Abortion

Anatomy and Physiology

The female genital tract consists of both external and internal genitalia. A thorough understanding of the anatomy and physiology of the female reproductive system is essential for delivering safe and effective abortion care. This knowledge enables accurate patient assessment, appropriate procedure selection, and effective management of potential complications.

 The external genitalia of the female reproductive system include:

• Mons pubis: This is a rounded mass of fatty tissue located over the joint of the pubic bones.
• Labia majora: These are 2 cutaneous folds of skin that extend from the mons pubis down to the perineum.
• Labia minora: This is the region of the female genital tract buried inside the labia majora.
• Bartholin glands: These glands, similar to the bulbourethral glands in men, produce lubrication at the vaginal opening.
• Clitoris: This visible portion is a pea-sized, highly sensitive organ that detects sensation and stimulation.
• Vulva: This term is used to describe the collective external genitalia of the female.

The internal genitalia of the female reproductive system include:

• Ovaries: They are female reproductive organs that produce ova (eggs) during a normal menstrual cycle.
• Fallopian tubes: These structures are also known as uterine tubes, and they transport ova from the ovaries to the uterus. They are clinically significant in abortion, as they are the most common site for ectopic (nonuterine) pregnancies.
• Uterus: A hormone-sensitive reproductive organ where a fertilized ovum implants. The uterus supports the growth and maintenance of pregnancy and is also responsible for menstruation.
• Cervix: The lower part of the uterus, serving as the connection between the uterus and vagina.
• Vagina: The lower segment of the female genital tract, extending from its external opening to the cervix.

Indications

According to NAF's 2020 Clinical Policy Guidelines for Abortion Care, patients seeking an abortion must receive nonjudgmental counseling about their available options. The patient's preferences should be explored, and options such as continuing the pregnancy, parenting, adoption, and termination of pregnancy should be discussed during this time. If the patient decides to terminate the pregnancy, the benefits, risks, and details of the procedure must be clearly explained. Avoiding further stigmatization of abortion care requires refraining from terms such as "medically necessary" and "therapeutic," as they imply that some abortions are unnecessary. While these terms may be useful in policymaking, clinical practice should focus on counseling patients according to their individual goals.

Medication abortion is a safe and effective method for terminating pregnancies up to 70 days of gestation. An estimated 39% of all abortions are carried out using medication.[4] This option is noninvasive, avoids the risks associated with procedural abortions and anesthesia, and is more affordable. Medication abortion may take longer to complete than a procedural abortion and requires greater patient involvement, as the pregnancy is expelled outside of a clinical setting.

Medication abortion, also known as self-managed abortion, offers patients greater control and privacy. Nationally and internationally recognized regimens include the use of mifepristone followed by misoprostol. When mifepristone is unavailable, misoprostol alone is an acceptable alternative.[4] Medication abortion after the first trimester can also be performed safely and effectively by trained clinicians in appropriately equipped settings to support the patient. 

Medication abortion may be preferred over procedural management in the following cases:

• Uterine fibroids that significantly distort the uterus or cervical canal 
• Congenital uterine anomalies
• Introital scarring related to infibulation [4]

Procedural abortion involves the use of instruments inserted into the vagina, cervix, and uterus to remove the products of conception. Uterine aspiration—performed using a manual syringe or electric vacuum aspiration for most pregnancies—is typically used up to 13 weeks and 6 days of gestation. Only 11% of induced abortions in the United States occur after 14 weeks of gestation, most commonly through dilation and evacuation.[5] 

A procedural abortion may be necessary for patients who experience an incomplete or failed medication abortion.[6] According to the 2020 NAF Clinical Policy Guidelines for Abortion Care, the incidence of aspiration following medication abortion is 2% to 9% for pregnancies beyond 63 days from the last menstrual period (LMP), and even lower (<1%-3%) when a second dose of misoprostol is administered. Another indication for a procedural abortion is a suspected molar pregnancy.[7] 

Medication or procedural abortion may also be used in the management of early pregnancy loss, in which case it is appropriate to refer to the process as medication or procedural management of early pregnancy loss. Options counseling and a shared decision-making approach should be used to ensure the patient has access to all treatment options, including expectant management.

Contraindications

Before providing abortion care, it is essential to identify any medical contraindications that may impact the safety or method of the procedure. Recognizing these conditions ensures appropriate clinical decision-making and patient safety.

Contraindications to medication abortion include:

• Confirmed or suspected ectopic pregnancy 
• Intrauterine device (IUD) in place, which should be removed before the medication abortion
• Allergy to mifepristone or misoprostol
• Chronic adrenal failure
• Current long-term systemic corticosteroid therapy
• Known coagulopathy or anticoagulant therapy, excluding aspirin
• Hemodynamic instability 
• Inherited porphyria [4]

Anemia, seizures, asthma managed with steroid inhalers, obesity, breastfeeding, HIV or AIDS, sexually transmitted infections, and multiple gestations are not considered contraindications to abortion. While caution should be exercised in patients with coagulopathy or other bleeding disorders, these are not absolute contraindications for procedural abortion. If products of conception are not confirmed in the aspirate after the procedure, hCG levels should be monitored to ensure that ectopic pregnancy or pregnancy of unknown location is ruled out or treated if present.

Equipment

The availability and proper use of equipment are essential for safe and effective abortion care. Equipment requirements vary depending on the method of abortion, gestational age, and clinical setting, with different needs for medication versus procedural approaches. A comprehensive understanding of the necessary instruments, supplies, and supportive technologies allows healthcare teams to uphold high standards of care, minimize complications, and ensure patient safety in diverse practice environments.

Equipment used for procedural abortion includes:

• Vacuum single-valve aspirator/manual vacuum aspirator plus
• A locking 60 cc syringe
• Cannula
• Specimen cup
• Standard Graves speculum
• Single tooth tenaculum
• Ring forceps with cotton
• Small polyp forceps
• Pratt cervical dilators
• Gauze
• Curette

Personnel

An abortion procedure typically requires a team of trained healthcare professionals, including a clinician, physician, nurse practitioner, physician assistant, and certified nurse-midwife, depending on local regulations and the procedure used. Support staff may include a nurse or medical assistant to assist with patient preparation, monitoring, and post-procedural care. Administrative and counseling personnel are crucial for scheduling, obtaining informed consent, and providing patient education. A coordinated team approach helps ensure the procedure is safe, efficient, and centered on the patient's needs.

Preparation

Proper preparation is essential for ensuring the safety and success of both medication and procedural abortion. This includes a thorough patient evaluation, counseling, and appropriate clinical assessments to determine the most suitable method and anticipate potential complications.

Medical Abortion

Once a pregnancy test is positive and the patient opts for abortion, the clinician should follow specific steps to determine eligibility for medication abortion. The LMP should be confirmed to estimate gestational age. The first day of the LMP alone can accurately estimate gestational age through the mid-first trimester. If the LMP is unknown or unreliable, an ultrasound should be obtained to date the pregnancy. However, an ultrasound is not required in all cases before medication abortion.[8]

A detailed medical history should be obtained from the patient, including information about allergies, medical conditions, medications, and substance use. A physical exam is warranted if indicated by the patient’s history or symptoms. Patients opting for medication abortion with a definite LMP do not require a pelvic examination. However, pelvic and bimanual exams may be performed before the procedure. Routine pre-abortion laboratory testing is not necessary for patients with no medical conditions.

Recommended labs include glucose testing for patients with insulin-dependent diabetes mellitus, international normalized ratio (INR) for individuals on anticoagulants (such as warfarin) beyond 12 weeks of gestational age, rhesus (Rh) D testing for consenting patients beyond 56 days from LMP with unknown Rh status, hemoglobin and hematocrit testing for those with a history or symptoms of anemia, and gonorrhea and chlamydia testing for those at increased risk or aged 25 or younger. If clinical dating is uncertain, an ultrasound scan is performed to confirm the pregnancy’s location and viability. Combined mifepristone or misoprostol regimens are more effective than misoprostol alone or methotrexate or misoprostol.[9]

According to the 2020 NAF guidelines, after counseling the patient about the methods, as well as the risks and benefits of the procedure, pregnancy dating and eligibility for medication abortion should be determined using one of the following criteria: 

• LMP ≤77 days from the anticipated date of mifepristone use
• First positive pregnancy test occurring less than 6 weeks ago
• No ectopic pregnancy risk factors, including a history of ectopic pregnancy or pelvic inflammatory disease, an IUD in place at the time of conception, bleeding since LMP, or unilateral pelvic pain
• Regular menses with no hormonal contraception use 2 months before LMP
• LMP and physical examination, including a bimanual examination if needed
• Pelvic ultrasound to confirm pregnancy dating

Clinicians should ensure that the patient has no contraindications to medication abortion. Informed consent must be obtained, including the manufacturer’s patient agreement and medication guide, after thoroughly discussing the risks associated with medication abortion and the potential adverse effects of the medications.

Adverse effects of mifepristone primarily include vaginal bleeding. Misoprostol may cause nausea, vomiting, diarrhea, low-grade fever, and muscle aches, which typically resolve within 6 hours of use. If mifepristone or misoprostol is vomited within 15 to 30 minutes of ingestion, repeating the dose may be considered. Antiemetic medications can help manage nausea and vomiting. Vaginal bleeding usually begins 4 to 6 hours after misoprostol use and may be heavy, with clots. Patients experiencing bleeding heavier than 2 pads per hour or for over 2 hours should be evaluated by a clinician. Bleeding can last from 1 to 45 days.

Patients must be informed of risks, including heavy bleeding requiring additional doses of misoprostol, nonsteroidal anti-inflammatory drugs (NSAIDs), potential aspiration in some cases, a small risk of endometritis, the possibility of medication abortion failure requiring additional doses of misoprostol or aspiration, and the rare teratogenicity of misoprostol. Additionally, the patient’s phone number or email should be confirmed, and transportation for follow-up care should be arranged.

Procedural Abortion

After obtaining a detailed medical history, the clinician must confirm the pregnancy and assess gestational age. Ultrasound is commonly used to verify the location of the pregnancy. Baseline vital signs, including pulse and blood pressure, should be recorded for all candidates, and a physical examination should be performed when indicated by the patient’s symptoms and history. All instruments required for the procedure should be confirmed and arranged in advance.

Technique or Treatment

Understanding the techniques involved in both medication and procedural abortion is essential for delivering safe, effective, and individualized care. Each method follows specific clinical protocols, requires careful consideration, and involves follow-up steps that healthcare professionals must be familiar with to ensure optimal patient outcomes.

Medication Abortion

Mifepristone-misoprostol protocol

Although misoprostol alone can be effective, the combination regimen of mifepristone and misoprostol is significantly more effective than either misoprostol alone or the methotrexate-misoprostol combination.[9]

• Mifepristone: A single 200 mg tablet of mifepristone is taken orally on day 1, either in the clinic or at home.

• Misoprostol: This drug can be administered using one of the following routes:
  • Buccal: A dosage of 4 misoprostol tablets, 200 mcg each, is placed between the gum and cheek for 30 minutes and swallowed thereafter, 24 to 48 hours after oral mifepristone administration. This is approved by the US Food and Drug Administration (FDA) and recommended by the World Health Organization (WHO).
  • Vaginal: A dosage of 4 misoprostol tablets, 200 mcg each, may be inserted into the vagina 6 to 48 hours after oral mifepristone administration. This is recommended by the WHO.
  • Sublingual: A dosage of 2 to 4 misoprostol tablets, 200 mcg each, is placed under the tongue for 30 minutes. This is recommended by the WHO.

According to the 2020 NAF guidelines, if the patient is more than 63 days from the LMP, a second dose of 800 mcg misoprostol may be administered 4 hours after the first dose. For patients beyond 70 days from LMP, a second dose of 800 mcg misoprostol is recommended 4 hours after mifepristone.

The Society for Family Planning recommends ibuprofen 800 mg orally for pain management. The most intense pain typically occurs 2.5 to 4 hours after misoprostol administration and lasts about 1 hour.[10] Prophylactic antibiotics are not routinely recommended for medical abortion.[11] Contraception can be discussed if the patient is willing to engage in the conversation at this time.

The patient should be instructed to contact their healthcare provider if any of the following occur:

• Heavy bleeding, defined as soaking 2 or more maxi or overnight pads per hour for 2 or more consecutive hours
• Severe pain that does not respond to the prescribed medication 
• A fever higher than 100.4 °F (38 °C) lasting more than 24 hours after taking misoprostol
• No bleeding within 24 hours of taking misoprostol
• Nausea, vomiting, diarrhea, or abdominal pain more than 24 hours after misoprostol administration

Confirmation of pregnancy expulsion can be accurately determined based on symptomatology in 96% to 99% of cases. Follow-up may be conducted by telephone 1 week after treatment, with an at-home urine pregnancy test performed at 4 weeks. In-person follow-up can include a transvaginal ultrasound to assess for the presence of the gestational sac; however, this is not routinely required.[4]

Procedural Abortion

Manual vacuum aspiration for abortion is typically performed up to 16 weeks of gestational age. Pain management options can vary, including local anesthesia, mild sedation, or deep sedation, depending on the capabilities of the facility and the shared decision-making process between the patient and clinician. The technique is described below.

Gloves should be donned, and a bimanual examination performed to confirm the uterine position and size. All necessary equipment must be confirmed before the procedure. The table and light are adjusted, and a speculum is inserted. The cervix is evaluated, and samples are collected for infection screening and testing. An antiseptic solution is applied to the cervix. A paracervical block is administered using either ester or amide local anesthetics.[12] A tenaculum is then placed on the cervix. The cervix should be dilated to the size of the cannula being used, based on gestational age in weeks ±1 to 2 millimeters. Tapered dilators, such as Pratt or Denniston dilators, are used for cervical dilation.[13] Misoprostol can also be used for cervical preparation before the procedure.[14][15][16] 

Osmotic dilators are utilized when cervical dilation is expected to be challenging. The cannula is inserted through the cervix with gentle yet firm traction using the tenaculum. The aspirator is then connected to the cannula. The procedure is completed by aspirating the uterus with either a manual or electric vacuum, rather than sharp curettage. The procedure is considered complete when the uterus is empty. Ultrasound can be used to confirm procedural completion. The tenaculum and speculum are removed, and the adequacy of the products of conception is assessed. If a molar pregnancy is suspected, the tissue should be sent to the pathologist for examination. The patient should be informed of the completed procedure and recovery process. The procedure typically takes 5 to 10 minutes, and antibiotics are administered at the end of the procedure to avoid infection.

Dilatation and evacuation are performed beyond 16 weeks by experienced clinicians in surgical settings. Intravenous access should be established before the procedure. If induced fetal demise is used, appropriate evidence-based protocols must be followed. Osmotic dilators, such as Dilapan and laminaria, along with misoprostol, mifepristone, and other cervical agents, are used to achieve adequate dilation before the procedure. All instruments entering the uterine cavity must be sterile. Ultrasound should be utilized during the procedure to locate fetal parts, visualize instruments, and confirm procedural completion, thereby reducing the risk of uterine perforation and shortening the procedure duration.[6] Uterotonics may be used to help control uterine bleeding during and after the procedure. 

Complications

Abortion is a safe procedure with a low risk of complications and is at least 14 times safer than childbirth.[17] The primary risk factor for complications is increasing gestational age. The risk of major complications (those requiring hospital admission, surgery, or blood transfusion) increases from 2 per 1000 procedures at 8 weeks of gestation to 15 per 1000 procedures at 20 weeks. In the United States, the mortality rate from septic abortion has significantly decreased since the legalization of abortion. However, the risk of death from septic abortion increases as gestation progresses.

Complications of Medication Abortion and Management

• Heavy bleeding and/or severe cramping, which are expected with medication abortion. 
• Management involves ibuprofen 800 mg. 
• Uterine aspiration procedure.[4]
• Blood transfusion may be required if the patient is hemodynamically unstable. However, this is rare, as the transfusion rate for medication abortion is less than 0.1%, compared to 0.001% for uterine aspiration procedures in early pregnancy is 0.001%.[4]
• Failure of medication abortion may be managed with either uterine aspiration or a repeat dose of misoprostol.[18]
• Infection or endometritis may present with fever lasting more than 24 hours after misoprostol use, abdominal or pelvic pain, vaginal discharge, and uterine or adnexal tenderness.
• Uterine aspiration is indicated if retained pregnancy tissue is present in the uterus, along with antibiotics following the Centers for Disease Control and Prevention (CDC) guidelines.
• Immediate hospital admission is required if the patient is hemodynamically unstable, with aggressive antibiotic treatment necessary.

Medication abortion is equally effective and safe whether completed at home or in a clinical setting.[19]

Complications of Procedural Abortion and Management

• Postabortion hemorrhage
• This is clinically defined as blood loss greater than 500 mL or bleeding that requires clinical intervention, such as hospitalization or transfusion. Common etiologies include uterine perforation, cervical laceration, retained products of conception, abnormal placentation, uterine atony, and coagulopathy.[20]
• Prophylactic oxytocin is recommended in settings where increased bleeding is a concern.
• Immediate administration of uterotonics should be considered if uterine massage alone is insufficient, with methylergonovine maleate and misoprostol serving as appropriate first-line treatments.
• In cases where retained tissue or hematometra is not suspected and the etiology appears to be uterine atony or lower uterine segment bleeding, a Foley or Bakri balloon may be used to tamponade the endometrium.

• Vasovagal episode from cervical dilation and stimulation
• Applying cool compresses
• Elevating the legs above chest level
• Encouraging isometric extremity contractions
• Administering atropine: 0.4 mg intramuscularly or 0.2 mg intravenously, with a maximum total dose of 2 mg.[21]

• Uterine perforation
• If uterine perforation is suspected, suction should be stopped immediately, and the aspirate should be examined for the presence of omentum, bowel, or products of conception.
• The procedure may be continued and completed under ultrasound guidance if the patient is stable. Uterotonics and antibiotics should be considered, and the patient should be observed for 1.5 to 2 hours following the procedure. 
• Patients should be transferred to a higher level of care if they are unstable.[5]

• Incomplete abortion
• Misoprostol or reaspiration should be offered if the patient is experiencing bleeding, pain, or signs of infection.

• Hematometra
• This is the nonthreatening accumulation of blood in the uterus following the procedure. The patient usually complains of severe cramping.[22]
• Management includes uterine aspiration or the use of uterotonics.

• Endometritis
• This is characterized by fever, pain, vaginal discharge, and leukocytosis. 
• Management includes antibiotics according to the CDC pelvic inflammatory disease regimen, ultrasound, and, if necessary, aspiration procedure.
• Testing for gonorrhea and chlamydia is also recommended.

• Ectopic pregnancy or cesarean scar pregnancy
• This should be suspected if the products of conception are inadequate at the time.
• The patient should be transferred to a hospital for treatment, which may involve methotrexate or procedural management.

Clinical Significance

Abortion is safer in countries with less restrictive abortion laws and higher gross national income. The stigma associated with abortion is a recognized barrier to accessing safe procedures and contributes to global maternal mortality rates. Overall, improving access to reproductive healthcare, including modern contraception, can enhance the safety of care and help reduce maternal and infant mortality rates.

Any woman with a positive pregnancy test should receive nonjudgmental counseling about her options during the consultation. Abortion is a generally safe and effective procedure. Clinicians should understand its prevalence, be informed about legal restrictions and access barriers, and remain committed to providing safe, patient-centered care for those seeking abortion services. 

Enhancing Healthcare Team Outcomes

Delivering high-quality, patient-centered abortion care requires a combination of clinical expertise, ethical awareness, effective communication, and strong interprofessional collaboration. Physicians, advanced practitioners, nurses, pharmacists, social workers, and other healthcare professionals must have the clinical competence to assess, counsel, and manage abortion care safely and with compassion.

Physicians and advanced practitioners must be proficient in clinical assessment, patient counseling, and the administration of both medication and procedural abortion. They are also responsible for managing complications and ensuring appropriate follow-up care. Nurses prepare patients, assist with procedures, monitor recovery, and provide emotional support. Pharmacists play a key role in dispensing medications such as mifepristone and misoprostol, educating patients on their proper use, and ensuring medication safety. A clear, evidence-based approach should guide the abortion process—from pre-procedural evaluation to post-procedural care—to promote consistency, safety, and high-quality outcomes across clinical settings.

Ethical principles form the foundation of abortion care. Clinicians are responsible for delivering nonjudgmental, confidential, and respectful care that upholds patient autonomy and informed consent. Ethical practice also includes recognizing and addressing social and systemic barriers to access, as well as understanding the impact of stigma on patients’ emotional and physical well-being. Providers must navigate institutional policies and regional laws while ensuring that patients receive accurate, unbiased information and compassionate support throughout their care.

Effective interprofessional communication is essential for patient safety and coordinated care. Timely and accurate information-sharing among clinicians, nurses, pharmacists, and administrative staff ensures smooth transitions, reduces errors, enhances team performance, and supports patient-centered decision-making. Open communication fosters trust and respect among healthcare team members, promoting collaborative problem-solving, especially when managing complex cases or addressing logistical challenges.

Coordinated care improves the patient experience and minimizes fragmentation by streamlining appointment scheduling, ensuring timely access to medications, facilitating post-abortion follow-up, and connecting patients to contraception and community resources. Patient-centered care involves recognizing and respecting each individual’s goals, preferences, and needs. This comprehensive approach promotes better health outcomes, enhances patient satisfaction, and strengthens trust in the healthcare system.