Abortion
Exam Tips
- In UK OSCEs, always integrate legal and ethical structure: capacity/consent, confidentiality, safeguarding, and non-directive counselling.
- Quote core regimen confidently: mifepristone 200 mg oral, then misoprostol 800 micrograms after 24-48 hours; explain expected cramping/bleeding and red flags.
- State method selection principle: choice depends on gestation plus patient preference, with both medical and surgical options discussed.
- High-yield viva fact: safe abortion is not associated with increased infertility, breast cancer, or long-term mental health disorders.
- If asked to interpret complications, mention gestation effect (later gestation = higher risk) and procedure-specific risks (perforation/cervical injury in surgical methods; incomplete abortion in medical methods).
Definition
Abortion (termination of pregnancy) is the intentional ending of an intrauterine pregnancy using medical drugs or surgical uterine evacuation. In UK practice, it is a common and generally very safe procedure when done by trained teams using gestation-appropriate methods in approved settings, with legal authorisation and informed consent.
Pathophysiology
Medical abortion combines progesterone-receptor blockade (mifepristone) with prostaglandin-induced uterine contraction and cervical ripening (misoprostol), causing decidual breakdown, detachment of products of conception, and expulsion. Surgical abortion achieves the same endpoint by mechanical cervical dilatation and uterine evacuation (vacuum aspiration or D&E), with risk profile increasing as gestation advances. Complication risk rises with later gestation, pre-existing infection, and uterine scar in second-trimester medical abortion (uterine rupture risk).
Risk Factors
- Unintended pregnancy (including contraceptive non-use or failure)
- Delayed presentation to services (higher gestation at procedure)
- Previous caesarean section or uterine scar (especially relevant in later medical abortion)
- Pre-existing untreated genital tract infection/STI
- Coagulation disorders or anticoagulant use (bleeding risk)
- Barriers to timely access (social deprivation, safeguarding concerns, service access delays)
Clinical Features
Symptoms
- Before procedure: may be asymptomatic or have pregnancy symptoms (amenorrhoea, nausea, breast tenderness)
- During medical abortion: crampy lower abdominal pain and vaginal bleeding, usually heavier than a period
- Passage of tissue/clots; bleeding may continue for up to 2-3 weeks
- Common drug adverse effects: nausea, vomiting, diarrhoea, chills, transient fever
- Red flags post-procedure: very heavy bleeding, offensive discharge, persistent severe pain, ongoing pregnancy symptoms
Signs
- Haemodynamic instability in severe haemorrhage (tachycardia, hypotension)
- Abdominal/pelvic tenderness; cervical motion or adnexal tenderness if infection or ectopic pathology
- Pyrexia or uterine tenderness in post-abortal infection
- Retained products may present with ongoing bleeding and enlarged/tender uterus
Investigations
Management
Lifestyle Modifications
- Use person-centred, non-judgemental counselling; confirm autonomous decision-making and capacity
- Provide clear safety-net advice: seek urgent care for heavy bleeding, severe pain, fever, fainting, or persistent pregnancy symptoms
- Discuss contraception at the same visit; most methods can start immediately (IUD after expulsion in medical abortion, or at surgical procedure)
- Maintain confidentiality (including in competent under-16s) and assess safeguarding where relevant
Pharmacological Treatment
Abortifacient regimen (medical abortion)
- Mifepristone 200 mg orally as a single dose
- Misoprostol 800 micrograms vaginally, buccally, or sublingually 24-48 hours later
- If needed (more common at later gestations): misoprostol 400 micrograms every 3 hours until expulsion, according to service protocol
Contraindications/cautions include suspected ectopic pregnancy, chronic adrenal failure, inherited porphyria, and severe uncontrolled asthma on long-term systemic corticosteroids (mifepristone anti-glucocorticoid effect). Counsel about expected pain/bleeding and possible need for further intervention if incomplete.
Analgesia and supportive medicines
- Ibuprofen 400 mg orally every 6-8 hours as required (max 2.4 g/day prescribed)
- Paracetamol 1 g orally every 4-6 hours as required (max 4 g/day)
- Codeine phosphate 30-60 mg every 4-6 hours as required (max 240 mg/day) if additional analgesia needed
- Cyclizine 50 mg up to three times daily as required for nausea/vomiting
Avoid NSAIDs if contraindicated (for example active peptic ulcer disease, severe renal impairment, NSAID hypersensitivity). Opioids can cause sedation/constipation; advise regarding driving and alcohol.
Infection and rhesus prophylaxis
- Prophylactic antibiotics are routinely used for surgical abortion (local regimen)
- Anti-D immunoglobulin for eligible RhD-negative non-sensitised patients (for example 250 IU before 20 weeks; 500 IU from 20 weeks onwards, per UK practice)
Check local NHS policy for exact thresholds and product availability. Do not delay urgent care while awaiting non-essential tests.
Surgical / Interventional
- Manual vacuum aspiration (MVA)
- Electric vacuum aspiration (EVA)
- Dilatation and evacuation (D&E), typically for later gestations
- Surgical completion for failed/incomplete medical abortion or ongoing pregnancy
Complications
- Failed abortion/continuing pregnancy
- Incomplete abortion or retained products requiring further intervention
- Infection (post-abortal endometritis/pelvic infection)
- Haemorrhage requiring transfusion (rare, but risk increases with gestation)
- Cervical trauma (surgical methods)
- Uterine perforation (surgical methods)
- Uterine rupture in second-trimester medical abortion, particularly with uterine scar
- Psychological distress in some individuals (while population-level evidence does not show increased long-term mental health disorder risk caused by abortion itself)
Prognosis
Prognosis is excellent when abortion is provided early and safely: major morbidity and mortality are rare, and future fertility is not reduced by uncomplicated abortion. Earlier gestation is associated with fewer complications, while delayed access increases (but does not dramatically raise) absolute risk.
Sources & References
✅NICE Guidelines(1)
- Abortion[overview]