NICE 140: Abortion Care

This is the summary of the NICE guideline “Abortion Care” published in September 2019.

There are some changes in this guideline. This guideline provides information about management of women undergoing abortion at different gestations, outline of the service organization and how the abortion services should be provided (which are relevant for the health professionals working in UK). In this summary, only main points are extracted.

It is advised to read the original guideline to grasp the topic and to make sure, no important point is missed.

The guideline can be downloaded by clicking here: NG140 Abortion Care

Some other relevant links of this topic are also provided at the end of this post.

Thanks

NICE 140: ABORTION CARE 

Service Organization

Making it easier to access services

• Commissioner & providers should work together to:
• Make information about abortion services widely available
• Ensure → prompt referral onwards if service cant provide abortion
• Avoid → need for women to repeat key steps (like GP return/referral, repeated assessments/investigations)
• Allow women to self-refer to abortion services
• Ensure → abortion services have capacity/ resources to deliver range of services with minimum delay
• Health Professionals → should NOT allow their personal believes to delay services access 
• Commissioners → should consider upfront funding for travel/ accommodation for women who:
• are eligible for NHS Healthcare Travel costs Scheme and/or
• need to travel to service not available locally 

Waiting Times

• Ensure minimal delay & ideally provide
• Assessment within → 1 wk of request
• Abortion within → 1 wk of assessment
• If woman prefer to wait longer → help her make informed decision by explaining implications including
• Legal time limits (as per Abortion Act)
• Delaying → ↑ risk of complications (although overall risk is low)

Location of Services

• Consider providing
• Assessment → phone / video call (if woman prefers)
• Abortion services in range of settings (community/hospitals)

Workforce and training

• Maximize the role of nurses/midwives in care
• Trainees healthcare professional/students → should have chance to gain experience in abortion services during training
• Specialities which include abortion training
• to ensure ALL trainees have training unless opt out due to conscientious objection
• include practical experience of services & procedures
• If trainee’s placement service does not provide abortion → trainee should gain experience with whoever is providing this service

Complex Comorbidities

• Specialist Centers → should be available as locally as possible→ to reduce delays & travel times
• Providers → should develop pathways to refer & minimize delays

Avoiding Stigma

• Be aware of 
• Anxiety a woman may have due to perceived negative & judgmental attitudes from healthcare professionals 
• Impact of verbal/nonverbal communication
• Services should → be sensitive to woman’s concern about privacy & confidentiality (including sharing information with health professional not directly involved in the care)

Providing Information 

• Reassure women → abortion is not associated with ↑ risk of infertility, breast cancer or mental health issues
• Provide information  
• about differences b/w medical/surgical abortion 
• in a range of formats e.g video or written
• DO NOT be directive → let woman make their own choice
• Detailed information to help them prepare for abortion (as early as possible) 
• What it involves & what happens afterwards
• How much pain/ bleeding to expect
• Ask women if they want information on contraception
• For women having medical abortion → explain
• They may see products of pregnancy when passed & how they look like/whether there may be any movement 
• How to be sure that pregnancy has ended
• Provide information about
• signs & symptoms which means that they may need medical help after abortion & who to contact
• different options for management/disposal of pregnancy remains

Information for women having abortion due to FETAL ANOMALY

• If her preferred method cannot be provided → establish clear referral pathway with ongoing communication b/w service so she can 
• Easily transfer to abortion service
• Receive ongoing support
• Get more information about anomaly
• Explain → there may be no physical signs of fetal anomaly

Anti-D Prophylaxis

• OFFER anti-D prophylaxis → RhD negative + having abortion after 10+0 wks
• Having abortion up to & including 10+0 wks 
• Medical → DO NOT offer anti-D prophylaxis
• Surgical → Consider anti-D prophylaxis
• Providers should ensure:
• Rhesus status testing & anti-D prophylaxis supply → does not cause any delays
• Anti-D prophylaxis → be available at the time of abortion

Preventing Infection

• Antibiotics prophylaxis
• Medical Abortion → DO NOT routinely offer
• Surgical Abortion → OFFER
• If using doxycycline in medical/surgical abortion → consider oral 100mg BD for 3 days
• If using metronidazole in medical/surgical abortion → DO NOT routinely offer it in combination with another broad-spectrum antibiotic (e.g doxycycline)

VTE Prophylaxis

• Women who need pharmacological thromboprophylaxis → consider LMWH → for at least 7 days after abortion
• Women at high risk of thrombosis → consider starting LMWH before abortion & giving it longer afterwards

Choice of procedure for abortion

• Offer choice between medical/surgical → up to & including 23+6wks 
• If a method not appropriate clinically → explain why

Abortion before definitive ultrasound evidence of an intrauterine pregnancy

• Consider abortion → if NO signs/symptoms of ectopic pregnancy
• To these women
• Explain → small chance of ectopic pregnancy; they may need follow-up to ensure pregnancy has terminated & to monitor for ectopic
• Provide 24-hr emergency contact details & advice to get in contact immediately if develop signs of ectopic  (refer NICE Guideline: Ectopic Pregnancy)

Expulsion at home for medical abortion up to & including 10 +0 weeks

Up to and including 9+6 wks

• Medical abortion + taking mifepristone → offer option of expulsion at home after taking misoprostol
• Can take misoprostol at home

At 10+0 wks

• Medical abortion + taking mifepristone → offer option of expulsion at home → after taking misoprostol
• Can take misoprostol in clinic or hospital

Medical abortion up to & including 10 +0 weeks

• Medical abortion up to & including 10+0 wks → Offer interval treatment (usually 24-48 hr) with mifepristone & misoprostol
• Medical abortion up to & including 9+0 wks → Give choice of mifepristone and vaginal misoprostol at same time, but explain
• Risk of ongoing pregnancy higher & ↑ with gestation
• May take longer for bleeding & pain to start
• Important to complete same follow-up programme (as for as medical abortion up to & including 10+0 wks)

Medical abortion between 10 +1 & 23 +6 weeks

• Taken 200 mg mifepristone → Offer initial doses (after 36-48 hrs after mifepristone) of:
• 800 μg misoprostol vaginally or
• 600 μg misoprostol sublingually (if woman decline per vaginum)
• Follow initial dose → with 400 μg of misoprostol (p/v, s/l or buccal) given every 3 hrs until expulsion
• If woman prefers → use shorter interval b/w mifepristone & misoprostol but do explain → it may take longer time to complete abortion 

Medical abortion after 23 +6 weeks

• Medical abortion between 24+0 & 25+0 wks
• Consider 200 mg oral mifepristone, followed by 400 μg misoprostol (p/v, s/l or buccal) every 3 hrs until delivery
• Medical abortion between 25+1 & 28+0 wks
• Consider 200mg oral mifepristone, followed by 200 μg misoprostol (p/v, s/l or buccal) every 4 hrs until delivery
• Medical abortion after 28+0 wks → Consider 200 mg oral mifepristone, followed by 100 μg misoprostol (p/v, s/l or buccal) every 6 hrs until delivery
• Be aware:
• Uterus → more sensitive to misoprostol as pregnancy advances
• Risk factors for uterine rupture → pre-existing uterine scar, ↑ gestational age & multiparity

Cervical priming before surgical abortion

Up to and including 13+6 wks

• Having surgical abortion → Offer cervical priming with 
• 400 μg s/l misoprostol, 1 hr before abortion or
• 400 μg p/v misoprostol, 3 hrs before abortion
• If misoprostol cannot be used → Consider cervical priming with 200 mg oral mifepristone, given 24-48 hrs before abortion
• Explain to women that cervical priming
• ↓ risk of incomplete abortion in parous women
• Makes dilatation easier in parous or nulliparous
• May cause bleeding & pain before the procedure 

Between 14+0 and 23+6 wks

• Surgical abortion b/w 14+0 wks & 23+0 wks → OFFER cervical priming 
• Surgical abortion b/w 14+0 & 16+0 wks → CONSIDER
• Osmotic dilators or
• Buccal, vaginal or sublingual misoprostol or
• 200 mg oral mifepristone, given day before abortion
• Surgical abortion b/w 16+1 & 19+0 wks → CONSIDER
• Osmotic dilators or
• Buccal, vaginal or sublingual misoprostol 
• Surgical abortion b/w 19+1 & 23+6 wks → OFFER osmotic dilators 
• In addition, consider → 200 mg oral mifepristone day before abortion and 
• Inserting osmotic dilators at same time as mifepristone
• Surgical abortion b/w 14+0 & 23+6 wks plus having cervical priming with osmotic dilators → CONSIDER inserting osmotic dilators day before abortion
• Do not offer misoprostol for cervical ripening → if osmotic dilator inserted day before abortion

Anaesthesia & Sedation for Surgical Abortion

• Having surgical abortion → CONSIDER local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation or GA
• To help woman make an informed choice → discuss options & explain
• Having local anaesthesia alone → will have to spend less time in hospital
• I/V sedation plus local → will help if anxious about procedure
• With deep sedation or GA → will not usually be aware during procedure
• Using conscious sedation → use I/V rather than oral sedation
• Using GA → Consider I/V propofol & short-acting opioid (like fentanyl) rather than inhalational 

Follow-up and support after an abortion

Follow-up after medical abortion up to & including 10 wks

• Expulsion at home → Offer choice of self-assessment, including remote assessment (e.g telephone/text messaging), as an alternative to clinic follow-up
• Provide → low sensitivity or multi-level urine pregnancy test to exclude ongoing pregnancy

Support after an abortion

• Explain to woman
• Expected aftercare & followup
• What to do if any problem later on, including how to get help out of hours
• Common to feel range of emotions after abortion
• Advised women to seek support, if they need it & how to access it. It could include
• Support from family/friends or postal support
• Peer support or support group of women who had abortion
• Counselling or psychological interventions
• Provider should
• be able to provide emotional support after abortion & tell women it’s available if she needs
• Provide or refer women for counselling if requested

Improving access to contraception

• Commissioners & providers → should ensure full range of reversible contraceptive options (DMPA, implant, IUCDs, oral, patches, vaginal rings or barrier) → available for women on the same day as medical/surgical abortion
• Providers should ensure
• Healthcare professional have knowledge & skills to provide ALL contraceptive options
• They can provide Implant & women who choose it are offered on day of surgical abortion or day they take mifepristone (for medical abortion)
• They can provide Intrauterine methods of contraception & women who choose it are offered at same time as surgical abortion or as soon as possible after expulsion of pregnancy (for medical abortion)
• Having medical abortion & choose DMPA I/M
• Consider → providing at same appointment when mifepristone taken
• Explain → having injection at this stage may ↑ risk of ongoing pregnancy although overall risk is low

Related Links

Termination of Pregnancy / Abortion
NICE	Abortion Care (Sep 2019)
RCOG	Care of women Requesting Induced Abortion
TOG	Manual Vaccum Aspiration 2015
CA	#10 Surgical Evacuation of Uterus after Early Pregnancy Loss
BPP	#2 Comprehensive Abortion Care #3 Comprehensive Postabortion Care
CGA	#6 Obtaining Valid Consent