*** 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 | Procedural Abortion | |
| General Description | Using medications to induce a process similar to a miscarriage. Used up to 11 weeks gestation. | Using gentle suction to remove uterine contents through the cervix. Used up to 14 weeks gestation. |
| Pre-Procedure Preparation | – Removal of Intrauterine Device (IUD) if applicable. | – Prophylactic antibiotics 60min before procedure – NSAIDS 30-60min before procedure – May also receive oral or IV sedation |
| Procedure Description | – Mifepristone plus misoprostol – If mifepristone is not accessible, solely using misoprostol can also be effective | – Mechanical cervical dilation – Aspiration of uterine contents using manual or electric vacuum aspirator – Warn patients: the machine can be loud – Recovery 20-30min |
| Efficacy | 95-98% | > 99% |
| Pain Management | – NSAIDs – Rarely, provider may prescribe 2-4 doses of oxycodone | – NSAIDS 30-60min before procedure – Paracervical block with local anesthetic – Oral/IV sedation |
| Post-Procedure | – Abdominal pain and cramps – Vaginal bleeding typically heavier than a menstrual period – Mean duration of bleeding: 8 to 17 days – May also experience GI upset, fever, headache, dizziness | – Abdominal pain and cramps – Vaginal bleeding, typically similar to a menstrual period. Occasionally passage of small clots. – Swollen breasts 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 | – Infection – Hemorrhage – Retained products of conception – Ongoing pregnancy 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 | – Infection – Hemorrhage – Cervical or vaginal laceration – Uterine perforation – Hematometra – Retained products of conception – Asherman syndrome – Ongoing pregnancy 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 |
| Contraindications | – Drug allergy – Hbg <9 – Anticoagulation therapy – Hemorrhagic disorders – Chronic adrenal failure – Long-term steroid use – Porphyrias – Current IUD use 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 – Some patients say that the process feels more “natural” – Patient may feel a greater degree of control as they can take medications privately at home | – Fast procedure – less than 15 minutes – Extremely effective – Heavy vaginal bleeding is rare |
| Cons | – Vaginal bleeding typically heavier than a menstrual period – Takes longer to completely evacuate the uterus – 2-3 days for pregnancy to pass – 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 – Requires in-person office visit |
| Reason to Follow Up | – Vaginal bleeding >2 maxi pads per hour for than 2 consecutive hours – Bleeding that persists after pregnancy tissue is passed – Severe abdominal pain that persists after pregnancy tissue passes, or if pain persists and no bleeding/tissue has passed | – Vaginal bleeding >2 maxi pads per hour for than 2 consecutive hours – Cramps persistent/worsens despite pain medications – Temp >100.4F or chills – Green, yellow, or foul-smelling vaginal discharge – Amenorrhea more than 2 months after the procedure (and patient is not using hormonal birth control) |
| Future Fertility | – Not shown to be decreased. – Some studies found a slight increased risk of future preterm births, low birth weights or small for gestational age. Other studies have not found this increased risk. | – Not shown to be decreased. – Some studies found a slight increased risk of future preterm births, low birth weights or small for gestational age. Other studies have not found this increased risk. |
References:
https://www.uptodate.com/contents/overview-of-pregnancy-termination
https://www.mayoclinic.org/healthy-lifestyle/getting-pregnant/expert-answers/abortion/faq-20058551
Second Trimester Terminations (14-20 week gestation)
| Medication Abortion | Procedural Abortion (Dilation and Evacuation) | |
| General Description | Use of medications to induce contractions to deliver the fetus and placenta | A surgical procedure to dilate the cervix and evacuate the products of conception |
| Locations | Labor & Delivery or Family Planning unit | Outpatient or ambulatory surgery center |
| Pre-Procedure | – Rh-negative patients should receive Rhogam – May see cervical dilation with osmotic dilators or an intrauterine balloon catheter – May induce fetal demise prior to initial dose | – Rh-negative patients should receive Rhogam – Cervical preparation: osmotic, pharmacologic (misoprostol/mifepristone), and/or mechanical dilators – Prophylactic antibiotics: doxycycline or azithromycin |
| Pain Management | Epidural | – NSAIDS – Paracervical Block – IV sedation |
| Procedure | – Administer mifepristone, wait 12-48h and administer misoprostol every 3 hours until delivery of placenta. – Oxytocin is typically not used as there is decreased efficacy due to the uterus having fewer oxytocin receptors at <20 weeks gestation. | – 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 |
| Post-Procedure | – Normal post-delivery care – Lactation suppression if desired | – Abdominal cramps, mild bleeding – Lactation suppression if desired |
| Contraindications | None | None |
| Complications | – Incomplete abortion – Retained placenta requiring surgical removal – Uterine rupture – Infection – Hemorrhage – Cervical laceration – Medication side effects: bleeding, cramping, nausea, vomiting | – Uterine perforation – Retained products of conception – Cervical laceration – Infection – Intrauterine adhesions – Hemorrhage – Anesthesia-related complications |
| Considerations For | – Avoidance of surgery – Experience intact fetus – Greater awareness of events | – Greater control over timing – Less experience of the procedure – Shorter procedure duration; can avoid prolonged labor – Decreased cost – Helpful for patients who have medical conditions that require controlled timing – Outpatient setting |
| Consideration Against | – More discomfort – Greater awareness of events – Heavier and/or longer duration of bleeding and cramping compared to D&E – Incomplete abortion is more common than in D&E (1 – 12.5% vs < 1%), may result in need for surgical intervention – Timing of delivery of fetus is less predictable; may take 24 hours or more | – Surgical procedure with associated risks and complications |
References:
Pacific Abortion Project 