Abortion Consultation: Evidence-Based Recommendations
For patients seeking abortion consultation, offer both medication and surgical options through shared decision-making, with the specific protocol determined by gestational age: medication abortion is highly effective through 27 6/7 weeks using mifepristone-misoprostol combinations, while surgical methods (vacuum aspiration or dilation and evacuation) remain safe and effective alternatives at all gestational ages.
Gestational Age-Specific Protocols
Early First Trimester (Up to 7 weeks)
Medication abortion is the preferred method with >95% effectiveness when protocols are properly followed 1.
Recommended regimen:
- Mifepristone 200 mg orally (not 600 mg—equally effective at lower dose) 1
- Followed 24-48 hours later by misoprostol 400 mcg administered orally, buccally, sublingually, or vaginally 2
- Repeat misoprostol 400 mcg after 3 hours if no bleeding occurs 2
Surgical alternative:
- Vacuum aspiration (electric or manual) is highly effective and safe even before 7 weeks 3
- Requires cervical preparation with misoprostol 400 mcg (vaginal route 3 hours before or sublingual 1-3 hours before) 3
- Systematic antibiotic prophylaxis recommended; doxycycline preferred in women under 25 due to Chlamydia prevalence 3
Late First Trimester (7-13 6/7 weeks)
Medication abortion remains highly effective with adjusted protocols 1, 4.
Recommended regimen:
- Mifepristone 200 mg orally
- 24-48 hours later: misoprostol 800 mcg via vaginal, sublingual, or buccal route (NOT oral—less effective and poorly tolerated) 4
- Between 9-14 weeks: repeat misoprostol 400 mcg every 3 hours as needed (maximum 5 doses) 4
- The sublingual/buccal routes have equal effectiveness to vaginal but cause more gastrointestinal side effects 4
Surgical alternative:
- Vacuum aspiration remains safe and effective 3
- Cervical preparation is mandatory to reduce complications 2, 3
- Consider adding mifepristone 200 mg 24-48 hours before procedure for pregnancies 12-14 weeks 3
Second Trimester (14 0/7 to 27 6/7 weeks)
Mifepristone plus misoprostol is the most effective medication regimen, with mean abortion times of 5.8-8 hours and 96-98% success rates at 24-48 hours 1.
Preferred medication regimen:
- Mifepristone 200 mg orally
- 24-48 hours later: misoprostol 400 mcg sublingually or buccally every 3 hours until expulsion 1
- "Unlimited dosing" protocol: Continue until complete expulsion (usually <48 hours); most patients need ≤6 doses 1
- No evidence-based rationale to stop after 5 doses if patient is stable 1
If mifepristone unavailable (misoprostol-only regimen):
- Misoprostol 400-600 mcg vaginally every 4-6 hours 1
- Less effective than combination (32% vs 4% ongoing pregnancy at 24 hours) 1
- Mean abortion time 11-12 hours 1
Surgical alternative:
- Dilation and evacuation (D&E) is the procedure of choice 5
- Requires adequate cervical preparation for safety 5
- Provider skill and experience are critical factors 5
Critical Clinical Considerations
Service Delivery for 14-27 6/7 Weeks
Medication abortion at this gestational age is primarily facility-based (ambulatory or hospital), though this is based on practice patterns rather than evidence 1. Facility-based care provides:
- Access to comprehensive pain control options
- Expedient management of retained placenta
- Bereavement services and fetal remains disposition 1
Key point: Patients don't need direct observation for the entire process. Mifepristone can be taken before facility presentation, and initial misoprostol doses can be started at home for low-risk patients, though abortion may occur within hours of first misoprostol dose 1.
Pain Management
- Ibuprofen is first-line analgesic 6, 4
- Add level 2 analgesics (codeine combinations) as needed 6
- Prophylactic anti-emetics should be offered 6, 4
- Pain intensity increases with gestational age 4
Special Populations and Precautions
Not contraindications:
- Breastfeeding
- Obesity
- Twin pregnancy
- Scarred uterus (single prior cesarean) 4
Important caveat: Two or more prior cesarean sections increase uterine rupture risk with misoprostol, though absolute risk remains low 1. Individualize care and counsel appropriately.
Absolute contraindications (rare):
- Known hypersensitivity to mifepristone or misoprostol
- Inherited porphyria
- Severe anemia or hemorrhagic disorders
- Current anticoagulation therapy
- Confirmed ectopic pregnancy 4
Pregnancy of Unknown Location (PUL)
PUL with hCG <1500-2500 IU/L is NOT a contraindication to medication abortion, provided:
- Patient is informed of undiagnosed ectopic pregnancy risk
- Patient knows when/how to seek emergency care
- Earlier-than-usual hCG follow-up is arranged 4
Follow-Up and Contraception
Confirming Completion
Follow-up assessment is mandatory to confirm complete abortion 4. Use either:
- Clinical history + ultrasound, OR
- hCG blood level: >80% decrease from baseline at 15 days indicates success 2, 4
Contraception Initiation
Most contraceptive methods can be started immediately 1:
Same day as surgical abortion or with mifepristone (medication abortion):
After medication abortion:
- Combined hormonal contraceptives: start same day as misoprostol or day after 2
- Vaginal ring: insert within 1 week after mifepristone 2
- IUD: insert 10 days after mifepristone, after ultrasound confirms no intrauterine pregnancy 2
Delay contraception if:
- Post-abortion hemorrhage occurs
- Infection confirmed or suspected
- Wait until symptoms resolve and antibiotics completed 1
Provider Qualifications
Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks with appropriate backup, as the care parallels obstetric delivery care routinely provided by these clinicians 1.