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Patient education: Abortion (pregnancy termination) (Beyond the Basics)

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Patient education: Abortion (pregnancy termination) (Beyond the Basics)
Author:
Katherine Simmonds, PhD(c), MPH, WHNP-BC
Section Editor:
Jody Steinauer, MD, MAS
Deputy Editor:
Alana Chakrabarti, MD
Literature review current through: Jul 2021. | This topic last updated: Mar 05, 2021.

ABORTION OVERVIEW — Abortion, also known as pregnancy termination, is a medical procedure that is done to end a pregnancy.

Deciding to have an abortion is a personal and medical decision. If you are considering abortion, it is important to understand the risks and benefits of the types of abortion, as well as the alternative of continuing the pregnancy. This article will help to explain these issues and will briefly discuss abortion procedures, including what to expect during the procedure and follow-up. If you have questions or concerns about abortion after reading this article, find a health care provider or clinic that provides abortion services. (See 'Where to get more information' below.)

GETTING AN ABORTION DURING THE COVID-19 PANDEMIC — Coronavirus disease 2019 (COVID-19) is caused by a virus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The virus first appeared in late 2019 and has since spread throughout the world. People in many areas are being told to stay home as much as possible. While this is very important in order to slow the spread of the virus, it also might make it harder to get certain types of medical care.

You can still get a legal abortion during the COVID-19 pandemic, but the health care provider or clinic might do certain things differently during this time. For example, they might make an appointment with you by phone instead of having you come in. If you need medication, they might be able to get it to you by mail or in some other way.

IS ABORTION RIGHT FOR ME? — If you are pregnant and considering abortion, only you can know if the decision is right for you. You may or may not want to talk to a friend or family member, your partner, or someone else you trust. You can talk to a supportive health care provider; clinics that provide abortion services usually have counselors that you can talk with, too. It is often helpful to share your thoughts and feelings about this decision with people who will support you no matter what you decide. Asking others for their input may be helpful, but if you feel that someone is not letting you make your own decision or is trying to force you to make a particular decision, we recommend seeking additional help from a clinic or counselor.

There are many reasons for choosing an abortion. Here are some common reasons:

You do not want to have children (ever) or do not want more children.

You do not want to be pregnant right now because it is not a good time to be pregnant or parent a child (for example, because it would interfere with school, work, family, or other responsibilities).

You are not able to afford to raise a child.

Your current situation makes it hard to be pregnant or parent a child.

You have problems in the relationship with your partner, or you do not have a partner and do not want to parent a child by yourself.

The fetus has a problem or birth defect.

You have health problems that make pregnancy difficult or risky.

The pregnancy is the result of a sexual assault.

If you are considering abortion, you can ask a health care provider for more information about the procedure and your options. This could be your primary care provider, pediatrician, gynecologist, or another type of health care provider (ie, nurse, social worker, therapist) whom you trust. They should be able to give you information or tell you where to find more information. You can also call or go to a clinic where abortion care is provided to get information. As with any type of health care, it is important to make sure the provider is qualified to give accurate and current information about abortion. (See 'Where to get more information' below.)

Your options for abortion may depend on how far along in pregnancy you are as well as the abortion services and laws in your area. Sometimes, a pregnancy is too far along to be able to get an abortion. This varies depending on where you live: In the United States, states have different laws about abortion. Some allow it until "viability" (the point at which a fetus can live outside the uterus) while others have limited it to earlier stages of pregnancy. If you are not sure whether you can legally have an abortion because of how far along you are in your pregnancy, you can ask a health care provider or a clinic that offers abortion services to help you figure this out.

To get an idea of how far along you are in your pregnancy based on the date of your last period, you can use an online calculator (calculator 1). If your periods are not regular (that is, you do not have a period approximately every 30 days), these calculators may not be accurate. To be sure about how far along you are, it is best to see a health care provider.

If you are a teenager, you may have to get permission from a parent or guardian to get an abortion. In the United States, more than half of states require anyone younger than 16 to 18 years old to get permission from a parent or guardian. However, if you are not able to get your parent's permission, most states have set up systems so you can get permission from a judge without involving your parents (this is called "judicial bypass"). Clinics and health care providers who offer abortion services can help you with this process.

More information about the laws in each state is available on the websites of some organizations. (See 'Where to get more information' below.)

TYPES OF ABORTION — There are two basic ways an abortion can be performed:

Medication abortion – This is when you take medication to end a pregnancy. It is also sometimes called a "medical abortion."

Procedural abortion – This is when a health care provider does a procedure to remove the pregnancy from your uterus. Other terms for this type of abortion include "surgical abortion," "aspiration abortion," "dilation and curettage" (D&C), and "dilation and evacuation" (D&E).

Which type of abortion is right for me? — The type of abortion you can have depends on a few factors, including how far you are in your pregnancy, which types are available in your area, and your personal preferences. The options may vary at different points in pregnancy; this is discussed below. A health care provider can also discuss the options with you to help you make an informed decision.

Some people decide to have a medication abortion because they want to avoid having a procedure that involves medical instruments and anesthesia, or they prefer the privacy of being at home when they actually pass the pregnancy tissue. With medication abortion, the medication does not work in a small number of cases (approximately 2 to 5 out of 100). In those cases, the person may be offered the option of taking more medication, or they might have a procedural abortion to complete the abortion. (See 'How effective is early medication abortion?' below.)

Some people choose to have a procedural abortion because they prefer to have the entire abortion take place at a clinic or hospital, they do not want to experience the pregnancy passing out of their body (which causes cramping and bleeding) at home, or they prefer the abortion to be completed during a specific (and usually shorter) time period.

Initial evaluation and discussion — No matter which type of abortion you decide to have, you will talk with a health care provider beforehand. During this appointment, the provider will:

Confirm that you are pregnant and determine how many weeks pregnant you are. This may include reviewing your menstrual history (last menstrual period), doing a pregnancy test, and/or performing a pelvic examination. Sometimes, the provider might recommend that you have an ultrasound to determine how many weeks pregnant you are. Some states also have laws that require a person seeking an abortion to have an ultrasound; however, this is not for medical reasons. Also, sometimes an ultrasound is done to make sure the pregnancy is in the uterus or that you have not miscarried. When a pregnancy implants outside of the uterus, it is called an "ectopic" pregnancy; this occurs in approximately 1 percent of pregnancies and may require emergency treatment. (See "Patient education: Ectopic (tubal) pregnancy (Beyond the Basics)".)

Order a blood test to determine your blood type. If you are a blood type that is negative (for example, "A negative"), you will need an injection of a medication called Rh immune globulin (RhoGAM) after the abortion. This helps prevent complications in future pregnancies.

Offer testing for sexually transmitted infections. Common tests include gonorrhea, chlamydia, and HIV. Testing for syphilis and hepatitis B and C may also be recommended.

Talk about the types of abortion that would be options for you, the risks and benefits, and alternatives (such as parenting or adoption) if you have not already considered these.

Review contraceptive (birth control) options. The health care provider may provide you with or make you a plan so you can get the method you want to use after your abortion.

In some states, a person must wait for a certain amount of time (usually 24 hours) between the counseling described above and the abortion. In other states, the abortion can be done on the same day as the counseling. Laws for each state are available on the websites of some organizations. (See 'Where to get more information' below.)

EARLY ABORTION (FIRST TRIMESTER) — If you are less than 14 weeks pregnant, there may be several options available to you. (How far along you are in your pregnancy can be determined from your last period if you have regular periods or, if necessary, by having an ultrasound.)

Early medication abortion — Early medication abortion usually involves taking two medications. In the United States, this method may be an option if you are less than 11 weeks pregnant (this means up to 11 weeks, or 77 days, since the first day of your last period); however, this can vary because providers follow different guidelines.

Early medication abortion is available in some medical offices and hospitals and in most clinics that provide procedural abortion. The following steps are usually part of this type of abortion:

A health care provider will confirm how many days pregnant you are.

You will most likely be given two medications, usually mifepristone (brand name: Mifeprex) and misoprostol (brand name: Cytotec). In some places, only misoprostol may be used.

You usually take the first medication (mifepristone) at the clinic or medical office; however, in some cases, it may be possible to take it at home.

You will take the second medication (misoprostol) one to two days later at home or in another place you choose (that is, not in the clinic or your health care provider's office). If you are between 70 and 77 days pregnant, you will be given another dose of misoprostol to take four hours after the first dose. Some providers have you take a second dose of misoprostol even if you are less than 70 days pregnant.

What to expect — Abdominal pain, cramps, and vaginal bleeding are expected during the abortion process. Some people also have fever, nausea, vomiting, or diarrhea on the day they take the misoprostol. This may be uncomfortable or unpleasant, but most strong effects last for only a few hours.

Vaginal bleeding — It is normal to experience vaginal bleeding during an early medication abortion; this means the medication is working. The bleeding may be heavy, especially in the first few hours after you take the misoprostol. You will likely see clots and may see some pregnancy tissue, especially if you are farther along in your pregnancy (more than 8 or 10 weeks pregnant). Bleeding usually decreases after the pregnancy tissue passes out of your uterus. It may continue for several weeks but should be lighter than a menstrual period after the first few days.

If you soak through two full menstrual pads in an hour for two hours in a row and are still bleeding, you should call your health care provider or clinic. If you do not have any bleeding at all after you take the medications, you should also call your health care provider or clinic because this could mean the medications did not work.

Pain and cramps — It is normal to have abdominal pain and cramps after taking the second medication (misoprostol). They may be mild or strong. The pain usually improves after the pregnancy tissue has passed out of your uterus. For most people, this happens within 2 to 24 hours after taking the misoprostol.

You can take ibuprofen (sample brand names: Advil, Motrin) for pain if needed (unless there is a medical reason you cannot take this medication). You can also use a heating pad on your abdomen, but make sure it is not hot enough to burn you. Some clinicians give a prescription for a stronger pain medication to use if needed. If you have severe pain that is not relieved by these treatments, call your health care provider or clinic immediately.

Other side effects — Some people experience a mild fever, nausea, vomiting, or diarrhea after taking the second medication (misoprostol). These side effects usually go away quickly on their own without treatment. If you get a fever higher than 100.4°F (38°C) or if you have chills, vomiting, or diarrhea that does not go away within several hours, call your health care provider or clinic.

How effective is early medication abortion? — Early medication abortion is very effective in ending pregnancies up to 10 weeks (70 days) and works in 95 to 98 percent of people who take it. Medication abortion between 10 and 11 weeks (70 to 77 days) of pregnancy can be less effective, and, therefore, taking a second dose of the misoprostol is often recommended because it can greatly increase the effectiveness (up to 98 percent).

If early medication abortion does not work in ending your pregnancy, you will need to have a procedural abortion. Continuing a pregnancy after a medication abortion is not recommended because there is an increased risk of birth defects from the misoprostol. It is possible that your medication abortion was not successful if:

You do not have vaginal bleeding after taking the medications.

You still have pregnancy symptoms (breast tenderness, nausea) more than a week after your abortion.

You continue to bleed for more than two weeks after your abortion.

You do not have a menstrual period within six weeks after your abortion.

If you have any of the above signs, tell your health care provider. They may want to see you or speak with you on the phone. Your provider may suggest taking a home pregnancy test; the results, along with your symptoms, can help them figure out if the medication abortion was successful. However, it is important to be aware that home pregnancy tests will continue to be positive for at least several weeks after an abortion. Also, if your home pregnancy test is negative but you feel unwell or that something may be wrong, let your provider know.

Procedural abortion — In a procedural abortion, the pregnancy is removed in a procedure that takes place in a clinic or hospital. If you are less than 11 weeks pregnant, you may have the option for either medication or procedural abortion. While medication abortion can be used to end a pregnancy that is beyond 11 weeks, in many settings, procedural abortion may be the only option offered to people beyond that stage of pregnancy.

Procedural abortion is also called "surgical abortion" or "aspiration abortion," but it does not involve any incisions in your skin. Instruments are passed through the vagina and cervix into the uterus to remove the pregnancy (figure 1). In many cases, the cervix (the opening to the uterus) has to be stretched first to widen the opening. To do this, the health care provider may use tools (called dilators) that pass through the cervical canal and gradually stretch it. Once the cervix is open, a thin tube is inserted through the vagina and cervix, and suction is used to remove the pregnancy tissue.

In most cases, a procedural abortion is done while you are awake. Local anesthesia is applied to your cervix to numb the area. In many settings, you may also be able to choose to have intravenous (IV) sedation; however, this is not usually needed in early pregnancy. If you do choose sedation, keep in mind that you will need to have someone else drive you home after the procedure. Some providers also offer other medicines (including some you can take by mouth) to help with pain and anxiety.

A procedural abortion usually takes between 5 and 20 minutes and is generally shorter the earlier you are in pregnancy. After the procedure, you will be monitored by health care staff until you are ready to leave; the time for this varies but is usually about one to one and a half hours.

What to expect after the procedure — Vaginal bleeding, abdominal pain, and cramping are expected side effects after a procedural abortion.

Abdominal pain and cramping — Most people have some abdominal pain and cramping after a procedural abortion. You can take ibuprofen (sample brand names: Advil, Motrin) for pain unless you have a medical reason to avoid this medication. Some clinicians also give a prescription for a stronger pain medication you can take if needed.

Cramping usually lasts several hours after an abortion. If you have severe pain that does not get better with treatment, or if your pain continues for more than a few days after the procedure, call the clinic where you had the abortion or your health care provider.

Vaginal bleeding — It is normal to have some vaginal bleeding after a procedural abortion; it is usually less than with a menstrual period and lasts only a few days, but can last up to several weeks. The bleeding should get lighter after the first few days. You may also pass some tissue or blood clots.

If you are bleeding so heavily that you soak through two menstrual pads in an hour for two or more hours in a row and you are still bleeding, you should call the clinic where you had the abortion or your health care provider.

LATER ABORTION (SECOND TRIMESTER) — If you are 14 weeks or more pregnant, you may be able to choose which type of abortion you will have; this may be a procedure (referred to as "surgical abortion" or "dilation and evacuation" [D&E]) or an induction abortion (also referred to as "medical abortion" or "medication abortion"). If both of these options are available to you, the decision will depend on your personal preferences about what you will experience (see 'Which type of abortion is right for me?' above). Your health care provider can talk to you about the risks and benefits of each option.

As mentioned above, laws regarding how far into a pregnancy a person can get an abortion vary by country and state. (See 'Is abortion right for me?' above.)

Cervical preparation — For many people, the cervix (the opening to the uterus (figure 1)) has to be stretched to widen the opening before the procedure. To do this, you may need to take a medication and/or have dilators (medical sponges that absorb moisture) placed in your cervix for several hours or one to two days before the procedure. This helps the cervix soften and stretch so the pregnancy tissue can come out. If this is done the day before the procedure, you can usually go home after the dilator is inserted and return to the hospital or clinic when it is time to complete the procedure. Your health care provider will discuss and give you detailed instructions about the plan.

Induction abortion — This type of abortion after 14 weeks of pregnancy takes place in a hospital under the supervision of a doctor or nurse (not at home, like early medication abortion). It is called an "induction abortion" because the medications cause the body to go into labor (making the uterus contract) and pass the pregnancy tissue out through the vagina.

You will have abdominal pain and cramps as the medication takes effect; pain medications can help with this. You may also choose to have epidural anesthesia (in which a thin tube is inserted into your back to deliver medicine to numb the lower half of your body). The entire process usually takes less than 24 hours. The uterine contractions are usually enough to cause the pregnancy to pass without you having to push. However, you may need to push if the pregnancy is further along.

Dilation and evacuation abortion — D&E during the second trimester involves a similar procedure to that used in early pregnancy for procedural abortion (see 'Procedural abortion' above). One difference in the second trimester is that cervical preparation is usually necessary; that added step can make the total time from start to completion of the abortion up to two or three days. (See 'Cervical preparation' above.)

As with early procedural abortion, tools (dilators) may be used to widen the opening of the cervix. Evacuation refers to a part of the procedure that involves inserting a tube through the cervix into the uterus. This is then attached to suction, which removes the pregnancy tissue. The provider may also insert an instrument into the uterus to remove any remaining tissue.

Typically, sedation is given as part of a D&E procedure. For this, you will have an intravenous (IV) line placed so you can get medication to help you relax or feel sleepy. Many people do not remember much about the procedure after the sedative medication is given. Local anesthesia will also be injected into your cervix after the sedative. General anesthesia (that makes you completely unconscious) is not needed or recommended for an abortion procedure in most cases.

What to expect after the procedure — Vaginal bleeding, abdominal pain, and cramping are expected side effects after a second trimester induction or D&E abortion.

Abdominal pain and cramping — Most people have some abdominal pain and cramping after abortion. You can take ibuprofen (sample brand names: Advil, Motrin) every six hours for pain if needed (unless you have a medical reason to avoid this medication). Some clinicians may prescribe a stronger pain medication for you if needed.

The pain may continue for several hours after the procedure. If you have severe pain that does not get better with these treatments or if your pain continues for more than a few days after the procedure, call the clinic where you had the abortion or your health care provider.

Vaginal bleeding — It is normal to have some vaginal bleeding after abortion. Usually the bleeding is less than with a menstrual period. The bleeding usually lasts a few days to two weeks, and should become light after the first few days. You may also pass some tissue or blood clots or have light bleeding for longer than two weeks.

If you are bleeding so heavily that you soak through two menstrual pads in an hour for two or more hours in a row and you are still bleeding, you should call the clinic where you had the abortion or your health care provider.

Discharge from breasts — After a second trimester abortion, some people experience breast pain, firmness (also called engorgement), and yellowish-white nipple discharge. This is normal and happens because the breasts begin to produce milk after a certain point in pregnancy. You can wear a firm bra for support and take ibuprofen for pain. The milky discharge should stop after one to two weeks.

WHEN TO SEEK HELP AFTER ABORTION — Call your health care provider or the clinic where you had the abortion immediately if:

You are bleeding so heavily that you soak through two menstrual pads per hour for two hours in a row and you are still bleeding.

You have severe abdominal or pelvic pain that is not relieved by pain medications.

You have shaking chills or develop a temperature higher than 100.4°F or 38°C (use a thermometer to measure your temperature).

You have foul-smelling or pus-like vaginal discharge.

FOLLOW-UP CARE — You should not have sex or put anything in your vagina (such as tampons or douches) for one to two weeks after an abortion. This can help prevent infection and give you time to recover.

Instructions for follow-up depend on which type of abortion you had and on the specific practice of your health care provider. These may include the following:

After a medication abortion, you will be instructed about a plan for follow-up. The main purpose of this follow-up is to confirm that you are no longer pregnant. It may involve a return visit to the clinic (or another health care provider closer to where you live), a phone appointment, or some other form of communication with your provider (telemedicine).

After a procedural or dilation and evacuation abortion, some abortion providers recommend a follow-up visit two to three weeks later, while others do not. Sometimes, the provider may need to do a pelvic examination at that visit. If you have any symptoms that worry you or if you would like to talk to someone about your feelings after your abortion, do not wait for this visit; call your provider.

Birth control after abortion — If you do not want to get pregnant again soon after an abortion, you should talk to your provider about contraception (birth control) options. Even after an abortion, you can get pregnant again quickly, even before your next menstrual period.

If you had a procedural or dilation and evacuation abortion, you can start using most birth control methods (pill, patch, vaginal ring, injection, intrauterine device [IUD], implant) on the same day.

If you had a medication abortion, you can start some kinds of birth control on the same day you take the first medication. Other methods, like the IUD, can be inserted soon after the abortion, usually within a few days after you take the medicine.

More detailed information about birth control is available separately. (See "Patient education: Birth control; which method is right for me? (Beyond the Basics)".)

ABORTION COMPLICATIONS — Legal abortions are safe and rarely cause serious complications. However, as with any medical procedure, complications sometimes occur. These can include excessive bleeding, infection, injury to the cervix or uterus (in the case of procedural or dilation and evacuation abortion only), or pregnancy tissue that remains in the uterus. These problems are rare, and serious complications occur in less than 1 percent of cases.

MYTHS AND FACTS ABOUT ABORTION — Many people have questions about what is true or not true that they have heard about abortion:

MYTH: Abortion is dangerous.

FACT: Legal abortion is one of the safest health care procedures available today. While abortion does have some risk, on the whole, carrying a pregnancy and giving birth have been found to be more risky than having an abortion. It is important to know that an abortion performed by someone who is not trained (for example, a person on themselves or from someone who is not a health care provider) is not safe and can lead to serious complications, including bleeding, infection, infertility, and even death.

MYTH: Abortion will make me infertile.

FACT: When an abortion is performed safely by someone who has training, it does not lead to difficulty getting pregnant in the future.

MYTH: Abortion increases risk of breast cancer.

FACT: Several studies have conclusively shown that having an abortion does not increase the risk of developing breast cancer.

PROBABLE MYTH: Abortion increases my chance of miscarriage in the future.

FACT: A number of well-designed studies have found that early abortions do not increase the risk of miscarriage, preterm delivery, or other complications with future pregnancies.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem. Several reliable sources of information are also listed below.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Abortion (The Basics)
Patient education: Pregnancy in Rh-negative people (The Basics)
Patient education: Spina bifida (myelomeningocele) (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Birth control; which method is right for me? (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Induced fetal demise
First-trimester pregnancy termination: Medication abortion
Misoprostol as a single agent for medical termination of pregnancy
Overview of pregnancy termination
Postpartum contraception: Counseling and methods
First-trimester pregnancy termination: Uterine aspiration
Overview of second-trimester pregnancy termination

The following organizations also provide reliable health information.

National Library of Medicine

(www.nlm.nih.gov/medlineplus/abortion.html)

Guttmacher Institute

(www.guttmacher.org)

Planned Parenthood

(www.plannedparenthood.org)

National Abortion Federation

(www.prochoice.org)

Reproductive Health Access Project

(www.reproductiveaccess.org)

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