In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Levels of evidence (Ia-IV) and grading of recommendations (A–C) are defined at the end of the "Major Recommendations" field.
Commissioning and Organising Services
Access to Services
B - Services should have arrangements which facilitate access without delay for referrals from a wide range of sources.
C - Commissioners should ensure that abortion providers do not restrict access on the grounds of age, ethnicity, religious beliefs, disability or sexual orientation.
C - Professionals who are ethically opposed to abortion have a duty of care to refer onward women requesting abortion without delay.
B - Services should facilitate access for all women, particularly those who traditionally have difficulties accessing health services.
C - Services should make sure that written, objective, evidence-guided information is available for women considering abortion to take away before the procedure. Information should be available in a variety of languages and formats.
C - Information for women and providers should emphasise the duty of confidentiality.
C - Women who decide to continue with the pregnancy should be referred for antenatal care without delay.
C - Services should identify issues which make women particularly vulnerable (for example, child protection needs and domestic abuse/gender-based violence) and refer/signpost them on to appropriate support services in a timely manner.
C - Elements of the assessment consultation can be provided via the telephone and/or the internet. However, women should be able to access face-to-face consultation, if preferred.
Arrangements for the Procedure
C - With respect to the method used to induce the abortion, service arrangements should be such that:
- Services should be commissioned for all women requesting induced abortion at all gestations.
- If a service cannot offer an abortion by any method after a specific gestation, timely onward referral must be ensured.
- All services should be able to offer abortion by at least one of the recommended methods for each gestation band.
- All services should be able to offer a choice of recommended methods for each gestation band.
- Services should provide surgical abortion under both local and general anaesthesia.
C - To minimise delay, service arrangements should be such that:
- Referral to an abortion provider should be made within 2 working days.
- Abortion services must offer assessment within 5 working days of referral or self-referral.
- Services should offer women the abortion procedure within 5 working days of the decision to proceed.
- The total time from seeing the abortion provider to the procedure should not exceed 10 working days.
- Women requiring abortion for urgent medical reasons should be seen as soon as possible.
C - Inpatient services, provided in an appropriate centre and clinical setting, should be available for women who are unsuitable for or who do not desire home or day case care.
Commissioners should ensure that services meet the recommendations relating to:
- B - Contraception after the abortion
- A and C - Antibiotic prophylaxis
- B - Screening for sexually transmitted infections (STIs)
- C - Information provision after the abortion
- C - Counselling after the abortion
Adverse Effects, Complications and Sequelae of Abortion: What Women Need to Know
B - Women should be informed that abortion is a safe procedure for which major complications and mortality are rare at all gestations.
B - Women should be informed of the following rare but serious complication that may occur:
- Uterine rupture has been reported in association with medical abortion at late gestations. The risk is less than 1 in 1000.
B - Women should be informed of the uncommon complications that may occur and of their possible clinical consequences. These may include:
- Severe bleeding requiring transfusion; the risk is lower for early abortions, occurring in less than 1 in 1000, rising to around 4 in 1000 at gestations beyond 20 weeks.
- Uterine perforation (surgical abortion only); the risk is in the order of 1–4 in 1000 and is lower for early abortions and those performed by experienced clinicians.
- Cervical trauma (surgical abortion only); the risk of damage to the external os is no greater than 1 in 100 and is lower for early abortions and those performed by experienced clinicians.
- Women must be informed that, should one of these complications occur, further treatment in the form of blood transfusion, laparoscopy or laparotomy may be required.
Failed Abortion and Continuing Pregnancy
B - Women should be informed that surgical and medical methods of abortion carry a small risk of failure to end the pregnancy (less than 1 in 100), necessitating another procedure.
C - Women should be informed that there is a small risk (usually much less than 5%) of the need for further intervention, such as surgical intervention following medical abortion or re-evacuation following surgical abortion.
B - Women should be informed that infection of varying degrees of severity may occur after medical or surgical abortion and is usually caused by pre-existing infection. Prophylactic antibiotic use and bacterial screening for lower genital tract infection reduces this risk.
A - Women should be informed that induced abortion is not associated with an increase in breast cancer risk.
Future Reproductive Outcome
B - Women should be informed that there are no proven associations between induced abortion and subsequent ectopic pregnancy, placenta praevia or infertility.
B - Women should be informed that induced abortion is associated with a small increase in the risk of subsequent preterm birth, which increases with the number of abortions. However, there is insufficient evidence to imply causality.
B - Women with an unintended pregnancy should be informed that the evidence suggests that they are no more or less likely to suffer adverse psychological sequelae whether they have an abortion or continue with the pregnancy and have the baby.
B - Women with an unintended pregnancy and a past history of mental health problems should be advised that they may experience further problems whether they choose to have an abortion or to continue with the pregnancy.
The Abortion Decision
C - Healthcare staff caring for women requesting abortion should identify those who require more support in the decision-making process.
C - Women who are certain of their decision to have an abortion should not be subjected to compulsory counselling.
C - Pre-abortion assessment should always include:
- Determination of rhesus blood status.
- Where clinically indicated, pre-abortion assessment should also include:
- Determination of blood group with screening for red cell antibodies
- Measurement of haemoglobin concentration
- Testing for haemoglobinopathies
B - It is not cost-effective or necessary to routinely cross-match women undergoing induced abortion.
B - Use of routine pre-abortion ultrasound scanning is unnecessary.
C - Ultrasound scanning must be available to all services as it may be required as part of the assessment.
C - Before ultrasound is undertaken, women should be asked whether they would wish to see the image or not.
Prevention of Infective Complications
A/C - Services should offer antibiotic prophylaxis effective against Chlamydia trachomatis and anaerobes for both surgical abortion (evidence grade: A) and medical abortion (evidence grade: C).
C - The following regimens are suitable for peri-abortion antibiotic prophylaxis:
- Azithromycin 1 g orally on the day of abortion, plus metronidazole 1 g rectally or 800 mg orally prior to or at the time of abortion
- Doxycycline 100 mg orally twice daily for 7 days, starting on the day of the abortion, plus metronidazole 1 g rectally or 800mg orally prior to or at the time of the abortion
- Metronidazole 1 g rectally or 800 mg orally prior to or at the time of abortion for women who have tested negative for C. trachomatis infection.
B - All women should be screened for C. trachomatis and undergo a risk assessment for other STIs (for example, human immunodeficiency virus [HIV], gonorrhoea, syphilis), and be screened for them if appropriate.
C - A system for partner notification and follow-up or referral to a sexual health service should be in place.
C - All appropriate methods of contraception should be discussed with women at the initial assessment and a plan agreed for contraception after the abortion.
C - Feticide should be performed before medical abortion after 21 weeks and 6 days of gestation to ensure that there is no risk of a live birth.
B - Vacuum aspiration is an appropriate method of surgical abortion up to 14 weeks of gestation.
A - Either electric or manual vacuum aspiration may be used as both are effective and acceptable to women and clinicians.
B - Vacuum aspiration under 7 weeks of gestation should be performed with appropriate safeguards to ensure complete abortion, including inspection of aspirated tissue.
A - Vacuum aspiration may be performed from 14 to 16 weeks of gestation; large-bore cannulae and suction tubing may be required to complete the procedure without the use of forceps to remove larger fetal parts.
C - Access to ultrasound during vacuum aspiration is recommended but not routinely required for uncomplicated procedures.
Dilatation and Evacuation
A - Surgical abortion by dilatation and evacuation (D&E), preceded by cervical preparation, is appropriate for pregnancies above 14 weeks of gestation.
B - Continuous ultrasound guidance during D&E is recommended to reduce the risk of surgical complications.
Cervical Preparation for Surgical Abortion
B - Cervical preparation should be considered in all cases.
B - The following regimens are recommended for cervical preparation up to 14 weeks of gestation:
- Misoprostol 400 micrograms administered vaginally 3 hours prior to surgery or sublingually 2–3 hours prior to surgery.
B - Vaginal misoprostol can be administered either by the woman herself or by a clinician.
B - After 14 weeks of gestation, osmotic dilators provide superior dilatation to medical methods; however, misoprostol is an acceptable alternative up to 18 weeks of gestation.
A - Use of medications containing oxytocin or ergometrine is not recommended for prophylaxis to prevent excessive bleeding at the time of vacuum aspiration.
Pain Relief for Surgical Abortion
B - Services should be able to provide surgical abortions without resort to general anaesthesia.
C - If conscious sedation is used during surgical abortion, it should be undertaken only by trained practitioners and in line with Department of Health (DH) guidance.
B - Women should routinely be offered pain relief such as non-steroidal anti-inflammatory drugs (NSAIDs) during surgical abortion.
A - Prophylactic paracetamol (oral or rectal) is ineffective in reducing pain after surgical abortion and is not recommended.
B - Medical abortion regimens using 200 mg oral mifepristone and misoprostol are effective and appropriate at any gestation.
Medical Abortion at ≤63 Days of Gestation (Early Medical Abortion)
B - The following regimens are recommended for early medical abortion:
- At ≤63 days of gestation, mifepristone 200 mg orally followed 24–48 hours later by misoprostol 800 micrograms given by the vaginal, buccal or sublingual route
- At ≤49 days, 200 mg oral mifepristone followed 24–48 hours later by 400 micrograms of oral misoprostol.
B - 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 upon preference and amount of bleeding).
Medical Abortion at 9–13 Weeks of Gestation
A - The following regimen is recommended for medical abortion between 9 and 13 weeks of gestation:
- Mifepristone 200 mg orally followed 36–48 hours later by misoprostol 800 micrograms vaginally. A maximum of four further doses of misoprostol 400 micrograms may be administered at 3-hourly intervals, vaginally or orally.
Medical Abortion at 13–24 Weeks of Gestation
A - The following regimen is recommended for medical abortion 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.
B - Surgical evacuation of the uterus is not required routinely following medical abortion between 13 and 24 weeks of gestation. It should be undertaken only if there is clinical evidence that the abortion is incomplete.
Pain Relief for Medical Abortion
B - Women should routinely be offered pain relief (for example, NSAIDs) during medical abortion.
A - Oral paracetamol has not been shown to reduce pain more than placebo during medical abortion and is not recommended.
B - Some women may require additional narcotic analgesia, particularly after 13 weeks of gestation.
C - Routine histopathological examination of tissue obtained at abortion procedures is not recommended.
Gestational Trophoblastic Neoplasia
C - Routine screening of women for gestational trophoblastic neoplasia (GTN) at the time of abortion is not recommended; providers should be aware of the signs and symptoms and, where appropriate, facilitate referral into a GTN monitoring programme.
Care after the Abortion
B - Anti-D IgG should be given, by injection into the deltoid muscle, to all non-sensitised RhD negative women within 72 hours following abortion, whether by surgical or medical methods.
Follow-up after Abortion
B - There is no medical need for routine follow-up after surgical abortion or after medical abortion if successful abortion has been confirmed at the time of the procedure.
C - Ultrasound examination should not be used routinely to screen women for incomplete abortion.
C - The decision to evacuate the uterus following incomplete abortion should be based on clinical signs and symptoms and not on ultrasound appearance.
Contraception After Abortion
B - Abortion services should be able to provide all methods of contraception, including long-acting methods, immediately after abortion.
B - Women should be advised of the greater effectiveness of long-acting reversible methods of contraception.
B - Before she is discharged, future contraception should have been discussed with each woman and contraceptive supplies should have been offered.
B - The chosen method of contraception should be initiated immediately.
B - Intrauterine contraceptives can be inserted immediately following medical and surgical abortion at all gestations as long as it is reasonably certain that the woman is not still pregnant.
B - Sterilisation can be safely performed at the time of induced abortion, although this may be more likely to be associated with regret and failure.
The definitions of the types of evidence used in this guideline originate from the United States Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research).
Levels of Evidence
||Evidence obtained from meta-analysis of randomised trials
||Evidence obtained from at least one randomised controlled trial
||Evidence obtained from at least one well-designed controlled study, without randomisation
||Evidence obtained from at least one other type of well-designed quasi-experimental study
||Evidence obtained from well-designed non-experimental descriptive studies, correlation studies, and case studies
||Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
Grades of Recommendation
|Grade of Recommendation
||Level of Evidence*
||Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation (evidence levels Ia, Ib)
||Requires the availability of well-conducted clinical studies, but no randomised clinical trials on the topic of the recommendation (evidence levels IIa, IIb, III)
||Requires evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities; indicates an absence of directly applicable clinical studies of good quality (evidence level IV)
|Good Practice Points
||Recommended best practice based on the clinical experience of the Guideline Development Group