Termination of pregnancy and early pregnancy care

• Induced abortion is the deliberate ending of a pregnancy, offered as a health service alongside care for pregnancy loss; medical and surgical methods are both safe and effective, and the choice between them belongs to the woman. ^[1][1]
• Medication abortion under 12 weeks uses mifepristone 200 mg by mouth followed 24 to 48 hours later by misoprostol 800 micrograms by the vaginal, buccal or sublingual route; misoprostol alone is an effective alternative when mifepristone is not available. ^{[1] [1]}
• From 12 weeks, medical abortion uses mifepristone 200 mg followed by misoprostol 400 micrograms every 3 hours by the vaginal, buccal or sublingual route; surgical abortion uses vacuum aspiration under 14 weeks and dilatation and evacuation from 14 weeks upward. ^[1]
• Where law and services permit, a choice between medical and surgical abortion should be offered up to and including 23 weeks plus 6 days; feticide is needed if surgery is carried out beyond that. ^[1]
• Counselling is voluntary and non-directive: abortion is not associated with increased risks of infertility, breast cancer or mental health problems, and no compulsory counselling or waiting period should be imposed. ^[1][1]
• Post-abortion contraception should be available on the day of the abortion, because ovulation returns as early as 8 to 10 days later. ^[1]

By the end of this page you should be able to:

1. Explain what induced abortion is, how it differs from miscarriage, and why it is framed as healthcare.
2. Choose and describe a medical or surgical method appropriate to the gestation, including drug, dose, route and interval.
3. Explain the roles of mifepristone, misoprostol and cervical priming, and the precautions that matter at later gestations.
4. Manage the common complications of abortion, including haemorrhage, infection, incomplete abortion and ongoing pregnancy.
5. Provide non-directive counselling and explain the consent, confidentiality and legal principles that surround abortion care.
6. Offer post-abortion contraception by method and timing, using standard eligibility categories.

"Termination of pregnancy", "abortion" and "pregnancy termination" are used interchangeably in practice. Miscarriage and early pregnancy care are closely linked because the same drugs, the same skills and often the same clinic are used for both. Many of the recommendations below therefore apply equally to the management of pregnancy loss, where the medical regimens already used for miscarriage (mifepristone 200 mg followed by misoprostol 800 micrograms for a missed miscarriage) match those used for induced abortion. Plain text note on related topics: miscarriage and recurrent pregnancy loss, ectopic pregnancy, gestational trophoblastic disease, pregnancy diagnosis and physiology, contraception, perinatal mental health. ^[1]

Early care decides whether an abortion is simple or dangerous. The earlier in pregnancy the procedure is carried out, the simpler the methods, the lower the complication risk and the wider the choice of provider and setting. Access should therefore be quick: the assessment within one week of the request and the abortion within one week of the assessment is the model NICE sets for commissioners, with minimal delay built into the service. Self-referral, phone or video assessment where preferred, and community provision are all part of that. ^[1]

Induced abortion is common. In Great Britain alone, over 200 000 procedures are performed each year, and the Royal College of Obstetricians and Gynaecologists frames it as a healthcare need and an important public health intervention rather than only a legal or ethical issue. ^[1]

NICE recommends that a choice between medical and surgical abortion be offered up to and including 23 weeks plus 6 days, with surgical abortion possible shortly after that point only if feticide is given at or before 23 weeks plus 6 days. If a method is not clinically appropriate for a particular woman, the reason must be explained. ^[1]

The factors that matter are gestational age, the woman's own preference, privacy and confidentiality, how much pain and bleeding she can manage, whether she wants to avoid an anaesthetic or an operation, how quickly the tissue passes, and access to follow-up. Information should be provided without being directive, using decision aids where available, and women are entitled to time and to the support they request but not to compulsory counselling or compulsory time for reflection. ^[1][1]

The two methods are equally safe overall, and the overall complication risk is low at any gestation but rises as pregnancy advances, which is one reason not to delay an abortion that is wanted and lawful. ^[1]

Gestational age is the single most important determinant of method, route and setting. It is assessed from the history and examination; ultrasound is used when the date is uncertain or later gestation is suspected. Clinical dating by last menstrual period and examination is usually enough for early abortion, and treatment should not be delayed to obtain imaging that will not change management. ^[1]

Do not routinely offer antibiotic prophylaxis for a medical abortion. For surgical abortion, offer antibiotic prophylaxis; when doxycycline is used, 100 mg by mouth twice daily for 3 days is considered, and metronidazole should not routinely be combined with another broad-spectrum antibiotic such as doxycycline. A HIV test is routinely offered at the first appointment, with sexually transmitted infection testing as appropriate. ^[1]

For RhD-negative women having a medical or surgical abortion up to and including 11 weeks plus 6 days, anti-D prophylaxis is not used, following the World Health Organization position. At 12 weeks or more, rhesus status testing and anti-D prophylaxis should be available and must not delay the abortion. ^[1][1]

Women needing pharmacological thromboprophylaxis may be offered low-molecular-weight heparin for at least 7 days after the abortion, and for longer if they are at high risk of thrombosis. For surgical abortion at later gestations, cervical priming is essential, as set out below. ^[1]

Medical abortion is a process over several days rather than a single event. It uses mifepristone, a progesterone receptor antagonist that ends the pregnancy, followed by misoprostol, a prostaglandin analogue that softens the cervix and produces uterine contractions and expulsion. It can be delivered with support in a clinic or, for suitable women, completed partly or wholly at home. ^[1]

Between 10+1 and 23+6 weeks, NICE allows mifepristone at home for women who choose to take it before 9 weeks plus 6 days, with the option of expulsion at home in that earlier group; at 10 weeks precisely, expulsion at home is offered after misoprostol taken in the clinic or hospital. ^[1]

Up to 9+0 weeks, mifepristone and vaginal misoprostol may be given at the same time rather than at an interval, but the woman should be warned that ongoing pregnancy may be more likely (and rises with gestation), bleeding and pain may start later, and follow-up must still be completed. ^[1]

For women under 12 weeks, up to 9 weeks plus 6 days, mifepristone and misoprostol can be taken at home, with the same follow-up as any medical abortion; for home-based care the woman should be given a 24-hour contact number, information on expected pain and bleeding, analgesia and antiemetics, and a low-sensitivity or multi-level urine pregnancy test to exclude ongoing pregnancy. ^[1][1]

For women who prefer an alternative to prostaglandin-based regimens, or where mifepristone is unavailable, letrozole 10 mg by mouth each day for 3 days followed by misoprostol 800 micrograms sublingually on the fourth day is suggested by WHO as a safe and effective option under 12 weeks, and may be effective up to 14 weeks; it works by suppressing oestrogen and reducing progesterone receptor expression. ^[1]

Women offered self-assessment after an early medical abortion with home expulsion should be given the choice of remote or clinic follow-up. ^[1]

Surgical abortion empties the uterus directly. It is precise, quick and does not depend on drug absorption, but it requires trained providers and a clinical setting. WHO recommends vacuum aspiration under 14 weeks and dilatation and evacuation from 14 weeks; sharp curettage (dilatation and curettage) should not be used, and there is no role for sharp curette checks after aspiration. ^[1]

Vacuum aspiration, manual or electric, is the method of choice under 14 weeks. It can be performed in a primary care facility and as an outpatient, and manual vacuum aspiration is particularly useful where electricity is unreliable. Electric and manual aspiration require similar skills. ^[1]

Dilatation and evacuation is recommended from 14 weeks and can be provided on an outpatient basis, though skills are greater than for vacuum aspiration. Vacuum aspiration may be used during a D&E to amniotomise or remove tissue. ^[1]

Cervical priming before surgical abortion makes dilation easier and, for parous women, reduces incomplete abortion. ^[1]

• Up to and including 13 weeks plus 6 days: 400 micrograms misoprostol sublingual 1 hour before, or 400 micrograms vaginal 3 hours before the procedure. If misoprostol cannot be used, 200 mg oral mifepristone 24 to 48 hours before is considered. ^[1]
• 14+0 to 16+0 weeks: osmotic dilators, or buccal, vaginal or sublingual misoprostol, or 200 mg oral mifepristone the day before. ^[1]
• 16+1 to 19+0 weeks: osmotic dilators or buccal, vaginal or sublingual misoprostol. ^[1]
• 19+1 to 23+6 weeks: osmotic dilators are offered, plus consideration of 200 mg mifepristone the day before and insertion of osmotic dilators at the same time. ^[1]
• Osmotic dilators should be inserted the day before when used, and misoprostol is not offered if an osmotic dilator has already been placed. ^[1]

Women should be told that priming may cause bleeding and pain before the procedure. ^[1]

For surgical abortion, local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation or general anaesthesia may all be considered. Intravenous conscious sedation is preferred to oral, and where general anaesthesia is used, intravenous propofol with a short-acting opioid such as fentanyl is preferred to inhalational anaesthesia. ^[1]

Surgical abortion carries a recommendation for antibiotic prophylaxis; doxycycline 100 mg by mouth twice daily for 3 days is one considered regimen, and metronidazole is not routinely combined with another broad-spectrum antibiotic. ^[1]

Most abortions are completed without complications; complications are usually manageable when identified early. The complications worth naming to the woman beforehand are the same ones to prepare for in the service.

• Pain and bleeding, which are expected; unusually heavy or prolonged bleeding needs review. ^[1]
• Incomplete abortion, managed by repeat misoprostol or surgical evacuation depending on gestation, extent of tissue and the woman's condition. ^[1]
• Ongoing pregnancy after an unsuccessful medical abortion: this needs a further dose, a surgical procedure, or continuation of pregnancy if that is her choice. ^[1][1]
• Infection, including pelvic inflammatory disease and septic abortion, which can become life-threatening. Antibiotics first, then urgent uterine evacuation for source control; any woman with fever, tachycardia, hypotension, uterine tenderness or purulent discharge needs immediate senior review. ^[1][1]
• Haemorrhage, usually from retained tissue, atony or (at later gestations) uterine rupture; managed with uterotonics, evacuation, fluid resuscitation and transfusion. ^[1][1]
• Uterine injury or perforation, mostly with surgical methods, particularly after 12 weeks or where an inexperienced operator is involved; risk rises with gestation and a scarred uterus. ^[1][1]
• Drug side effects of medical abortion, especially nausea, vomiting, diarrhoea, fever and chills, which usually settle. ^[1]
• Emotional reactions ranging from relief to sadness, grief or anxiety; no increased risk of serious mental health problems, infertility or breast cancer is associated with having an abortion, but support should be available. ^[1]

WHO notes that uterine rupture is a rare complication of later medical abortion and that clinical judgement and health system preparedness, with caution in women with a prior uterine incision, are the safeguards. ^[1] Early recognition of haemodynamic compromise and clear escalation pathways matter more than any single drug.

Counselling in abortion care is voluntary, interactive support from a trained person, distinct from giving information, and it should take place in an environment where the woman can speak freely. ^[1]

The principles that WHO sets for offering and providing counselling are:

• make clear that counselling is not required, and that the woman may decline it; ^[1]
• ensure privacy and confidentiality, and tailor the setting for young people and others with particular needs; ^[1]
• ask what she wants and needs, listen actively and check understanding; ^[1]
• present all suitable options tailored to her needs without imposing personal values or beliefs; ^[1]
• provide or refer for counselling only if she requests it. ^[1][1]

NICE adds that compulsory counselling or compulsory time for reflection must not be required, that women should be reassured about the absence of links with infertility, breast cancer and mental health problems, and that they need information on what the procedure involves, how much pain and bleeding to expect, the disposal of pregnancy remains, and signs that require urgent help. For medical abortion they should be told they may see the products of pregnancy, what these will look like, and that there may be some movement. ^[1]

Consent should follow the Montgomery standard: the woman is informed of material risks, reasonable alternatives and what happens if she does nothing. Information should be provided without being directive and in formats she can use, with decision aids for choosing between medical and surgical abortion. ^[1]

Conscientious objection is permitted but may not delay or deny access; services must arrange care through other providers, and the woman can self-refer. ^[1][1]

Laws on abortion vary across the world and a clinician's first responsibility is to know the law where they practise. WHO recommends a legal and policy environment that protects health, including decriminalisation of abortion, regulation that does not make abortion a crime, and the removal of grounds-based and gestational age limits, which are not evidence-based and disproportionately affect adolescents, women living far from services, the poor and those with limited understanding of how systems work. Access depends on availability and affordability of services as much as on the statute. ^[1]

In Great Britain the Abortion Act 1967 (as amended) and the Abortion Regulations 1991 remain the framework: two medical practitioners must form the opinion that the grounds are met, certification is required, and treatment must usually be carried out in an approved place. Under grounds C and D the time limit is 23 weeks plus 6 days; later abortions are permitted on ground E (substantial risk that the child would be seriously handicapped) and on grounds relating to grave permanent injury or risk to life. A surgical abortion can be performed just after 23 weeks plus 6 days only if feticide has been given at or before 23 weeks plus 6 days. Northern Ireland has its own framework, decriminalised in 2019 and regulated by the Abortion (Northern Ireland) Regulations 2020; learners should check the current legal position there and in any country in which they practise. ^[1]

After an early medical abortion with home expulsion, self-assessment including remote assessment by phone or text can be offered instead of clinic follow-up. A low-sensitivity or multi-level urine pregnancy test is provided to exclude ongoing pregnancy. ^[1]

Every woman should be told what aftercare and follow-up to expect, what to do if problems occur (including out-of-hours contact), that a range of emotions is common, and how to access support if needed, including from family and friends, peer support, pastoral care or professional counselling. Providers should be able to offer emotional support and should provide or refer for counselling if requested. ^[1]

Ovulation can return as early as 8 to 10 days after an abortion, usually within one month, so contraception should be offered before the woman leaves. All reversible options may be considered, and the woman's wishes are paramount. ^[1]

WHO uses standard Medical Eligibility Criteria categories after abortion: ^[1]

• Combined hormonal contraceptives, progestogen-only methods and barrier methods can be started immediately after an abortion in the first or second trimester, including after septic abortion, without restriction. ^[1]
• With barrier methods, the diaphragm and cap are not suitable until 6 weeks after a second-trimester abortion. ^[1]
• Intrauterine devices can be started immediately after a first-trimester surgical or medical abortion without restriction, and after a second-trimester abortion where the advantages generally outweigh the risks, but should not be inserted immediately after septic abortion. ^[1]
• Fertility-awareness methods need caution: symptom-based methods (cervical mucus and symptothermal) may be started only with special counselling on correct use, and calendar-based methods should be delayed until the condition is evaluated and temporary methods offered in the meantime. ^[1]

• After surgical abortion, contraception may be started at the time of the procedure. ^[1]
• After medical abortion, hormonal contraception (pills, patch, ring, implant or injection) may be started immediately after the first abortion pill; intrauterine devices are placed once the success of the abortion is confirmed. ^[1]
• Intramuscular depot medroxyprogesterone given immediately may slightly reduce the effectiveness of the medical abortion regimen, but it should still be offered. ^[1]
• Women choosing the contraceptive ring should be told to check for its expulsion if bleeding is heavy during the medical abortion. ^[1]
• NICE expects commissioners and providers to make the full range of reversible contraception available on the same day as the abortion, including the contraceptive implant on the day of surgery or on the day mifepristone is taken, and intrauterine methods at the time of surgery or as soon as possible after expulsion. ^[1]
• Depot medroxyprogesterone injection may be considered at the appointment when mifepristone is taken, with an explanation that starting it then may slightly increase the chance of ongoing pregnancy, although the overall risk remains low. ^[1]

Adolescents and people with complex needs are entitled to confidential, prompt care, with the same information standards and without parental authorisation for counselling. Women with significant comorbidities should be referred to specialist centres, with pathways that minimise delay. ^[1]

Abortion for fetal anomaly raises further counselling needs; if the preferred method is not available in the maternity service, there should be a clear referral pathway with ongoing support from both services. ^[1]

• Clinical dating plus a positive pregnancy test is enough to arrange an early abortion in many settings; ultrasound is valuable but should not delay care. ^[1]
• Vacuum aspiration and misoprostol are the backbone of safe services where infrastructure is limited; both can be provided in primary care by trained nurses, midwives and associate clinicians under the WHO task-sharing recommendations, with referral for surgical complications. ^[1]
• Misoprostol alone is an important fallback where mifepristone is unavailable. ^[1]
• Infection prevention relies on clean technique; routine prophylactic antibiotics are reserved for surgery in the NICE framework, so services in low-resource settings should follow the simplest effective local protocol rather than improvising. ^[1]
• Rhesus prophylaxis, analgesia and follow-up are easily neglected where supplies are short; teams should prioritise by gestation and method. ^[1][1]

• Induced abortion is a safe, common healthcare service; medical and surgical methods are both offered and the choice belongs to the woman. ^[1][1]
• The earlier in pregnancy, the simpler the methods and the lower the risk, so assessment within one week and treatment within one week of assessment is the service standard. ^[1]
• Under 12 weeks: mifepristone 200 mg plus misoprostol 800 micrograms 24 to 48 hours later; misoprostol alone 800 micrograms is the alternative. ^[1]
• From 12 weeks: mifepristone 200 mg plus misoprostol 400 micrograms every 3 hours. ^[1]
• NICE sets more specific misoprostol schedules from 10+1 weeks to 23+6 weeks and beyond. ^[1]
• Surgical abortion under 14 weeks uses vacuum aspiration; from 14 weeks uses dilatation and evacuation; sharp curettage is not recommended. ^[1]
• Cervical priming is needed before surgery and is particularly important later in pregnancy. ^[1]
• Surgical abortion is offered antibiotic prophylaxis; medical abortion is not. ^[1]
• Feticide at or before 23 weeks plus 6 days allows surgical abortion to proceed just after 23 weeks plus 6 days. ^[1]
• Complications are uncommon and manageable: mainly pain, bleeding, incomplete abortion, ongoing pregnancy, infection, haemorrhage, drug side effects and emotional reactions. ^[1][1]
• Counselling remains voluntary and non-directive; no compulsory counselling or waiting period; abortion is not linked to infertility, breast cancer or mental health problems. ^[1][1]
• Legal frameworks differ worldwide; WHO advises decriminalisation and no gestational limits, while the United Kingdom retains grounds and time limits. ^[1][1]
• Follow-up uses self-assessment and a low-sensitivity pregnancy test, with psychological support if requested. ^[1]
• Contraception must be available on the day of the abortion: combined hormonal and progestogen-only methods and most barrier methods without restriction, IUDs first trimester without restriction and second trimester where advantages outweigh risks, not immediately after septic abortion. ^[1]
• Ovulation can return 8 to 10 days after the abortion, so never delay contraception. ^[1]