Medical and surgical abortion pathways — Rapid

Synopsis

Compare medical and surgical abortion pathways, select clinically and legally appropriate care and prescribe evidence-based regimens with safe follow-up.

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.
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.

Key red flags

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 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.

Investigation priorities

Gestational dating assessmentFirst step

Identify legally and clinically available methods and the correct medicine and cervical-preparation regimen.

Management branches

Method selectionMatch preference, gestation and safety

The patient has chosen abortion and needs to decide between available medical and surgical methods.

Confirm jurisdiction, gestation, pregnancy-location risk, medical and anaesthetic history and the service's trained method range without compulsory counselling.
Compare timing, setting, expected pain and bleeding, awareness, visible passage, completion, follow-up and contraception opportunities in neutral language.
Record informed preference, obtain valid consent and book the chosen clinically appropriate pathway with minimal avoidable delay.

Key medicines

Mifepristone and misoprostol through 10 weeksMifepristone 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.

Mifepristone and misoprostol from 10+1 to 23+6 weeksMifepristone 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.

Open full textbook →Answer 2 questions