Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Medical and surgical abortion pathways
Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
!
Instability overrides the planned method
Shock, major haemorrhage, sepsis, peritonism or suspected ruptured ectopic pregnancy is not a routine abortion-choice scenario and requires immediate emergency assessment and source control.
Action: Use ABCDE resuscitation, obtain senior gynaecology and anaesthetic help, secure venous access and blood support, give indicated antibiotics, and move to urgent imaging or surgery without waiting for outpatient pathway steps.
Purpose and principles
Compare medical and surgical abortion pathways, select clinically and legally appropriate care and prescribe evidence-based regimens with safe follow-up.
Method choice is a shared clinical decision, not a hierarchy. Medical abortion avoids instrumentation and can offer privacy and home management early, but involves cramping, bleeding, visible passage and a small risk of ongoing pregnancy or later uterine aspiration. Surgical abortion is a short procedure with more predictable completion and options for local anaesthesia, sedation or general anaesthesia, but requires instrumentation and a trained facility. Describe what the patient will experience and which options the service can safely provide at the current gestation.
Before either method, confirm the patient's decision, applicable legal process, estimated gestation, symptoms suggesting ectopic pregnancy, relevant medical history, allergies, medicines and safeguarding needs. Ultrasound is used when gestation or location is uncertain, symptoms raise concern, or results will alter care; it need not become a universal barrier. NICE permits abortion before a yolk sac is seen in an asymptomatic patient, but the patient must understand the small ectopic risk, complete structured follow-up and have immediate access for new pain, dizziness or bleeding.
Indications, selection and cautions
Suitable early home pathway
Reliable gestation, absence of ectopic symptoms, informed preference, safe medicine use, communication access and ability to complete follow-up support home medical care.
Need for ultrasound
Uncertain dates, pain, bleeding, ectopic risk or discrepancy between history and examination makes imaging clinically useful before selecting the pathway.
Surgical preference
Desire for rapid predictable completion, avoidance of visible passage or concurrent intrauterine contraception can reasonably favour a procedure when available.
Medical contraindication
Chronic adrenal failure, porphyria, allergy or interacting long-term steroid therapy requires an alternative plan or specialist medical review.
Higher-acuity setting
Later gestation, major comorbidity, severe anaemia, scarred uterus or limited emergency access can make inpatient or theatre-based care safer.
Red flags requiring action
Unilateral pain, shoulder-tip pain, syncope or haemodynamic change before location is established raises ectopic-pregnancy concern and requires urgent assessment.
Severe anaemia, anticoagulation, bleeding disorder or major cardiopulmonary disease changes the suitability and setting of either method and needs senior planning.
Long-term systemic corticosteroids, chronic adrenal failure, inherited porphyria or severe uncontrolled asthma can contraindicate or complicate
Assessment before treatment
01Gestational dating assessmentFirst step
Why
Identify legally and clinically available methods and the correct medicine and cervical-preparation regimen.
Interpretation and limitations
Use menstrual history when reliable and ultrasound when uncertainty changes care; avoid routine scans that add delay without clinical value.
02Pregnancy-location assessment
Why
Identify ectopic risk before treatment, especially when pain, bleeding or risk factors are present.
Interpretation and limitations
A pregnancy can be treated before a yolk sac is seen if asymptomatic and followed carefully; symptoms override a reassuring hCG or remote plan.
03Full blood count
Why
Assess suspected anaemia, heavy bleeding history or comorbidity that affects setting and transfusion preparation.
Interpretation and limitations
Testing can be selective early in a well patient; severe anaemia requires senior method, location and blood-support planning.
04RhD status when indicated
Why
Arrange current gestation-specific anti-D care without introducing a treatment delay.
Interpretation and limitations
No anti-D is recommended through 11+6 weeks; from 12 weeks, ensure RhD testing and prophylaxis are available at treatment.
Treatment approach
01Method selectionMatch preference, gestation and safetyFirst stepThe patient has chosen abortion and needs to decide between available medical and surgical methods.+
1Confirm jurisdiction, gestation, pregnancy-location risk, medical and anaesthetic history and the service's trained method range without compulsory counselling.
2Compare timing, setting, expected pain and bleeding, awareness, visible passage, completion, follow-up and contraception opportunities in neutral language.
3Record informed preference, obtain valid consent and book the chosen clinically appropriate pathway with minimal avoidable delay.
02Early medicalProvide interval medicines and completion checkA patient through 10+0 weeks chooses medical abortion and meets the service's eligibility requirements.+
1Give mifepristone and misoprostol using the authorised service regimen and location, with written timing, administration route, analgesia and expected symptoms.
Regimens, contraindications and interactions
Produces cervical softening, uterine sensitivity and expulsion for early medical abortion.
Mifepristone and misoprostol through 10 weeks
Mifepristone 200 mg orally, followed usually 24 to 48 hours later by misoprostol 800 micrograms buccally, sublingually or vaginally. If expulsion has not occurred within four hours, give a further 400 micrograms by the vaginal, buccal or sublingual route under the authorised service protocol.
Confirm jurisdictional home-use rules, gestation and ectopic safety; ensure patients treated at home beyond nine weeks have the additional dose and instructions; review chronic adrenal failure, porphyria, allergy, severe uncontrolled asthma and long-term systemic corticosteroid treatment before prescribing.
Provides medical abortion in a supported clinical setting at later gestations.
Mifepristone and misoprostol from 10+1 to 23+6 weeks
Mifepristone 200 mg orally, then after 36 to 48 hours misoprostol 800 micrograms vaginally or 600 micrograms sublingually, followed by 400 micrograms vaginally, buccally or sublingually every three hours until expulsion.
Later gestation and a uterine scar require senior assessment because uterine sensitivity and rupture risk increase; follow legal, fetal-indication, haemorrhage and analgesia planning.
Reduces post-procedure upper genital tract infection after surgical abortion.
Doxycycline prophylaxis for surgical abortion
Consider doxycycline 100 mg orally twice daily for three days around the surgical procedure according to the provider's protocol.
Complications, monitoring and follow-up
During medical abortion, record medicine timing, observations where attended, bleeding, pain, expulsion and any additional doses or procedure needed.
After sedation or general anaesthesia, use standard airway, consciousness, haemodynamic, pain and discharge criteria and confirm safe transport and supervision.
Ensure the early home-medical follow-up test is supplied, understood and actively followed when positive, equivocal, missed or accompanied by persistent symptoms.
Track pathology or genetic tests requested for fetal indication and return results through the agreed maternity or fetal-medicine team with chosen support.
Review contraception satisfaction, infection symptoms, ongoing bleeding and emotional needs without imposing routine counselling or an unnecessary clinic visit.
Special situations
Choice includes experience
Method counselling should cover visible passage, privacy, anaesthetic awareness and predictability, not only numerical complication rates.
A visible sac is not always required
Early treatment before definite intrauterine ultrasound evidence can be safe in selected asymptomatic patients only when ectopic follow-up is robust.
Same-time medicines trade speed
Through 9+0 weeks, simultaneous mifepristone and vaginal misoprostol is an option but may delay onset and slightly increase ongoing pregnancy risk.
DMPA needs a specific conversation
Giving intramuscular depot medroxyprogesterone with mifepristone is convenient but may slightly increase ongoing-pregnancy risk, although absolute risk remains low.
Anti-D policy changed
NICE now recommends against prophylaxis through 11+6 weeks for either method, replacing older thresholds that created inconsistent early care.
Common pitfalls
01
Presenting medical or surgical abortion as universally superior instead of eliciting the patient's priorities.
02
Making ultrasound mandatory for every early request even when location risk and dating are adequately assessed.
03
Sending ectopic symptoms down a remote home-medical route without urgent examination.
04
Using the early medical regimen unchanged at later gestations or in a scarred uterus without specialist planning.
05
Offering routine antibiotic prophylaxis for medical abortion or omitting it for a surgical procedure.
06
Applying the pre-2025 anti-D threshold and delaying care for blood-group testing before 12 weeks.
Practice
Two practice questions
Your practice draft is saved in this browser.
Question 1 of 2
0 correct
Obstetrics and gynaecologyOriginal SBA
Anti-D at early gestation
An RhD-negative patient is having a surgical abortion at 10+4 weeks and is otherwise well. What does current NICE guidance recommend about anti-D prophylaxis?
Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
For medical abortion through 10+0 weeks, NICE recommends interval mifepristone and misoprostol, usually separated by 24–48 hours. A widely used regimen is mifepristone 200 mg orally followed by misoprostol 800 micrograms by buccal, sublingual or vaginal route according to the service protocol. If expulsion has not occurred within four hours, provide a further misoprostol 400 micrograms vaginally, buccally or sublingually; patients treated at home beyond nine weeks should have access to the extra dose and clear instructions. Same-time mifepristone and vaginal misoprostol can be offered through 9+0 weeks, with explanation that ongoing pregnancy may be more likely and onset slower. Nation-specific law determines which doses can be taken at home.
Medical abortion from 10+1 to 23+6 weeks uses mifepristone 200 mg orally, followed 36–48 hours later by misoprostol 800 micrograms vaginally or 600 micrograms sublingually, then 400 micrograms vaginally, buccally or sublingually every three hours until expulsion under an appropriate service. Later gestations require plans for analgesia, fetal indication, examination of the pregnancy, lactation and bereavement. After 23+6 weeks, highly specialist regimens and legal grounds apply, with lower misoprostol doses as uterine sensitivity rises.
Early surgical abortion is usually manual or electric vacuum aspiration after cervical preparation as indicated. NICE recommends cervical priming through 13+6 weeks with misoprostol 400 micrograms sublingually one hour before, or vaginally three hours before; oral mifepristone 200 mg 24–48 hours beforehand is an alternative when misoprostol cannot be used. Between 14+0 and 23+6 weeks, cervical preparation is required and may use osmotic dilators, misoprostol or mifepristone according to gestation; trained services perform dilatation and evacuation.
Anaesthesia should match preference and safety. Options for surgical care include local anaesthesia alone, conscious intravenous sedation with local anaesthesia, deep sedation or general anaesthesia. Explain awareness, recovery time, escort and fasting requirements. Provide antibiotic prophylaxis for surgical abortion. NICE gives doxycycline 100 mg orally twice daily for three days as a regimen to consider; do not routinely combine metronidazole with another broad-spectrum prophylactic antibiotic. Routine prophylactic antibiotics are not recommended for medical abortion.
Analgesia is anticipatory. Offer an NSAID when suitable for cramping and add service-defined stronger analgesia, antiemetic and non-pharmacological measures according to gestation and method. Avoid presenting pain as evidence that something is wrong, while clearly defining escalation thresholds. For RhD-negative patients, current NICE guidance recommends against anti-D through 11+6 weeks for either method. At 12 weeks or more, testing and anti-D provision should occur without delaying the abortion.
After early medical abortion with home expulsion, offer self-assessment or remote review and provide the specified low-sensitivity or multi-level urine test to exclude ongoing pregnancy. Surgical completion is usually confirmed during the procedure, but symptoms still guide review. Offer the full range of contraception without coercion: an implant can be placed with mifepristone or on the procedure day, and an intrauterine method can be inserted with surgical abortion or soon after medical expulsion. Provide emotional support and counselling only when wanted.
Key points
Offer a clinically appropriate choice between medical and surgical abortion through 23+6 weeks, explaining experience, timing, pain, bleeding, anaesthesia, privacy and follow-up without steering the decision.
Early medical abortion usually uses oral mifepristone followed 24–48 hours later by misoprostol; home use eligibility and gestational limits depend on the UK nation and service.
NICE allows consideration before definitive ultrasound evidence of an intrauterine pregnancy when ectopic symptoms are absent, provided ectopic risk, follow-up and a 24-hour contact are explained.
From 10+1 to 23+6 weeks, medical care usually occurs in a clinical service using mifepristone then repeated misoprostol until expulsion, with additional planning for fetal indication and later gestation. Where birth after 21+6 weeks follows abortion for fetal anomaly, RCOG advises offering feticide while preserving the patient's choice and documenting the plan for possible signs of life, palliation or live-birth care if feticide is declined or not indicated.
Vacuum aspiration is used for early surgical abortion; dilatation and evacuation is the established later surgical method in trained services, with cervical preparation matched to gestation.
mifepristone
-based care.
A prior uterine scar at later gestation increases rupture risk during prostaglandin treatment and requires individual specialist dosing and monitoring.
Uncertain gestation close to a legal or service threshold requires prompt reliable dating and referral rather than avoidable administrative delay.
05
STI and HIV offer
Why
Identify infection and connect the patient with sexual-health treatment while preserving abortion access.
Interpretation and limitations
Offer testing according to national recommendations and risk; results need not delay abortion, and prophylactic antibiotics remain method-specific.
06Post-medical pregnancy test
Why
Exclude ongoing pregnancy after home expulsion when routine ultrasound follow-up is unnecessary.
Interpretation and limitations
Use the service-provided low-sensitivity or multi-level test at the stated time; persistent positivity, little bleeding or pregnancy symptoms requires review.
2Supply a 24-hour number and direct emergency instructions for collapse, severe pain, very heavy bleeding, fever, offensive discharge or persistent illness.
3EscalationArrange self or remote assessment and the specified pregnancy test, escalating persistent positivity, absent expected bleeding or continuing pregnancy symptoms.
03Later medicalUse repeated misoprostol in supported careMedical abortion is chosen from 10+1 weeks and service admission or attendance is arranged.+
1Administer mifepristone, then the gestation-appropriate initial and repeated misoprostol regimen with observations, analgesia and access to urgent intervention.
2Plan sensitively for fetal indication, examination or genetics, pregnancy remains, lactation, memory making and emotional support according to patient wishes.
3Confirm complete expulsion, inspect placenta when appropriate and treat retained tissue, haemorrhage or infection using senior clinical assessment.
04SurgicalPrepare the cervix and complete safelyA trained service and patient select vacuum aspiration or dilatation and evacuation.+
1Choose cervical preparation, local anaesthesia, sedation or general anaesthesia according to gestation, history, preference and procedural complexity.
2Give antibiotic prophylaxis, perform the procedure with appropriate ultrasound and haemorrhage support, and inspect tissue for expected gestational completeness.
3Recover with observations, pain and bleeding review, written aftercare and same-day chosen contraception when desired and clinically suitable.
Check allergy and interactions, explain gastrointestinal and photosensitivity effects, do not delay treatment for screening results and do not routinely add metronidazole to another broad-spectrum prophylactic regimen.
Offer antibiotic prophylaxis for surgical abortion but not routinely for medical abortion; assess STI testing and treatment without delaying care.
Do not offer anti-D prophylaxis for medical or surgical abortion through 11+6 weeks; at 12 weeks or more, ensure testing and anti-D availability do not delay treatment.
Give method-specific written aftercare, 24-hour help, contraception if wanted and reliable confirmation of success after early home medical abortion, commonly using a low-sensitivity or multi-level urine test.