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

ABORTION OVERVIEW — Abortion, also known as pregnancy termination, is a way to end a pregnancy. This can be done by taking medications or having a procedure.

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 helps to explain these issues and briefly discusses the different types of abortion, including what to expect during and afterwards. If you have other questions or concerns, talk with your health care provider if possible, or seek information from a clinic that provides abortion. (See 'Where to get more information' below.)

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 who 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. Some common reasons include:

●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 do not want more children or are not planning on having children.

●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.

●You do not want to continue the pregnancy and make a plan for adoption.

●The fetus has a congenital anomaly or other problem.

●You have health problems that make pregnancy difficult or risky.

●The pregnancy is the result of a sexual assault or other unwanted sexual contact.

Is abortion legal? — The laws depend on where you live. In the United States, each state has its own laws about abortion. For example:

●Some states have banned abortion completely.

●Some states have laws that make it illegal to aid and abet people accessing abortion, and some hospitals and institutions have interpreted these laws to include referral for abortion care.

●In states where abortion is legal, rules vary about how far along in pregnancy you can get an 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.

●Some states require people younger than 18 years to get permission from parent or guardian. (See 'What if I am a minor?' below.)

If you are not sure whether you can have an abortion because of how far along you are in your pregnancy, you can ask a clinic that provides abortion or knowledgeable health care providers to help you figure this out. You can also use an online calculator to get an idea of how far along you are in your pregnancy based on the date of your last period (calculator 1). If your periods are not regular (that is, you do not have a period approximately every month), these calculators may not be accurate. To be sure about how far along you are, it is best to see a health care provider.

To learn more about the laws where you live, you can get information from a clinic like Planned Parenthood or from Abortion Finder (www.abortionfinder.org). A summary of United States abortion laws can also be found through the Guttmacher Institute (www.guttmacher.org/global/abortion).

What if I am a minor? — If you are a minor, 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 a parent's permission, most states, where abortion is legal, have set up systems so you can get a judge to grant you permission without involving your parents (this is called "judicial bypass"). Clinics that provide abortion and other health care providers (in states where abortion is legal) 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" or "abortion with pills."

●Procedural abortion – This is when a trained health care provider performs 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 where you live, how far you are in your pregnancy, and your personal preferences; in some cases, certain health conditions may impact your options. The options may vary at different points in pregnancy; this is discussed below. Your health care provider can also talk about the options with you to help you make an informed decision; if you live in a state where they cannot discuss this with you, a clinic that provides abortion can help.

Some things you may want to consider:

●Some people decide to have a medication abortion because they want to avoid having a procedure that involves medical instruments and anesthesia. In the case of an early medication abortion, they may choose it because they prefer the privacy of being at home when the pregnancy tissue leaves their body. And in some cases, it may be possible to have an early medication abortion without visiting a clinic or health care provider’s office at all. (See 'Can I have a medication abortion without going to a doctor or clinic?' below.)

In a small number of cases (approximately 2 to 5 out of 100), the medication does not work. In those cases, the person may be offered the option of taking more medication or having a procedural abortion to complete the abortion. (See 'How effective is early medication abortion?' below.)

●Some people decide 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 — If you go to a health care provider or clinic for an abortion, you will meet with a trained medical professional and be able to ask them any questions you may have and about what to expect during the abortion process. While this may occur in the clinic setting, it can sometimes be done during a "telemedicine" visit (by phone or video) or through other online communication (eg, chat, email). (See 'Can I have a medication abortion without going to a doctor or clinic?' below.)

During this appointment, the provider may do the following:

●Confirm you are pregnant and determine how many weeks pregnant you are. This may include reviewing your menstrual history (date of last menstrual period), doing a pregnancy test, and/or performing a pelvic examination. Sometimes, the provider might recommend an ultrasound to determine exactly how far along in pregnancy 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 has not implanted outside the uterus or that you have not had a miscarriage. When a pregnancy implants in the fallopian tube, it is called an "ectopic" pregnancy; this occurs in approximately 1 out of 100 (1 percent) of pregnancies and may require emergency treatment. (See "Patient education: Ectopic (tubal) pregnancy (Beyond the Basics)".)

●Discuss the types of abortion that are options for you. This includes a through discussion of the available options, the risks and benefits of each, and what to expect during and after the abortion. The provider can also discuss alternatives to abortion (ie, continuing the pregnancy and choosing to either parent or make an adoption plan) if you have not already considered these options.

●Order a blood test to determine your blood type. If you have a blood type that is Rh group negative (for example, "A negative"), and depending on how far along you are in pregnancy, you may need an injection of a medication called Rh immune globulin (RhoGAM) after your abortion. This helps prevent complications in future pregnancies.

●Offer testing for sexually transmitted infections. Depending on your situation, you might be offered testing for gonorrhea, chlamydia, HIV, or other infections.

●Review contraceptive (birth control) options. If you do not wish to get pregnant again right away, the health care provider can discuss birth control options with you. (See 'Birth control after abortion' below.)

In some states, a person is required to wait for a certain amount of time (usually 24 hours) between the counseling described above and the abortion. In other states, an abortion can be done on the same day as the counseling. (See 'Is abortion legal?' above.)

EARLY ABORTION (BEFORE 14 WEEKS) — 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, with 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 may vary because providers follow different guidelines.

Early medication abortion is available in some health care settings (ie, community health centers, private practices, hospitals), in clinics focused on family planning, and by telemedicine through one of these clinical care centers or from online pharmacies. This type of abortion usually includes the following steps:

●Confirming how many days pregnant you are.

●You will probably be given two different medications, most commonly mifepristone (brand name: Mifeprex) and misoprostol (brand name: Cytotec). In some places, only misoprostol may be given. Less commonly, a medication called methotrexate may be used in place of mifepristone.

●You will take the first medication (mifepristone) at the clinic, health care site, or at a place of your choice (such as your home).

You will be instructed to take the second medication (misoprostol) at home one and two days after taking the mifepristone. It is important to wait one to two days before taking the second medication (misoprostol) because the first medication (mifepristone) takes time to work on the uterus. If you are between 70 and 77 days pregnant, you will be given a second 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 medication abortion process. Some people also experience fever, nausea, vomiting, or diarrhea on the day they take the misoprostol. This may be uncomfortable or unpleasant, but most strong effects only last for 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 contact your health care provider, clinic, or online pharmacy. If you do not have any bleeding at all after you take the medications, you should also contact them 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 for 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 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 congenital anomalies in the fetus 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 have a positive pregnancy test four weeks after the abortion.

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

If you have any of these signs, contact your health care provider or clinic. They may want to see you or speak with you on the phone. They may suggest taking a home pregnancy test (if you have not already done so); 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.

Can I have a medication abortion without going to a doctor or clinic? — If you are having a medication abortion, it may be possible to do this without going to a clinic or health care provider's office. Other ways to have a medication abortion include:

●"Telemedicine" – This means that you talk to a trained healthcare professional, but over the phone or online instead of in person. They will ask questions to make sure it is safe for you to have a medication abortion. Then, they will arrange a way for you to get the medications (eg, through the mail) and explain how to take them.

●"Self-managed" abortion – This involves getting the medicines needed for the abortion on your own. It does not involve any direct contact with a health care provider or clinic. If you choose to self-manage your abortion, never use herbs, chemicals, or objects in the vagina to try to end your pregnancy. These things are unsafe and could cause serious harm or even death. If you have any concerning symptoms or questions, you should seek care from a healthcare provider in your community.

Procedural abortion — In a procedural abortion, the pregnancy is removed in a procedure that takes place in a clinic, medical office, 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 or organs. 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) needs to be stretched to widen the opening before these instruments can be inserted. To do this, the health care provider may use tools (called dilators) to gradually stretch the cervical canal. Once the cervix is open, a thin tube is inserted through the cervix into the uterus, 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 it is in the pregnancy. After the procedure, you will be monitored by health care staff until you are ready to leave; the time for this varies but typically ranges from half an hour 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 a procedural 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 (14 WEEKS OR AFTER) — 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). You can talk to your health care provider about the risks and benefits of each option.

As discussed above, laws regarding how far into a pregnancy a person can get an abortion vary by country and state. (See 'Is abortion legal?' 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 takes place in a hospital (not at home, as with early medication abortion). It involves being given medication under the supervision of a doctor or nurse that causes you to go into labor (making the uterus contract) so the pregnancy tissue will pass out of your body 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.

Dilation and evacuation abortion — D&E at 14 weeks or after involves a similar procedure to that used in early pregnancy for procedural abortion (see 'Procedural abortion' above). One difference in later pregnancy 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, a provider may give you medication or insert tools (called dilators) to make the opening of the cervix wider. Evacuation refers to a part of the procedure that involves inserting a tube through the cervix into the uterus. This is attached to suction, which removes the pregnancy tissue. The provider may also insert an instrument into the uterus to remove any remaining pregnancy tissue.

Often, 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 to help with pain. General anesthesia (that makes you completely unconscious) is not needed or recommended for an abortion procedure; however, this may be an option for some people. Some providers also offer other medicines (including some you can take by mouth) to help with pain and anxiety.

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 an 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.

●Breast discharge — After a later 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. Your health care providers can also give you a medication to help stop this process.

WHEN TO SEEK HELP AFTER ABORTION — Call a health care provider or seek care 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 discharge from your vagina.

FOLLOW-UP CARE — Specific instructions for follow-up depend on which type of abortion you had (medication or procedural) and where you received care. 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 provider (or another health care provider closer to where you live) or some other form of communication with your provider (telemedicine).

●After a procedural 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 or ultrasound 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; contact 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. After an abortion, you can get pregnant again quickly, even before your next menstrual period.

●If you had a procedural 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 (pill, patch, vaginal ring, infection) 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 and emergency contraception are available separately. (See "Patient education: Birth control; which method is right for me? (Beyond the Basics)" and "Patient education: Emergency contraception (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 (hemorrhage), infection, injury to the cervix or uterus (in the case of procedural abortion), or pregnancy tissue that remains in the uterus. These problems are very rare, and serious complications occur in less than 1 out of 100 (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: While abortion does have some small risk, carrying a pregnancy and giving birth is more risky than having an abortion. It is important to know that an abortion performed by someone who is not trained 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, it does not lead to difficulty getting pregnant in the future.

●MYTH: Abortion increases risk of breast cancer.

FACT: Having an abortion does not increase the risk of developing breast cancer.

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

FACT: 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 (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)

(See "Patient education: Emergency contraception (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.

Overview of pregnancy termination
First-trimester pregnancy termination: Medication abortion
Misoprostol as a single agent for medical termination of pregnancy
First-trimester pregnancy termination: Uterine aspiration
Overview of second-trimester pregnancy termination
Counseling in abortion care
Unsafe abortion
Contraception: Postpartum counseling and methods

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)