*** This is a general resource and is NOT meant to serve as medical advice or guidance. For a comprehensive resource on how provide abortion care, please visit the following resources:
- UpToDate: Pregnancy Termination
- TEACH: Training in Early Abortion for Comprehensive Healthcare
- Medication Abortion training for providers (1 hour online)
First Trimester Termination
| Medication Abortion | Surgical Abortion | |
| General Description | Using medications to induce similar processes as a miscarriage. Used up to 11 weeks gestation | 15 minute in-office procedure with local anesthesia or sedation. Used up to 14 weeks gestation. |
| Pre-Procedure Preparation | None | Prophylactic antibiotics, typically doxycycline NSAIDS 30-60min before procedure |
| Procedure Description | Mifepristone plus misoprostol If Mifepristone is not accessible, solely using misoprostol can also be effective | Mechanical cervical dilation Aspiration of uterine contents Warn patients: The machine can be loud Recovery 20-30min |
| Pain Management | NSAIDs | NSAIDS 30-60min before procedure Paracervical block with local anesthetic Oral/IV sedation Lorazepam 0.5 to 2mg 30min prior Opioid optional, no proven benefit If IV: fentanyl 100mcg and midazolam 2mg |
| Post-Procedure | Abdominal pain and cramps Vaginal bleeding typically heavier than a menstrual period, but not excessive Mean duration of bleeding is 8 to 17 days. | Abdominal pain and cramps Light bleeding, like a menstrual cycle. Occasionally passage of small clots Some patients will be followed with serial hCG if products of conception are not fully visualized during the procedure – expect a short-term elevation with return to undetectable levels varies widely from 7-60 days |
| Complications | Major Complications 0.31% Minor Complications 4.88% Hemorrhage – secondary to uterine atony, retained tissue, infection, uterine AV malformation, placenta accreta spectrum, coagulopathy Ongoing pregnancy Infection or Retained products of conception Maternal mortality – far less than maternal mortality rates among live births in the U.S., but does increase with gestational age. Comparable to other procedures such as plastic surgery or dental procedures | Major Complications 0.16% Minor Complications 1.1% Overall complication rate: 9.05 per 1000, with major complications (perforation, ectopic pregnancy, hemorrhage, sepsis) very rare, 0.71 per 1000. Complications include: Infection Hemorrhage Cervical laceration Uterine perforation Postabortal endometritis Hematometra Retained products of conception Ongoing Pregnancy Mortality risks: infection, anesthesia complications, hemorrhage |
| Contraindications | Hbg <9, hemorrhagic disorders, suspected ectopic pregnancy, chronic adrenal failure, long-term steroid use, porphyrias Note: Asthma is NOT a contraindication (misoprostol is a prostaglandin, but acts as a bronchodilator | fibroid restricting access to uterine cavity |
| Pros | Can receive medications through telehealth services and delivery to home (in available locations) No surgical procedure/anesthesia May feel “more natural” to patients More control as patient can take medications privately at home | No need for repeat visits Fast Procedure Failure is rare – More common at early <7 weeks gestation because it can be harder to see on ultrasound Vaginal bleeding post-procedure |
| Cons | Increased bleeding that can be unpredictable Takes longer to completely evacuate the uterus Can be difficult if privacy is an issue (adolescent, domestic violence, etc.) Slightly lower efficacy Greater awareness of blood loss/passage of pregnancy tissue If it fails, will require a surgical abortion | Surgical procedure with associated risks |
| Reason to Follow Up | Severe abdominal pain that persists after pregnancy tissue passes, or if pain persists and no bleeding/tissue has passed Bleeding that not decreased after pregnancy tissue is passed or soaking 2 maxi pads per hour for 2 consecutive hours. | Vaginal bleeding >2 maxi pads per hour for than 2 hours in a row Cramps persistent/worsens despite pain medications Temp >101 |
| Future Fertility | Not shown to be decreased May have increased risk of future preterm births, low birth weights or small for gestational age | Not shown to be decreased May have increased risk of future preterm births, low birth weights or small for gestational age |
References:
https://www.uptodate.com/contents/overview-of-pregnancy-termination
Second Trimester Terminations (14-20 week gestation)
| Dilation and Evacuation | Induction | |
| General Description | Surgical procedure to evacuate uterine cavity | Induce labor and deliver fetus |
| Locations | Outpatient or Inpatient surgical center | Labor and Delivery floor |
| Pre-Procedure | Cervical preparation: osmotic, pharmacologic (misoprostol/mifepristone) and/or mechanical dilators Osmotic dilators often placed a couple hours to days before procedure to open cervix Prophylactic antibiotics: doxycycline or azithromycin | None |
| Pain Management | NSAIDS Paracervical Block IV sedation | Epidural |
| Procedure | Dilation of cervix Uterine evacuation with combination of suction, extraction with forceps and curettage Fetus and placenta entirely removed Occasionally an intact D&E will be utilized in which entire fetus removed intact | Induction with misoprostol and mifepristone Oxytocin is NOT used as there is decreased efficacy due to the uterus having fewer oxytocin receptors at <20 weeks gestation. |
| Post-Procedure | Abdominal cramps, mild bleeding | Normal post-delivery care |
| Contraindications | None | None |
| Complications | Uterine perforation <1% – Increased risk with increasing gestational age, cervical abnormalities, multiparity or inexperienced provider Retained products of conception <1% Cervical laceration <3% Infection up to 4% Hemorrhage 0-0.3% Risk with uterine atony, retained products of conception, coagulopathy, abnormal placentation, uterine or cervical injury, prior caesarean. Anesthesia-related complications | Infection Hemorrhage Bleeding Cramping Nausea, vomiting Retained placenta needing surgical removal (2-10%) Incomplete abortion more common than in D&E (1-7 vs 0%) Uterine rupture |
| Considerations For | Greater control over timing Less experience of the procedure Decreased procedure duration Decreased cost Helpful for patients who have medical conditions that require controlled timing Outpatient setting | Avoidance of surgery Experience intact fetus |
| Consideration Against | Surgical procedure with associated risks and complications | More discomfort Awareness of events happening Larger blood loss Potential for need of surgical intervention |
References:
Pacific Abortion Project 