In the United States, about half of pregnancies are unintended. About 40% of unintended pregnancies end in a procedural or medical abortion; 93% of abortions occur prior to 13 weeks of gestation (1). The same medications or procedural techniques are utilized in circumstances of pregnancy loss.
In the United States, both medical and procedural abortion is regulated by state-specific restrictions (eg, mandatory waiting periods, gestational age restrictions). In countries where abortion is legal, abortion is safe and complications are rare. Worldwide, 13% of maternal deaths are secondary to unsafe induced abortion (2), and the overwhelming majority of these deaths occur in countries where abortion is illegal.
Often, gestational age is established by ultrasound, but sometimes history and physical examination are used to estimate gestational age during the first trimester. Further evaluation should be considered if a woman is in the second trimester and has risk factors for complications. Cervical preparation (using pharmacologic and/ mechanical methods to soften and dilate the cervix), starting at 12 weeks of gestation, is recommended to reduce procedural complications.
Completion of a procedural abortion can be confirmed by directly observing removal of uterine contents or via ultrasound used during the procedure. If ultrasound is not used during the procedure, resolution of the pregnancy can be confirmed by tissue evaluation. For a pregnancy of unknown location in which tissue is not clearly identified, measuring quantitative serum beta–human chorionic gonadotropin (beta-hCG) levels before and after the procedure; a decrease of > 50% after 1 week confirms resolution.Completion of a procedural abortion can be confirmed by directly observing removal of uterine contents or via ultrasound used during the procedure. If ultrasound is not used during the procedure, resolution of the pregnancy can be confirmed by tissue evaluation. For a pregnancy of unknown location in which tissue is not clearly identified, measuring quantitative serum beta–human chorionic gonadotropin (beta-hCG) levels before and after the procedure; a decrease of > 50% after 1 week confirms resolution.
Antibiotics effective against reproductive tract infections (including chlamydia) should be given to the patient prior to a procedural abortion. The optimal regimen has not been clearly delineated but doxycycline 200 mg or azithromycin 500 mg combined with metronidazole 500 mg have been utilized () should be given to the patient prior to a procedural abortion. The optimal regimen has not been clearly delineated but doxycycline 200 mg or azithromycin 500 mg combined with metronidazole 500 mg have been utilized (3). After the procedure, Rho(D) immune globulin is given to women with Rh-negative blood measuring at 12 weeks of gestation or later. Rh typing and RhIG are not required prior to 12 weeks of gestation; data has demonstrated that the amount of blood required for fetomaternal hemorrhage and thus sensitization is not transferred prior to 12 weeks of gestation (4).
Anesthetic options should be offered according to patient preference. A first trimester abortion can be performed using a local paracervical block but is still associated with pelvic cramping at the time of the procedure. Second trimester procedural abortion care can be performed using moderate to deep sedation and requires general anesthesia only in circumstances of significant medical comorbidity (5).
Contraception (all forms) can be started immediately after an induced abortion performed at < 28 weeks of gestation. For abortion care performed at> 28 weeks of gestation, hormonal initiation should be dependent upon coagulation factor resolution (> 21 days).
References
1. Ramer S, Nguyen AT, Hollier LM, Rodenhizer J, Warner L, Whiteman MK. Abortion Surveillance - United States, 2022. MMWR Surveill Summ. 2024;73(7):1-28. Published 2024 Nov 28. doi:10.15585/mmwr.ss7307a1
2. Ahman E, Shah IH. New estimates and trends regarding unsafe abortion mortality. Int J Gynaecol Obstet 115(2):121-126, 2011. doi:10.1016/j.ijgo.2011.05.027
3. Low N, Mueller M, Van Vliet HA, Kapp N. Perioperative antibiotics to prevent infection after first-trimester abortion. Cochrane Database Syst Rev. 2012;2012(3):CD005217. Published 2012 Mar 14. doi:10.1002/14651858.CD005217.pub2
4. Horvath S, Huang ZY, Koelper NC, et al. Induced Abortion and the Risk of Rh Sensitization. JAMA. 2023;330(12):1167-1174. doi:10.1001/jama.2023.16953
5. Aksel S, Lang L, Steinauer JE, et al. Safety of Deep Sedation Without Intubation for Second-Trimester Dilation and Evacuation. Obstet Gynecol. 2018;132(1):171-178. doi:10.1097/AOG.0000000000002692
Methods of Procedural and Medical Abortion
Common methods of abortion include:
Procedural abortion: Dilation of the cervical canal and use of suction or instruments to evacuate pregnancy tissue
Medical abortion: Use of medications to stimulate uterine contractions and passage of pregnancy tissue
The method available depends on the gestational age and access to care. Procedural evacuation can be used for most pregnancies, requiring additional training and cervical preparation for later second trimester care. Medical abortion can be utilized at any gestational age, with the understanding that early pregnancies (< 5 weeks of gestation) may require measurement of quantitative serum beta–human chorionic gonadotropin (beta-hCG) level before and then serial measurements after the medical abortion to ensure resolution of the pregnancy. Medical abortion can be offered up to 12 weeks of gestation on an outpatient basis; health care providers should provide patients with a clear explanation of bleeding expectations and precautions.The method available depends on the gestational age and access to care. Procedural evacuation can be used for most pregnancies, requiring additional training and cervical preparation for later second trimester care. Medical abortion can be utilized at any gestational age, with the understanding that early pregnancies (human chorionic gonadotropin (beta-hCG) level before and then serial measurements after the medical abortion to ensure resolution of the pregnancy. Medical abortion can be offered up to 12 weeks of gestation on an outpatient basis; health care providers should provide patients with a clear explanation of bleeding expectations and precautions.
Uterine surgery (hysterotomy or hysterectomy) is associated with higher morbidity and mortality rates and should be avoided.
Procedural abortion
Procedures performed at < 14 weeks of gestation are typically completed using dilation and suction curettage (D&C), approximating the cannula size to gestational age. For procedures at 14 to 16 weeks, intrauterine instrumentation and a large-diameter suction cannula may be required. Some providers may use a gentle sharp curette to ensure all products of conception have been removed.
Manual vacuum aspiration (MVA) devices are portable, do not require an electrical source, and are quieter than electrical vacuum aspiration (EVA) devices. MVAs can be utilized through 12 weeks of gestation. Since MVAs lose suction capacity once filled to >80%, some providers prefer an electric vacuum aspiration (EVA) to have continuous suction capacity after 9 weeks. EVA involves attaching a cannula to an electrical vacuum source. MVAs or EVAs can be used to perform a D&C.
Procedures performed at ≥ 14 weeks of gestation require dilation of the cervical canal and forceps to evacuate pregnancy tissue, referred to dilation and extraction (D&E). Suction is used to aspirate the amniotic fluid and remove any remaining placental tissue (sometimes sharp curettage is also required). D & E requires additional training.
Starting at 12 weeks of gestation, medication or a combination of medication and dilators are used to dilate the cervix before the procedure and decrease procedural complications (1).
MisoprostolMisoprostol (a prostaglandin E1 analog) dilates the cervix by stimulating prostaglandin release. Misoprostol is usually given vaginally or buccally 2 to 4 hours before the procedure. (a prostaglandin E1 analog) dilates the cervix by stimulating prostaglandin release. Misoprostol is usually given vaginally or buccally 2 to 4 hours before the procedure.
Osmotic dilators (either synthetic polymer [dilapan] or dried and compacted seaweed [laminaria]) dilate the cervical canal by expanding as they absorb fluid within the cervical canal. Dilators an be inserted into the cervix and left for ≥ 4 hours or overnight. Osmotic dilators are recommended for gestational ages > 16 to 18 weeks.
MifepristoneMifepristone (a progesterone and glucocorticoid antagonist) may be used as an adjuvant for cervical ripening for gestational ages > 20 weeks ((a progesterone and glucocorticoid antagonist) may be used as an adjuvant for cervical ripening for gestational ages > 20 weeks (1).
Medical abortion
In the United States in 2023, medical abortion accounted for 63% of all abortion care, an increase of 10% from 2020-2023 (2).
The medical abortion regimen includes the progesterone-receptor blocker mifepristone (RU 486) and the prostaglandin E1 analog misoprostol, as follows by gestational age:The medical abortion regimen includes the progesterone-receptor blocker mifepristone (RU 486) and the prostaglandin E1 analog misoprostol, as follows by gestational age:
< 9 weeks: Mifepristone 200 mg orally, followed by misoprostol 800 mcg vaginally or buccally within 48 hours of taking the mifepristoneMifepristone 200 mg orally, followed by misoprostol 800 mcg vaginally or buccally within 48 hours of taking the mifepristone
9 to 11 weeks: Mifepristone 200 mg orally, followed by 2 doses of misoprostol 800 mcg buccally 4 hours apart 24 to 48 hours after the mifepristone 9 to 11 weeks: Mifepristone 200 mg orally, followed by 2 doses of misoprostol 800 mcg buccally 4 hours apart 24 to 48 hours after the mifepristone
11 to 12 weeks: Mifepristone 200mg orally, followed by 3 doses of misoprostol 800 mcg buccally 4 hours apart 24 to 48 hours after the mifepristone 11 to 12 weeks: Mifepristone 200mg orally, followed by 3 doses of misoprostol 800 mcg buccally 4 hours apart 24 to 48 hours after the mifepristone
Both mifepristone and misoprostol may be self-administered by the patient and do not need to be given at a clinic or hospital.Both mifepristone and misoprostol may be self-administered by the patient and do not need to be given at a clinic or hospital.
Mifepristone 200 mg and one-dose misoprostol 800 mcg is about 95% effective in pregnancies of 8 to 9 weeks and 87 to 93% effective in pregnancies of 9 to 11 weeks (Mifepristone 200 mg and one-dose misoprostol 800 mcg is about 95% effective in pregnancies of 8 to 9 weeks and 87 to 93% effective in pregnancies of 9 to 11 weeks (3). Effectiveness after 9 weeks of gestation is improved with an additional dose of misoprostol 800 mcg; effectiveness after 11 weeks of gestation is improved with 2 additional doses.). Effectiveness after 9 weeks of gestation is improved with an additional dose of misoprostol 800 mcg; effectiveness after 11 weeks of gestation is improved with 2 additional doses.
Resolution of the pregnancy can be confirmed by one of the following:
Ultrasound follow-up
Measurement of beta-hCG on the day of administration and 1 week later
A urine pregnancy test 5 weeks after administration
At 13 weeks or greater, medication induction takes place in a clinic or hospital. Pretreatment with mifepristone 200 mg 24 to 48 hours before induction with prostaglandins, typically vaginal or buccal misoprostol, reduces induction to delivery times. Misoprostol dosing varies by gestational age. However, studies indicate that with pretreatment using mifepristone, misoprostol dosing of 200 mcg every 3 to 4 hours is sufficient (At 13 weeks or greater, medication induction takes place in a clinic or hospital. Pretreatment with mifepristone 200 mg 24 to 48 hours before induction with prostaglandins, typically vaginal or buccal misoprostol, reduces induction to delivery times. Misoprostol dosing varies by gestational age. However, studies indicate that with pretreatment using mifepristone, misoprostol dosing of 200 mcg every 3 to 4 hours is sufficient (4).
Adverse effects of prostaglandins include nausea, vomiting, diarrhea, hyperthermia, facial flushing, vasovagal symptoms, bronchospasm, and decreased seizure threshold.
Methods references
1. Diedrich JT, Drey EA, Newmann SJ. Society of Family Planning clinical recommendations: Cervical preparation for dilation and evacuation at 20-24 weeks' gestation. Contraception. 2020;101(5):286-292. doi:10.1016/j.contraception.2020.01.002
2. DoCampo I, Jones RK, Maddow-Zimet I. The Role of Medication Abortion Provision in US States Without Total Abortion Bans, 2023. Perspect Sex Reprod Health. 2025;57(1):3-7. doi:10.1111/psrh.12294
3. Kapp N, Eckersberger E, Lavelanet A, Rodriguez MI. Medical abortion in the late first trimester: a systematic review. Contraception. 2019;99(2):77-86. doi:10.1016/j.contraception.2018.11.002
4. Zwerling B, Edelman A, Jackson A, Burke A, Prabhu M. Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine. Am J Obstet Gynecol. 2025;233(4):229-249. doi:10.1016/j.ajog.2023.09.097
Complications of Procedural and Medical Abortion
Complications are rare with legal abortion (serious complications in < 1%; mortality in < 1 in 100,000). Complication rates increase as gestational age increases. Complication rates are 14 times lower than those after delivery of a full-term infant, and rates are the lowest in settings with safe and legal access to care.
Serious early procedural complications include
Perforation of the uterus (0.1%) or, less often, of the intestine or another organ by an instrument
Major hemorrhage (0.06%), which may result from trauma or an atonic uterus
Lacerations of the cervix (0.1 to 1%), which are typically superficial tenaculum tears but can be more serious and require repair
General or local anesthesia rarely causes serious complications.
The most common delayed medical or procedural complications include
Bleeding and significant infection (0.1 to 2%)
Delayed complications may occur due to retained placental fragments. If bleeding occurs or infection is suspected, retained placental fragments may be visible on ultrasound. Mild inflammation is expected, but if infection is moderate or severe leading to peritonitis or sepsis, emergent management may be required. Synechiae in the endometrial cavity (Asherman syndrome) or tubal fibrosis due to infection are rare. Forceful dilation of the cervix in more advanced pregnancies may contribute to incompetent cervix. However, with evidence-based techniques, including gentle suction and adequate cervical preparation, induced abortion is not expected to increase risks during subsequent pregnancies.
All patients experiencing pregnancy loss should be offered mental health resources. Patients with the following may require additional resources:
Psychologic symptoms before pregnancy
Significant emotional attachment to the pregnancy
Limited social support or feel stigmatized by their support system
Key Points
About 40% of unintended pregnancies end in medical or procedural abortion.
Common methods for abortion are instrumental evacuation of the uterus after cervical dilation or medical abortion (to induce uterine contractions).
Before abortion care, confirm that the woman is pregnant, and if so, determine gestational age based on history and physical examination and/or ultrasound.
For procedural abortion, providers usually use suction D & C at < 16 weeks of gestation and D & E at 16 or more weeks, preceded by cervical dilation at 12 weeks of gestation using misoprostol or osmotic dilators.For procedural abortion, providers usually use suction D & C at misoprostol or osmotic dilators.
For medical abortion, give mifepristone followed by misoprostol buccally or vaginally according to gestational age.For medical abortion, give mifepristone followed by misoprostol buccally or vaginally according to gestational age.
Serious complications (eg, uterine perforation, major bleeding, serious infection) occur in < 1% of abortions.
