Abortion care

1Regulatory and Legal Framework

• Statutory LawAbortion in England, Scotland, and Wales is regulated by the Abortion Act 1967 (as amended by the Human Fertilisation and Embryology Act 1990) and the Abortion Regulations 1991.
  • The Act strictly regulates both when and where abortions can lawfully take place.
• CQC RegistrationAbortion is a 'regulated activity' under the Health and Social Care Act 2008. All providers must register with the Care Quality Commission (CQC). Carrying out an abortion without registration is a criminal offence under section 10 of the Act.
• Licensing & Off-Label UseMifepristone and misoprostol do not have UK marketing authorisations for most of the clinical indications and regimens recommended in this guideline.
  • Prescribers must follow professional guidance on prescribing unlicensed or off-label medicines.
  • All adverse events or problems related to medicines or medical devices must be reported to the MHRA using the Yellow Card Scheme.
• ConsentHealthcare professionals must ensure women have the information needed to make decisions and give consent in line with GMC guidance and the 2015 Montgomery ruling.
• Key DefinitionsLegal and clinical definitions of terms used within the abortion care guideline:
  • Fetal Anomaly (Ground E): Defined under section 1(1)(d) of the 1967 Abortion Act. Requires the opinion of 2 medical practitioners that there is a 'substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped' (HSA1 form).
  • Feticide: The injection of digoxin or potassium chloride (KCl) into the fetus, or digoxin into the amniotic cavity, to stop the fetal heart before an abortion.
• EpidemiologyKey statistical baselines for abortion care in England and Wales (based on 2018 data):
  • Approximately 200,608 women underwent abortions in 2018.
  • Almost all abortions are NHS-funded, but 72% were performed by providers in the independent sector.
  • The majority of procedures (80%) are conducted in the first 10 weeks of pregnancy.
  • There is a continuing trend towards medical abortion, accounting for 71% of all abortions and 83% of abortions under 10 weeks.

2Service Organisation and Access

• AccessCommissioners and providers must facilitate easy access to abortion services:
  • Allow self-referral to bypass GP appointment delays and avoid potential negative attitudes.
  • Ensure prompt onward referral if a service cannot provide an abortion due to gestational age limits or preferred method.
  • Avoid repeating key steps (e.g., returning to GP for referral, repeated assessments, or duplicate investigations).
  • Consider upfront funding for travel and accommodation for women eligible for the NHS Healthcare Travel Costs Scheme or those traveling to non-local services, shifting from a retrospective 'pay-and-claim' model.
• BeliefsHealthcare professionals must not allow personal beliefs to delay access to abortion services.
  • Conscientious objection (e.g., GMC guidance) protects the right to opt out of performing abortions, but does NOT protect the right to opt out of providing access (onward referral must not be delayed).
• CounsellingDo not require compulsory counselling or compulsory time for reflection before the abortion.
  • Provide or refer for decision-making support only if requested by the woman.
• LocationConsider providing assessments by phone or video call (telemedicine) for women who prefer this, and offer services in a range of community and hospital settings.
  • Mandatory physical separation of abortion services from maternity services is not recommended due to resource constraints, safety concerns, and the risk of stigmatising/identifying patients.
• WorkforceMaximise the role of nurses and midwives in providing abortion care within legal limits to increase appointment availability.
  • Trainees and students (nurses, midwives, GPs) should have opportunities to gain experience in abortion services.
  • For specialties with abortion in the core curriculum, training is mandatory unless the trainee opts out due to conscientious objection.
  • If a trainee's placement site does not provide abortions, they should gain experience with an external NHS or independent sector provider.
• ComplexEstablish clear pathways for women with complex physical or mental health needs or significant comorbidities.
  • Specialist centres should be located as locally as possible to minimize travel and delays.
• StigmaAddress and minimize stigma and anxiety regarding healthcare attitudes.
  • Be mindful of verbal and non-verbal communication and perceived judgmental attitudes. Negative experiences are strongly associated with delayed presentation in subsequent pregnancies.
  • Maintain strict confidentiality; address concerns about sharing abortion information with uninvolved healthcare professionals.

3Providing Information

Key communication requirements, reassurance points, and specific details to provide to women undergoing medical or surgical abortions.

• ReassuranceReassure women that having an abortion is NOT associated with an increased risk of:
  • Infertility
  • Breast cancer
  • Mental health issues
• ChoiceProvide objective, non-directive information comparing medical and surgical abortion (including risks and benefits) to support informed personal choice. Utilise NICE patient decision aids to support these discussions.
• PreparationProvide detailed preparatory information as early as possible, covering what the procedure involves, post-procedure expectations, and expected levels of pain and bleeding.
  • Provide information in diverse formats (e.g., video, written) and incorporate real-world experiences of women who have undergone abortions.
• MedicalSpecific counseling points for medical abortion:
  • Explain that they may see the products of pregnancy as they are passed.
  • Describe what the products of pregnancy will look like and advise that there may be movement.
  • For home medical abortions, clearly explain how to confirm that the pregnancy has successfully ended.
• Safety NettingProvide clear information on signs and symptoms that necessitate urgent medical help, alongside 24-hour contact details.
  • Provide information on options for the management and disposal of pregnancy remains, aligning with the Human Tissue Authority (HTA) 2015 guidance (including the right to take remains home).
• Fetal AnomalySpecific pathways for abortion due to fetal anomaly:
  • If the preferred abortion method is unavailable in maternity services, establish a clear referral pathway with ongoing communication.
  • Ensure easy transfer to the abortion service, ongoing support from the maternity service, and access to detailed information about the anomaly (best addressed by the diagnosing maternity service).
  • Explain to the woman that there may not be any physical signs of a fetal anomaly.

4Anti-D Prophylaxis

Guidelines on the administration of anti-D prophylaxis based on gestational age thresholds to avoid unnecessary testing and treatment delays.

• Up to 11+6Do NOT routinely test rhesus D status or offer anti-D prophylaxis to individuals having a medical or surgical abortion up to and including 11+6 weeks' gestation.
  • This aligns with the World Health Organization (WHO) abortion care guideline (section 3.3.3).
  • Omitting routine testing and prophylaxis under 12 weeks reduces unnecessary interventions, minimizes treatment delays, and yields cost savings.
• 12+0 Weeks+For non-sensitised rhesus D-negative individuals having an abortion at 12+0 weeks or over:
  • Offer anti-D prophylaxis and administer the dose within 72 hours of the abortion.
  • Ensure rhesus status testing and anti-D supply do not cause any delays to the abortion.
  • Ensure anti-D prophylaxis is available at the time of the abortion.

5Preventing Infection

Routine screening and antibiotic prophylaxis recommendations for medical and surgical abortions, balancing infection risk against antibiotic stewardship.

• ScreeningRoutinely offer and recommend an HIV test to all women at their first appointment, in line with the dedicated NICE guideline on HIV testing.
  • Encourage screening for other sexually transmitted infections (STIs). Withholding routine antibiotics in medical abortion may increase STI screening uptake.
• MedicalDo NOT routinely offer antibiotic prophylaxis to women having a medical abortion.
  • The absolute risk of severe post-abortion infection is very low.
  • Routine prescription increases the risk of antibiotic resistance and has uncertain efficacy due to low patient adherence.
  • Exception: Prophylaxis may be appropriate for individuals at high risk of infection, or those who would find it difficult to access follow-up treatment if they screened positive for an STI.
• SurgicalOffer routine antibiotic prophylaxis to all women having a surgical abortion.
• RegimenAntibiotic selection and dosing considerations for surgical abortion (or indicated medical abortion):
  • Doxycycline: Recommend oral doxycycline 100 mg twice a day for 3 days (rather than a 7-day course). A 3-day course is as effective as a 7-day course regarding pelvic inflammatory disease (PID) rates, improves adherence, and minimizes side effects.
  • Metronidazole: Do NOT routinely combine metronidazole with another broad-spectrum antibiotic (such as doxycycline). It does not show a clinically important difference in PID rates and is poorly tolerated due to GI side effects. Metronidazole remains indicated only if there is specific clinical suspicion or diagnosis of an anaerobic infection.

6Venous Thromboembolism (VTE) Prophylaxis

Pharmacological thromboprophylaxis recommendations for women undergoing abortion who are identified as having VTE risk factors.

• Standard RiskFor women requiring pharmacological thromboprophylaxis, consider low-molecular-weight heparin (LMWH) for at least 7 days post-abortion.
  • Base management on the NICE guideline for reducing VTE risk (specifically recommendations for termination within the last 6 weeks).
  • Apply these recommendations to all at-risk individuals, not just those admitted to an inpatient hospital setting.
• High RiskFor women at high risk of thrombosis, consider starting LMWH before the abortion and extending the duration of administration afterwards.
  • Align risk assessment and management with the RCOG antenatal and postnatal risk assessment tools.

7Choice of Procedure for Abortion

Gestational age limits, clinical rules, and service requirements regarding the choice between medical and surgical abortion.

• Up to 23+6Offer a choice between medical or surgical abortion up to and including 23+6 weeks' gestation, where clinically appropriate.
  • If a specific method is clinically inappropriate, explain the clinical reasoning to the patient.
  • Up to and including 12+6 weeks: Both medical and surgical methods are highly safe with similar effectiveness.
  • Between 13+0 and 23+6 weeks: Choice should be offered; medical abortion has a higher rate of incomplete abortion requiring surgical intervention, but other major complication rates are similar.
• After 23+6Surgical abortion can be performed shortly after 23+6 weeks' gestation ONLY if feticide was administered at or before 23+6 weeks' gestation (in line with the Abortion Act). Otherwise, all abortions after 23+6 weeks are medical procedures.
• InfrastructureService requirements to support choice of procedure:
  • Surgical abortion (Dilatation and Evacuation - D&E) in the second trimester requires theatre teams to have access to ultrasound machines directly in the operating theatre and staff trained in intraoperative scanning.
  • Medical abortion in the second trimester requires dedicated inpatient beds and nursing staff trained in second-trimester medical abortion care.

8Abortion Before Definitive Ultrasound Evidence

Management and safety-netting protocols when performing an abortion before a yolk sac is visible on ultrasound.

• EfficacyConsider performing the abortion before there is definitive ultrasound evidence of an intrauterine pregnancy (yolk sac) if the woman has no signs or symptoms of an ectopic pregnancy.
  • Abortion (medical or surgical) is highly effective and works just as well before definitive ultrasound evidence as it does after.
• Safety NettingIf proceeding before definitive ultrasound evidence, providers must:
  • Explain that there is a small risk of an ectopic pregnancy.
  • Explain the necessity of follow-up appointments to confirm successful termination and monitor for ectopic pregnancy.
  • Provide 24-hour emergency contact details.
  • Advise the patient to seek immediate medical attention if they develop symptoms suggestive of an ectopic pregnancy.
• SurgicalProviders of surgical abortion before definitive ultrasound evidence must have systems to confirm successful aspiration of the pregnancy:
  • Staff must be trained to inspect the products of conception for the presence of chorionic villi and a gestational sac.
  • Necessary equipment must be available, typically a light box and a clear receiver, or immediate access to ultrasound.
• DiagnosticsServices offering early abortion before ultrasound evidence must have diagnostic and referral pathways in place:
  • Ability to assess serum human chorionic gonadotrophin (hCG) levels.
  • Staff trained in interpreting serial hCG test results.
  • Established processes to refer the woman promptly to an early pregnancy assessment unit (EPAU) if an ectopic pregnancy is suspected.

9Medical Abortion Up to and Including 10+0 Weeks

Gestational age thresholds, location requirements, and dosing regimens for early medical abortion.

• Home ExpulsionLocation requirements for administering mifepristone and misoprostol:
  • Up to and including 9+6 weeks' gestation: Offer the option of full expulsion at home. Both mifepristone and misoprostol can be taken at home, or in a clinic/hospital setting.
  • At 10+0 weeks' gestation: Offer the option of expulsion at home ONLY after misoprostol has been taken. Mifepristone is taken first in the clinic/hospital. Misoprostol must be taken in the clinic or hospital, after which the patient may return home for expulsion.
  • Comparing gestations up to 9+0 weeks against 9+1 to 10+0 weeks shows no difference in the risk of serious complications (emergency care, hospitalisation, or haemorrhage).
• RegimensOffer interval treatment (usually 24 to 48 hours) with mifepristone and misoprostol to women having a medical abortion up to and including 10+0 weeks' gestation.
• SimultaneousSimultaneous administration option (up to and including 9+0 weeks' gestation):
  • Give women the choice of taking mifepristone and vaginal misoprostol at the same time.
  • Counsel that the risk of ongoing pregnancy is higher with simultaneous administration (2.4% vs 0.9% with interval), and this risk increases with gestation.
  • Counsel that it may take longer for bleeding and pain to start compared to interval dosing (which may benefit women travelling home from a clinic).
  • Vaginal misoprostol is the only recommended route for simultaneous treatment.
  • Simultaneous treatment is NOT recommended for gestations between 9+1 and 10+0 weeks; interval treatment remains the standard of care.

10Medical Abortion from 10+1 Weeks and Beyond

Dosing regimens, routes of administration, and interval options for mid- and late-trimester medical abortions.

• 10+1 to 23+6Regimen for medical abortion between 10+1 and 23+6 weeks' gestation:
  • Initial misoprostol dose (36 to 48 hours after 200 mg oral mifepristone): Offer 800 micrograms misoprostol vaginally as the standard route. Offer 600 micrograms misoprostol sublingually for women who decline the vaginal route. Oral misoprostol is NOT recommended as a loading dose.
  • Subsequent misoprostol doses: Follow the initial dose with 400 micrograms of misoprostol every 3 hours until expulsion (vaginal, sublingual, or buccal routes). A 400 microgram follow-up dose results in a shorter time to expulsion compared to a 200 microgram dose.
  • Shorter interval option: A shorter interval between mifepristone and misoprostol can be used if preferred, but counsel that it may result in a longer time from taking the first misoprostol dose to completing the abortion.
• After 23+6Medical abortion after 23+6 weeks' gestation (rare, accounting for 0.1% of abortions):
  • Statutory Grounds: Legally restricted to fetal anomaly, emergency risk to the life of the pregnant woman, or to prevent grave permanent injury to her physical or mental health.
  • Uterine Sensitivity: The uterus becomes increasingly sensitive to misoprostol as pregnancy advances, requiring lower doses and longer intervals to prevent uterine rupture.
  • Uterine Rupture Risk: Risk factors include a pre-existing uterine scar (previous caesarean section or uterine surgery), increased gestational age, and multiparity.
  • Feticide: The RCOG recommends feticide for abortions after 21+6 weeks' gestation to prevent live birth (note: evidence on feticide was not reviewed in this NICE guideline).

11Cervical Priming Before Surgical Abortion

Recommendations for cervical priming to reduce incomplete abortion risk and cervical dilation force, stratified by gestational age.

• BenefitsExplain the clinical benefits and side effects of cervical priming to women:
  • Reduces the risk of incomplete abortion for parous women.
  • Makes cervical dilation easier for both parous and nulliparous women (reduces mechanical force).
  • May cause bleeding and cramping/pain before the surgical procedure.
• Up to 13+6Cervical priming up to and including 13+6 weeks' gestation:
  • First-line options: Sublingual misoprostol (400 mcg) 1 hour before, or vaginal misoprostol (400 mcg) 3 hours before.
  • Vaginal misoprostol requires a longer lead time than sublingual, which increases preoperative pain and bleeding time.
  • Sublingual misoprostol is associated with more gastrointestinal side effects than the vaginal route.
  • Alternative: Oral mifepristone (200 mg) given 24 to 48 hours before the procedure if misoprostol cannot be used.
• 14+0 to 23+6Cervical priming between 14+0 and 23+6 weeks' gestation:
  • Mifepristone alone: Only recommended between 14+0 and 16+0 weeks (200 mg oral, administered the day before).
  • Misoprostol alone: Only recommended between 14+0 and 19+0 weeks.
  • Osmotic dilators: Recommended across the entire 14+0 to 23+6 week range; they are the only recommended single option after 19+0 weeks.
  • Dilator timing: Inserting osmotic dilators the day before (overnight) makes the procedure easier than same-day insertion, especially at later gestations, though it requires an extra clinic visit.
• CombinationsRules for combining priming agents between 14+0 and 23+6 weeks:
  • Mifepristone + Osmotic Dilators: Recommended for gestations between 19+1 and 23+6 weeks to reduce procedural difficulty at later gestations.
  • Misoprostol + Osmotic Dilators: NOT recommended. Misoprostol provides no additional benefit, increases side effects, and may increase the risk of preoperative expulsion.
  • Do not offer misoprostol for cervical priming if the woman has had an osmotic dilator inserted the day before.

12Anaesthesia and Sedation for Surgical Abortion

Options, clinical preferences, and safety profiles for anaesthesia and sedation during surgical abortion procedures.

• OptionsDiscuss anaesthesia options to support informed choice, explaining the trade-offs:
  • Local anaesthesia (LA) alone: Minimises time spent in the hospital. There is insufficient evidence to recommend one specific method of administering LA (including intrauterine anaesthesia).
  • Intravenous (IV) sedation + LA: Helps manage anxiety during the procedure.
  • Deep sedation or General Anaesthesia (GA): The woman will usually not be aware during the procedure.
• SedationWhen using conscious sedation, use intravenous (IV) rather than oral sedation:
  • IV sedation results in less pain and nausea compared to oral sedation.
  • IV sedation has a faster onset and shorter recovery time, reducing hospital stay and improving scheduling flexibility.
  • Women are significantly more likely to report they would choose IV sedation again.
• General AnaesthesiaWhen using general anaesthesia, consider intravenous propofol and a short-acting opioid (such as fentanyl) rather than inhalational anaesthesia.
  • Inhalational anaesthetics cause dose-dependent uterine relaxation, which may theoretically increase bleeding compared to propofol.

13Follow-up and Support After an Abortion

Post-procedure follow-up protocols for early medical abortions and requirements for emotional and psychological support.

• Follow-upFollow-up for medical abortion up to and including 10+0 weeks' gestation (with expulsion at home):
  • Offer the choice of self-assessment (including remote options like telephone or text) as an alternative to clinic follow-up.
  • Remote follow-up and self-assessment are safe, effective, and acceptable alternatives with no difference in missed ongoing pregnancy or complication rates.
  • Provide a low-sensitivity or multi-level urine pregnancy test to exclude an ongoing pregnancy at 2 weeks.
  • Do not use high-sensitivity urine pregnancy tests (detection threshold 10 to 25 IU hCG) for routine follow-up as they remain false-positive for up to a month, leading to unnecessary clinic visits.
• SupportInformation and emotional support requirements:
  • Explain expected aftercare, follow-up, and how to access out-of-hours help.
  • Normalise experiencing a wide range of emotions post-abortion.
  • Providers must be capable of providing emotional support and must refer for counselling if requested.
  • Support must be tailored to the woman's specific circumstances (e.g., abortion for fetal anomaly).

14Improving Access to Contraception

Guidance on integrating immediate, same-day contraceptive provision into abortion services to improve uptake and reduce subsequent abortion rates.

• Service DeliveryCommissioners and providers must ensure the full range of reversible contraceptive options is available on the same day as the surgical or medical abortion.
  • Includes: DMPA, contraceptive implant, intrauterine methods (IUD/IUS), oral contraceptives, patches, vaginal rings, and barrier methods.
  • Immediate provision improves uptake and continuation rates, and significantly reduces subsequent abortion rates.
• ImplantsContraceptive implant timing: Offer on the day of surgical abortion, or the day mifepristone is taken for medical abortion.
  • Provides a clinically important reduction in subsequent unintended pregnancy rates compared to delayed insertion, with no increase in complications.
• IUD/IUSIntrauterine methods (IUD/IUS) timing: Offer at the same time as surgical abortion, or as soon as possible after pregnancy expulsion for medical abortion.
  • Evidence supports safety across all gestational periods for LNG-IUS, and up to 9+0 weeks for Copper IUD.
  • Absolute risk of uterine perforation is very small. Infection risk within 1 month does not differ significantly from baseline.
• DMPAFor women choosing depot medroxyprogesterone acetate (DMPA) injection during a medical abortion:
  • Consider administering DMPA at the same appointment when mifepristone is taken.
  • Caution: Advise the woman that administering DMPA at this stage may slightly increase the risk of an ongoing pregnancy, though the overall risk remains low.
  • There is currently no evidence to recommend a specific timing for subcutaneously administered DMPA.