Methods

Methods of abortion can be either surgical or medical (1,2).

Surgical:

• vacuum aspiration
  • <7 weeks
    • should follow strict protocol such as examination of the aspirate for the presence of the gestational sac and follow-up serum human chorionic gonadotrophin (hCG) estimation if needed
  • 7-14 weeks
    • using electric or manual vacuum aspiration
    • uterus is emptied using a suction cannula
    • sharp curettage is not recommended
  • 14-16 weeks
    • may require large-bore suction cannula and tubing
    • forceps may be needed to remove larger fetal parts
• dilatation and evacuation (D&E)
  • appropriate for pregnancies above 14 weeks of gestation
  • D&E is preceded by cervical preparation
• cervical preparation for surgical abortion
  • should be considered in all cases

Medical:

• combination of progesterone antagonist RU-486 (now known as mifepristone) followed by misoprostol is the most efficacious, well tolerated, and cost effective regimen in the first and second trimesters
• single-agent regimens have no role in abortion practice in Great Britain
• recommended regimens are as follows :
  • at ≤49 days of gestation
    • 200 mg oral mifepristone followed 24–48 hours later by 400 micro grams of oral misoprostol
  • at ≤63 days of gestation
    • mifepristone 200 mg orally followed 24–48 hours later by misoprostol 800 micrograms (vaginal, buccal or sublingual)
    • for women at 50–63 days of gestation, if abortion has not occurred 4 hours after administration of misoprostol, a second dose of misoprostol 400 micrograms may be administered vaginally or orally (depending on preference and amount of bleeding)
  • between 9 and 13 weeks of gestation
    • mifepristone 200 mg orally followed 36–48 hours later by misoprostol 800 micrograms vaginally
    • maximum of four further doses of misoprostol 400 micrograms may be administered at 3-hourly intervals, vaginally or orally
  • between 13 and 24 weeks of gestation
    • mifepristone 200 mg orally, followed 36–48 hours later by misoprostol 800 micrograms vaginally, then misoprostol 400 micrograms orally or vaginally, 3-hourly, to a maximum of four further doses
    • if abortion does not occur, mifepristone can be repeated 3 hours after the last dose of misoprostol and 12 hours later misoprostol may be recommenced
• it is safe and acceptable for women who wish to leave the abortion unit following misoprostol administration to complete the abortion at home
  • adequate support strategy and robust follow-up arrangements for these women
• surgical evacuation of the uterus is not required routinely following medical abortion between 13 and 24 weeks of gestation
  • should only be undertaken if there is clinical evidence that the abortion is incomplete (not on ultrasound appearances)

Pain relief during abortion:

• surgical methods
  • general anaesthesia and local cervical anaesthesia, with or without oral or intravenous analgesics and sedatives can be used during vacuum aspiration
  • for second trimester procedures, general anaesthesia is the preferred pain management option
• medical methods
  • ibuprofen has been shown to be is more effective than paracetamol in management of pain in early medical abortion
  • some women may require additional narcotic analgesia, particularly after 13 weeks of gestation.

Note:

• where possible, women should be given the abortion method of their choice
• hysterectomy has previously been performed to undertake termination of pregnancy at 5-16 weeks, however, it is rarely indicated as a method of termination of pregnancy today

References:

1. Lohr PA et al. Abortion.  BMJ 2014;348:f7553
2. Royal college of obstetricians and gynaecologists (RCOG) 2011. The care of women requesting induced abortion. Evidence based clinical guideline number 7.