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.
Organisation of Services
B - The earlier in pregnancy an abortion is performed, the lower the risk of complications. Services should therefore offer arrangements that minimise delay (for example, a telephone referral system and a formal care pathway with arrangements for access from a wide range of referral sources, not just general practitioners).
Service arrangements should be such that:
- Ideally, all women requesting abortion are offered an assessment appointment within 5 days of referral.
- As a minimum standard, all women requesting abortion are offered an assessment appointment within 2 weeks of referral.
- Ideally, all women can undergo the abortion within 7 days of the decision to proceed being agreed.
- As a minimum standard, all women can undergo the abortion within 2 weeks of the decision to proceed being agreed.
- C - As a minimum standard, no woman need wait longer than 3 weeks from her initial referral to the time of her abortion.
- Women should be seen as soon as possible if they require termination for urgent medical reasons.
C - An adequate number of staffed inpatient beds must be available for those women who are unsuitable for day case care. In a typical abortion service, up to 5% of women will require inpatient care.
Information for Women
B - Verbal advice should be supported by accurate, impartial printed information that the woman considering abortion can understand and may take away to consider further before the procedure.
B - The risk of haemorrhage at the time of abortion is low. It complicates around 1 in 1,000 abortions overall. The risk is lower for early abortions (0.88 in 1,000 at less than 13 weeks; 4.0 in 1,000 at more than 20 weeks).
B - The risk of uterine perforation at the time of surgical abortion is moderate. The incidence is of the order of 1–4 in 1,000. The risk is lower for abortions performed early in pregnancy and those performed by experienced clinicians.
B - Uterine rupture has been reported in association with mid-trimester medical abortion. However, the risk is very low, at well under 1 in 1,000.
B - Cervical trauma: The risk of damage to the external cervical os at the time of surgical abortion is moderate (no greater than 1 in 100). The risk is lower when abortion is performed early in pregnancy and when it is performed by an experienced clinician.
B - Failed abortion and continuing pregnancy: All methods of first-trimester abortion carry a small risk of failure to terminate the pregnancy, thus necessitating a further procedure. The risk for surgical abortion is around 2.3 in 1,000 and for medical abortion between 1 and 14 in 1,000 (depending on the regimen used and the experience of the centre).
B - Post-abortion infection: Genital tract infection, including pelvic inflammatory disease of varying degrees of severity, occurs in up to 10% of cases. The risk is reduced when prophylactic antibiotics are given or when lower genital tract infection has been excluded by bacteriological screening.
B - Breast cancer: Induced abortion is not associated with an increase in breast cancer risk.
B - Future reproductive outcome: There are no proven associations between induced abortion and subsequent ectopic pregnancy, placenta praevia, or infertility. Abortion may be associated with a small increase in the risk of subsequent miscarriage or preterm delivery.
B - Psychological sequelae: Some studies suggest that rates of psychiatric illness or self-harm are higher among women who have had an abortion compared with women who give birth and to nonpregnant women of similar age. It must be borne in mind that these findings do not imply a causal association and may reflect continuation of pre-existing conditions.
Pre-abortion Management
The Abortion Decision
C - Clinicians caring for women requesting abortion should try to identify those who require more support in decision making than can be provided in the routine clinic setting (such as those with a psychiatric history, poor social support, or evidence of coercion). Care pathways for additional support, including access to social services, should be available.
Blood Tests
C - Pre-abortion assessment should include:
- Measurement of haemoglobin concentration
- Determination of ABO and rhesus blood groups with screening for red cell antibodies
- Testing for other conditions such as haemoglobinopathies, human immunodeficiency virus (HIV), and hepatitis B and C if indicated in the light of clinical features, individual risk factors, or local prevalence
B - It is not cost effective routinely to crossmatch women undergoing induced abortion.
Ultrasound Scanning
B - All services must have access to scanning, as it can be a necessary part of pre-abortion assessment, particularly where gestation is in doubt or where extrauterine pregnancy is suspected. However, ultrasound scanning is not considered to be an essential prerequisite of abortion in all cases.
C - When ultrasound scanning is undertaken, it should be in a setting and manner sensitive to the woman's situation. It is inappropriate for pre-abortion scanning to be undertaken in an antenatal department alongside women with wanted pregnancies.
Prevention of Infective Complications
A - Abortion care should encompass a strategy for minimising the risk of post-abortion infective morbidity. As a minimum, services should offer antibiotic prophylaxis.
B - Ideally, services should offer testing for lower genital tract organisms with treatment of positive cases.
C - The following regimens are suitable for periabortion prophylaxis:
- Metronidazole 1 gram (g) rectally at the time of abortion
plus
- Doxycycline 100 milligrams (mg) orally twice daily for 7 days, commencing on the day of abortion
OR
- Metronidazole 1 g rectally at the time of abortion
plus
- Azithromycin 1 g orally on the day of abortion.
Abortion Procedures
B - Ideally, abortion services should be able to offer a choice of recommended methods for each gestation band.
Surgical Methods
B - Conventional suction termination should be avoided at gestations below 7 weeks.
B - Early surgical abortion using a rigorous protocol (which includes magnification of aspirated material and indications for serum beta-human chorionic gonadotrophin [hCG] follow-up) may be used at gestations below 7 weeks, although data suggest that the failure rate is higher than for medical abortion.
B - Conventional suction termination is an appropriate method at gestations of 7-15 weeks, although, in some settings, the skills and experience of practitioners may make medical abortion more appropriate at gestations above 12 weeks.
B - Suction termination is safer under local anaesthesia than under general anaesthesia. Consideration should be given to making this option available, particularly for low gestation procedures.
C - If conscious sedation is used in place of general anaesthesia to reduce the pain and anxiety associated with surgical abortion, it should be undertaken only by trained practitioners and in line with Department of Health guidance.
A - For first-trimester suction termination, either electric or manual aspiration devices may be used, as both are effective and acceptable to women and clinicians. Operating times are shorter with electric aspiration.
A - For gestations above 15 weeks, surgical abortion by dilatation and evacuation (D&E), preceded by cervical preparation, is safe and effective when undertaken by specialist practitioners with access to the necessary instruments and who have a sufficiently large caseload to maintain their skills.
B - Cervical preparation is beneficial prior to surgical abortion and should be routine if the woman is aged under 18 years of age or at a gestation of more than 10 weeks.
C - Abortion regimens containing misoprostol are not licensed within manufacturers' summaries of product characteristics. European Community regulations permit doctors to prescribe unlicensed regimens and permit pharmacists to dispense and nurses to administer medicines prescribed outside of a product license. Women should be informed if a prescribed treatment is unlicensed.
B - Based on available evidence, the following regimen appears to be optimal for cervical preparation prior to first- or second-trimester surgical abortion. This advice is based on considerations of efficacy, adverse-effect profile, and cost:
* Misoprostol 400 micrograms (2 x 200-microgram tablets) administered vaginally, either by the woman or a clinician, 3 hours prior to surgery
The following regimens are licensed within manufacturers' summaries of product characteristics and are also appropriate for cervical preparation prior to first- or second trimester surgical abortion:
- Gemeprost 1 mg vaginally, 3 hours prior to surgery
- Mifepristone 600 mg orally 36-48 hours prior to surgery.
* This regimen is unlicensed.
Medical Methods
B - Medical abortion using mifepristone plus prostaglandin is the most effective method of abortion at gestations of less than 7 weeks.
A - Medical abortion using mifepristone plus prostaglandin continues to be an appropriate method for women in the 7–9 week gestation band.
A - * For early medical abortion a dose of 200 mg of mifepristone in combination with a prostaglandin is appropriate.
A - * Misoprostol (a prostaglandin E1 analogue) is a cost-effective alternative for all abortion procedures for which the E1 analogue gemeprost is conventionally used (that is, early medical abortion, cervical priming, mid-trimester medical abortion).
B - Based on available evidence, the following regimen appears to be optimal for early medical abortion up to 9 weeks (63 days) of gestation. This advice is based on considerations of efficacy, adverse-effect profile, and cost:
* Mifepristone 200 mg orally followed 1-3 days later by misoprostol 800 micrograms vaginally. The misoprostol may be administered by a clinician or self-administered by the woman. For women at 49-63 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).
The following regimen is licensed within manufacturer's summary of product characteristics and is also appropriate for early medical abortion up to 9 weeks (63 days) of gestation:
* Mifepristone 600 mg orally followed 36-48 hours later by gemeprost 1 mg vaginally
A - Medical abortion using the following regimen is a safe, effective, and acceptable alternative to surgical abortion for women between 9 and 13 weeks of gestation:
* Mifepristone 200mg 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 (depending on the amount of bleeding).
B - For mid-trimester abortion (13-24 weeks of gestation) medical abortion with mifepristone followed by prostaglandin is an appropriate method and has been shown to be safe and effective.
A - For mid-trimester medical abortion, a dose of *200 mg of mifepristone is adequate.
B - Surgical evacuation of the uterus is not required routinely following mid-trimester medical abortion. It should only be undertaken if there is clinical evidence that the abortion is incomplete.
A - Based on available evidence, the following regimen appears to be optimal for midtrimester medical abortion. This advice is based on considerations of efficacy, adverse effect profile, and cost:
* Mifepristone 200 mg orally, followed 36-48 hours later by misoprostol 800 micrograms vaginally, then misoprostol 400 micrograms orally, 3-hourly, to a maximum of four oral doses
The following regimen is licensed within manufacturer's summary of product characteristics and is also appropriate for mid-trimester medical abortion.
* Mifepristone 600 mg orally, followed 36–48 hours later by gemeprost 1 mg vaginally every 3 hours, to a maximum of five pessaries.
* This regimen is unlicensed.
General
B - Some women will require analgesia after surgical abortion or during and after medical abortion. Requirements for analgesia vary and there is no benefit in routine administration of prophylactic analgesics. Services should make available a range of oral and parenteral analgesics in order to meet women's needs.
B - Routine histopathological examination of tissue obtained at abortion procedures is unnecessary.
Aftercare
Rhesus Prophylaxis
B - Anti-D immunoglobulin G (250 international units [iu] before 20 weeks of gestation and 500 iu thereafter) should be given, by injection into the deltoid muscle, to all nonsensitised RhD negative women within 72 hours following abortion, whether by surgical or medical methods.
Post-Abortion Information and Follow-up
C - Each woman should be offered, or advised to obtain, a follow-up appointment (either within the abortion service or with the referring clinician) within 2 weeks of the abortion.
C - Referral for further counselling should be available for the small minority of women who experience long-term post-abortion distress. Risk factors are ambivalence before the abortion, lack of a supportive partner, a psychiatric history, or membership of a cultural group that considers abortion to be wrong.
Contraception Following Abortion
B - Before she is discharged following abortion, future contraception should have been discussed with each woman and contraceptive supplies should have been offered if required. The chosen method of contraception should be initiated immediately following abortion.
B - Intrauterine contraception can be inserted immediately following a first- or second trimester termination of pregnancy.
B - Sterilisation can be safely performed at the time of induced abortion. However, combined procedures are associated with higher rates of failure and of regret on the part of the woman.
Definitions:
Levels of Evidence
Ia: Evidence obtained from meta-analysis of randomised trials
Ib: Evidence obtained from at least one randomised controlled trial
IIa: Evidence obtained from at least one well-designed controlled study, without randomisation
IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
III: Evidence obtained from well-designed non-experimental descriptive studies, correlation studies, and case studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
Grading of Recommendations:
Grade A - 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)
Grade B - Requires the availability of well-conducted clinical studies but no randomised clinical trials on the topic of the recommendation (evidence levels IIa, IIb, III)
Grade C - 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)
