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Termination of pregnancy

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of termination of pregnancy are prepared by our editorial team based on guidelines from the Society of Family Planning (SFP 2024,2014,2013,2012), the American Academy of Family Physicians (AAFP 2021), the American College of Obstetricians and Gynecologists (ACOG 2021,2020,2013), and the Society of Obstetricians and Gynaecologists of Canada (SOGC 2016).
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Diagnostic investigations

Determination of gestational age: as per AAFP 2021 guidelines, obtain menstrual dating or ultrasound to confirm gestational age prior to medication abortion. Obtain ultrasound in patients at risk of ectopic pregnancy or if gestational age cannot be confirmed using clinical data alone.
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  • Pre-abortion evaluation

  • Evaluation for placenta accreta

Diagnostic procedures

Pathological examination: as per SFP 2013 guidelines, avoid obtaining routine pathological assessment of tissue aspirates as they add little diagnostic value in settings where gross or microscopic examination of pregnancy tissue is routinely carried out by well-trained and experienced staff members, and where local or regional laws mandating outside pathologic examination do not supervene.
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Medical management

Medication abortion, setting: as per SFP 2024 guidelines, refer females with a diagnosis of or concern for placenta accreta spectrum or Cesarean scar ectopic pregnancy to a higher-acuity site.
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  • Medication abortion (regimens)

  • Medication abortion (contraindications)

  • Pain management

  • RhD immune globulin

  • Antibiotic prophylaxis

  • Methylergonovine maleate prophylaxis

  • Oxytocin prophylaxis

Surgical interventions

Surgical abortion, indications: as per SFP 2024 guidelines, ensure that the decision between medication and procedural abortion is patient driven.
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  • Surgical abortion (cervical preparation)

  • Surgical abortion (procedures)

  • Surgical abortion (intraoperative ultrasound)

  • Surgical abortion (paracervical vasopressin)

  • Surgical abortion (outcomes)

Specific circumstances

Patients with pregnancy of unknown location: as per SOGC 2016 guidelines, provide abortion care without delay in females with a pregnancy of unknown location and requesting medical abortion, provided that they have no clinical symptoms of ectopic pregnancy.
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Patient education

Pre-abortion counseling: as per ACOG 2020 guidelines, counsel patients that medication abortion failure rates, especially continuing pregnancy rates, increase as gestational age approaches 10 weeks.
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Follow-up and surveillance

Follow-up assessment: as per AAFP 2021 guidelines, obtain confirmation of completed early pregnancy loss or abortion following medication management through clinical history and an 80% decline from pretreatment in serum β-hCG levels, ultrasound documenting the absence of a previously seen gestational sac, or a negative urine pregnancy test result.
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  • Management of post-abortion bleeding

  • Management of ongoing pregnancy

  • Post-abortion contraception

Quality improvement

Health professional training: as per ACOG 2020 guidelines, train clinicians wishing to provide medication abortion services in performing uterine evacuation procedures or to ensure they are able to refer patients to a clinician having this training.
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