be used in combination with misoprostol as it shortens the
induction-to-abortion interval, reduces side effects and decreases the rate of ongoing pregnancy.
The most effective regimen is mifepristone 200mg orally, followed 24–48 hours later by misoprostol
800 micrograms vaginally, buccally or sublingually, followed by misoprostol 400 micrograms vaginally,
buccally or sublingually every 3 hours until abortion occurs.
Where mifepristone is not available, use misoprostol 800 micrograms followed by misoprostol
400 micrograms every 3 hours until abortion occurs.
The uterus is more sensitive to misoprostol as pregnancy advances, and therefore, in pregnancies
over 24 weeks, lower doses of misoprostol should be used and increased intervals between
misoprostol doses may be considered, especially for people with uterine scars.
Pain management for medical abortion
Analgesia (pain relief) should always be offered.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended either prophylactically or
at the time that cramping begins. - Non-pharmacological pain management measures (e.g. hot water bottle/heat pad) may be helpful.
- Pain increases with pregnancy duration so narcotic analgesics may be required when other pain
management measures are insufficient. Epidural anaesthesia can also be used, where available.
Surgical abortion
Before 14 weeks of pregnancy
Surgical abortion before 14 weeks can be performed using vacuum aspiration (electrical (EVA)
or manual (MVA)).
Vacuum aspiration involves evacuation of the contents of the uterus through a plastic or metal
cannula, attached to a vacuum source. EVA employs an electric vacuum pump. With MVA, the
vacuum is created using a hand-held, hand-activated, plastic 60ml aspirator (also called a syringe). - MVA aspirators accommodate 4–12mm cannulas.
- There is no lower limit of pregnancy duration for surgical abortion.
- It is best practice to inspect aspirated tissue at all durations of pregnancy, to confirm that the
pregnancy has been fully removed. - During vacuum aspiration, the uterus should be emptied using only a suction cannula (and
forceps if required). The procedure should not be routinely completed by sharp curettage.
14–24 weeks of pregnancy
Surgical abortion between 14 and 24 weeks can be performed using dilatation and evacuation (D&E).
D&E requires preparation of the cervix using osmotic dilators or pharmacological agents, and
evacuating the uterus using long forceps and vacuum aspiration with cannulas. It is the safest and most
effective surgical technique after 14 weeks, as long as skilled, experienced providers are available.
Vacuum aspiration can be used up to 15–16 weeks of pregnancy with larger bore suction tubing
and cannulas up to 16mm in diameter.
Dilatation and sharp curettage (D&C) is an obsolete method of surgical abortion and
should not be used.
Cervical preparation before surgical abortion
Cervical preparation should be used for all patients as it reduces the risk of incomplete abortion
and makes dilation easier. It may cause some bleeding and pain before the procedure. If osmotic
dilators are used, consider inserting them the day before the abortion, especially if pregnancy
duration is 19 weeks or greater.
Before 12 weeks of pregnancy: - mifepristone 200mg orally, 24–48 hours before the procedure, or
- misoprostol 400 micrograms sublingually, 1–2 hours before the procedure, or
- misoprostol 400 micrograms vaginally or buccally, 2–3 hours before the procedure.
12–18+6 weeks of pregnancy:
- combination of mifepristone and misoprostol*
(using above regimens), or - osmotic dilators plus either mifepristone or misoprostol, or with both mifepristone and
misoprostol (using above regimens in all cases).
19–24 weeks of pregnancy: - osmotic dilators plus either mifepristone or misoprostol, or with both mifepristone and
misoprostol (using above regimens in all cases).
Pain management for surgical abortion
Analgesia should always be offered. - In most cases, analgesics, such as NSAIDS, local anaesthesia and/or conscious sedation,
supplemented by verbal reassurance, are sufficient. - General anaesthesia is not recommended for routine use in pain management for abortion
procedures, as it has been associated with higher rates of complications, and with longer
hospital stays, than local anaesthesia. - Local anaesthesia, such as lidocaine given as a paracervical block, can be used to alleviate
discomfort from mechanical cervical dilatation and uterine evacuation. - Where conscious sedation is available, it should be offered with a cervical block.
- If general anaesthesia is used, consider intravenous propofol and a short-acting opioid (such as
fentanyl) rather than inhalational anaesthesia. - NSAIDS can be used to alleviate abdominal cramping caused by misoprostol given for cervical
preparation
Information to provide after an abortion
Clients should receive instructions about signs and symptoms that might indicate a complication
that requires urgent medical help, including if they:
- soak through two or more maxi-size sanitary towels per hour, for 2 hours in a row
- develop an unusual, unpleasant-smelling vaginal discharge
- develop a fever or flu-like symptoms after 24 hours
- develop worsening pain, including that which might indicate an undiagnosed ectopic pregnancy
(for example, if lower abdominal pain is one-sided, under the ribs, or goes up to the shoulders. - Health workers should also provide information on signs and symptoms that might indicate an
- ongoing pregnancy for which clients should seek medical attention, including if they:
- have no bleeding or only spotting or smearing of blood on sanitary towel or underwear in the
24 hours after misoprostol for medical abortion - still feel pregnant 1 week after the abortion.
Anti-D
If available, anti-D should be offered to non-sensitised RhD-negative individuals from 12 weeks of
pregnancy and provided within 72 hours of the abortion.
Unsafe abortion
An abortion is unsafe when it is carried out either by a person lacking the necessary skills or in an
environment that does not conform to minimal medical standards, or both.
In many settings it is important to distinguish between safe and unsafe abortion because the latter is
much more likely to be associated with infection. Indications that an abortion has been attempted
by unsafe methods include the presence of:
- vaginal laceration.
- cervical injury
- uterine enlargement equivalent to a pregnancy of more than 12 weeks’ duration
- products of conception visible at the cervix or in the vagina
- in patients with uterine injury, any of fever, significant lower abdominal pain, tenderness or
abdominal distension - the presence of a foreign body in the vagina or cervix.
Infection
It is vital to identify those who may have an infection and to manage this urgently. Infection is
much more likely, and much more likely to be severe, if the abortion has been performed unsafely.
Clinical features suggestive of infection include: - temperature above 37.5°C
- localised or general abdominal tenderness, guarding or rebound
- unusual, unpleasant odour or pus visible in the cervical os
- uterine tenderness.
Features suggestive of sepsis and indicating the need for urgent intervention include: - hypotension
- tachycardia
- increased respiratory rate.
Management
If there is no suspicion of infection and uterine size is less than 14 weeks - Medical management with misoprostol 400 micrograms sublingually, buccally or vaginally or
600 micrograms orally: - for a missed abortion (retained non-viable fetus), mifepristone 200mg orally should be
administered 24–48 hours before the misoprostol.
OR - Uterine evacuation with vacuum aspiration and antibiotic prophylaxis (see above).
If there is no suspicion of infection and uterine size is 14 weeks or larger - Medical management with misoprostol:
- 14–24 weeks: misoprostol 400 micrograms administered sublingually, buccally or vaginally
every 3 hours - the uterus is more sensitive to misoprostol as pregnancy advances, and therefore, in
pregnancies over 24 weeks, lower doses of misoprostol should be used and increased intervals
between misoprostol doses may be considered, especially for people with uterine scars - in order to align protocols, services may use the same dosing and intervals as recommended
in regimens for induced abortion - for a missed abortion (retained non-viable fetus), mifepristone 200mg orally should be
administered 24–48 hours before misoprostol.
OR
Surgical management with antibiotic prophylaxis (see above):
- vacuum aspiration for removal of retained tissue when the fetus has been expelled; blunt
forceps may also be needed to remove a retained placenta - if the fetus is retained, vacuum aspiration is suitable before 14 weeks of pregnancy; from
14 weeks and up to 16 weeks of pregnancy, forceps removal of larger fetal parts may also be
required; from 16 weeks of pregnancy, a dilatation and evacuation (D&E) may be performed - if removal of the pregnancy requires the use of forceps, either in combination with
vacuum aspiration or for a D&E, this should only be carried out by a skilled provider; if not
available, medical management is recommended.
If infection is present, the uterus should be evacuated urgently - Start broad-spectrum antibiotics immediately – intravenously if infection is severe.
- Transfer to a unit with the facilities for undertaking surgical evacuation if it cannot be done in
the facility to which the individual presents. - If the patient is in septic shock, they should be transferred immediately to a specialist unit for
surgical uterine evacuation – broad-spectrum antibiotics, such as a combination of ampicillin
0.5–1g every 6 hours, metronidazole 500mg every 8 hour and gentamicin 120mg daily (with
appropriate monitoring), should be administered intravenously prior to transfer if available. - If the skills necessary for urgent surgical uterine evacuation are not available, misoprostol can
be administered using the dose regimens above.
contraception
All contraceptive methods can be started at the time of a surgical abortion.
All contraceptive methods except for IUDs can be started at the time mifepristone and/or
misoprostol is taken for medical abortion. An IUD can be inserted following expulsion of the
pregnancy after a medical abortion.
Additional contraceptive precautions are not required if contraception is initiated immediately or
within 5 days of an abortion.
If sterilisation is requested, this should ideally only be performed after some time has elapsed after
abortion. Individuals who request that tubal occlusion be performed at the time of an abortion
should be advised of the possible increased failure rate and risk of regret.
If a client’s chosen method is not available, they should be provided with an interim, bridging method
that they can start immediately and they should be referred to a service where the preferred
method can be provided.
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