Medical Termination of Pregnancy Protocol
First Trimester (≤9 weeks gestation)
For a healthy woman with no medical contraindications, medical termination using mifepristone 200 mg orally followed by misoprostol 800 μg vaginally 24-48 hours later is the recommended first-line approach, achieving 95% complete abortion rates. 1, 2
Medical Method Protocol
- Mifepristone 200 mg orally as initial dose 1, 2
- Misoprostol 800 μg administered vaginally 24-48 hours after mifepristone 1, 2, 3
- Success rate: approximately 95% complete abortion 2
- Efficacy remains high through 9 weeks gestation (63 days), with 94.5% success rate even at 63-83 days 3
Surgical Alternative
- Vacuum aspiration (VA) by electrical suction or manual aspiration achieves approximately 97% complete abortion rate 2
- Risk of significant bleeding ≤5%, major complications <1% 2
- Prophylactic antibiotics mandatory to reduce infection risk from 5-20% to 1.3% 4, 2
- Pre-operative misoprostol 400 μg administered 2 hours before procedure reduces complications 5
Second Trimester (14-24 weeks gestation)
Dilation and evacuation (D&E) is definitively the safest procedure for second-trimester termination and should be performed in a hospital setting by experienced providers under sedation or general anesthesia. 1, 4, 6
Why D&E is Superior
- Hemorrhage rate: 9.1% vs 28.3% with medical methods 1, 4, 6
- Infection rate: 1.3% vs 23.9% with medical methods 1, 4, 6
- Most procedures performed under sedation or general anesthesia 4, 6
Medical Alternative (if D&E unavailable)
- Mifepristone 200 mg orally followed by misoprostol 800 μg vaginally 36-48 hours later 7
- Repeat misoprostol 400 μg vaginally every 3 hours (maximum 4 doses in 24 hours) 7
- Success rate: 97.9% within 24 hours, 99.5% within 36 hours 7
- Avoid prostaglandin F compounds - use prostaglandin E1 (misoprostol) or E2 only, as F compounds increase pulmonary arterial pressure 4, 6
Special Considerations at 24+ Weeks
- Specialized expertise required due to increased risks 4
- Must be managed in experienced centers with on-site cardiac surgery capabilities 4, 6
Essential Post-Procedure Care (All Methods)
Every patient requires two mandatory interventions regardless of method chosen:
- Antibiotic prophylaxis to prevent post-abortal endometritis (occurs in 5-20% without antibiotics) 1, 4, 6
- Anti-D immunoglobulin for all Rh-negative women to prevent alloimmunization 1, 4, 6
Monitoring Requirements
- Monitor for signs of infection, retained products, and excessive bleeding 1
- Medical methods require close hospital monitoring during prostaglandin administration 1, 6
Critical Counseling Points
Counseling must be performed expeditiously to optimize choices and outcomes, as delays directly impact success rates and complication risks. 1
Required Discussion Elements
- Short- and long-term maternal health risks 1
- Risks/benefits of pregnancy continuation versus termination 1
- All treatment options with success rates and complication profiles 1
- Contraception counseling addressing safety, effectiveness, accessibility, affordability, and acceptability of full range of options 8
Legal Authority
- The pregnant woman with decision-making capacity has sole legal and ethical authority to consent - no spousal or partner consent required 1
- Document the woman's capacity and informed consent from her alone 1
Common Pitfalls to Avoid
- Never delay counseling or procedure - timing directly impacts success rates and complication risks 1
- Never use prostaglandin F compounds in medical termination - they cause adverse hemodynamic effects 4, 6
- Never omit antibiotic prophylaxis - infection rates increase from 1.3% to 5-20% 1, 4
- Never forget anti-D immunoglobulin in Rh-negative women 1, 4, 6
- Fetal analgesia is not indicated - no evidence of fetal pain awareness before 24-25 weeks gestation 1, 4, 6