People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. Note that mifepristone and misoprostol do not have UK marketing authorisations for most of the uses recommended in this guideline. When an unlicensed use is recommended, this is highlighted with a footnote in the recommendation.
Abortion Act 1967
Abortion in England, Scotland and Wales is primarily regulated by the Abortion Act 1967 (as amended by the Human Fertilisation and Embryology Act 1990) and regulations made under that Act – currently the Abortion Regulations 1991 (SI 1991/499). The Abortion Act regulates when and where abortions can take place lawfully.
In May 2014, the Department of Health and Social Care issued guidance in relation to requirements of the Abortion Act 1967. This guidance is intended for those responsible for commissioning, providing and managing the provision of abortion services to help them comply with the Abortion Act. Also in May 2014, the Department of Health and Social Care published procedures for the approval of independent sector places for the termination of pregnancy. Further government guidance has recently been issued in the form of letters from the Chief Medical Officer.
Providers of abortion services must comply with the Health and Social Care Act 2008 and regulations made under that Act. In particular, providers must register with the Care Quality Commission (CQC). This is because under section 10 of the Health and Social Care Act 2008, it is an offence to carry out a regulated activity without being registered with the CQC, and abortion is a 'regulated activity' under Regulation 3 and Schedule 1 (paragraph 11) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). The CQC imposes specific requirements on providers that are not English NHS bodies (see regulation 20 of the Care Quality Commission (Registration) Regulations 2009).
Additional relevant guidance:
This NICE guideline makes evidence-based recommendations on how to organise services and on how to conduct abortions within the legal framework set out by the Abortion Act 1967. It does not repeat things already covered by the legislation, Department of Health and Social Care guidance or other statutory regulations, and practitioners should therefore ensure they are adhering to all other applicable requirements when using this guideline.
Consent and Montgomery
Healthcare professionals should ensure that women have the information they need to make decisions and to give consent in line with General Medical Council guidance and the 2015 Montgomery ruling.
Gender
This guideline makes recommendations for women and people who are pregnant. For simplicity of language the guideline uses the term women throughout, but this should be taken to also include people who do not identify as women but who are pregnant.
1.9 Medical abortion up to and including 10+0 weeks
In September 2019, mifepristone for abortion only has a UK marketing authorisation for:
-
600 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 400 micrograms misoprostol orally or 1 mg gemeprost vaginally, up to and including 49 days of amenorrhoea
-
600 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 1 mg gemeprost vaginally, between 50 days and 63 days of amenorrhoea
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200 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 1 mg gemeprost vaginally, between 50 days and 63 days of amenorrhoea
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200 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 800 micrograms misoprostol vaginally, up to and including 63 days of amenorrhoea
-
600 mg orally for medical abortion for medical reasons, followed 36 to 48 hours later by prostaglandin administration, beyond the first trimester
-
200 mg orally for cervical priming, 36 to 48 hours before first trimester surgical abortion.
All other uses of mifepristone are off label. See NICE's information on prescribing medicines.
In September 2019, misoprostol for medical abortion only has a UK marketing authorisation for:
-
400 micrograms orally as an initial dose for medical abortion of developing intrauterine pregnancy, 36 to 48 hours after 600 mg mifepristone orally, up to and including 49 days of amenorrhoea
-
800 micrograms vaginally as an initial dose for medical abortion of developing intrauterine pregnancy, 36 to 48 hours after 200 mg mifepristone orally, up to and including 63 days of amenorrhoea.
All other uses of misoprostol (including for cervical priming and for abortion at later gestations) are off label. See NICE's information on prescribing medicines.
1.9.1
Offer interval treatment (usually 24 to 48 hours) with mifepristone and misoprostol to women who are having a medical abortion up to and including 10+0 weeks' gestation.
1.9.2
For women who are having a medical abortion up to and including 9+0 weeks' gestation, give them the choice of having mifepristone and vaginal misoprostol at the same time, but explain that:
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the risk of ongoing pregnancy may be higher, and it may increase with gestation
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it may take longer for the bleeding and pain to start
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it is important for them to complete the same follow-up programme that is recommended for all medical abortions up to and including 10+0 weeks (recommendations 1.14.1 and 1.14.2).
1.10 Medical abortion between 10+1 and 23+6 weeks
In September 2019, mifepristone for abortion only has a UK marketing authorisation for:
-
600 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 400 micrograms misoprostol orally or 1 mg gemeprost vaginally, up to and including 49 days of amenorrhoea
-
600 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 1 mg gemeprost vaginally, between 50 days and 63 days of amenorrhoea
-
200 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 1 mg gemeprost vaginally, between 50 days and 63 days of amenorrhoea
-
200 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 800 micrograms misoprostol vaginally, up to and including 63 days of amenorrhoea
-
600 mg orally for medical abortion for medical reasons, followed 36 to 48 hours later by prostaglandin administration, beyond the first trimester
-
200 mg orally for cervical priming, 36 to 48 hours before first trimester surgical abortion.
All other uses of mifepristone are off label. See NICE's information on prescribing medicines.
In September 2019, misoprostol for medical abortion only has a UK marketing authorisation for:
-
400 micrograms orally as an initial dose for medical abortion of developing intrauterine pregnancy, 36 to 48 hours after 600 mg mifepristone orally, up to and including 49 days of amenorrhoea
-
800 micrograms vaginally as an initial dose for medical abortion of developing intrauterine pregnancy, 36 to 48 hours after 200 mg mifepristone orally, up to and including 63 days of amenorrhoea.
All other uses of misoprostol (including for cervical priming and for abortion at later gestations) are off label. See NICE's information on prescribing medicines.
1.10.1
For women who are having a medical abortion between 10+1 and 23+6 weeks' gestation and who have taken 200 mg mifepristone, offer an initial dose (36 to 48 hours after the mifepristone) of:
-
800 micrograms misoprostol, given vaginally, or
-
600 micrograms of misoprostol, given sublingually, for women who decline vaginal misoprostol.
Follow the initial dose with 400 microgram doses of misoprostol (vaginal, sublingual or buccal), given every 3 hours until expulsion.
1.10.2
Use a shorter interval between mifepristone and misoprostol if the woman prefers this, but explain that it may take a longer time from taking the first misoprostol dose to complete the abortion.
1.11 Medical abortion after 23+6 weeks
In September 2019, mifepristone for abortion only has a UK marketing authorisation for:
-
600 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 400 micrograms misoprostol orally or 1 mg gemeprost vaginally, up to and including 49 days of amenorrhoea
-
600 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 1 mg gemeprost vaginally, between 50 days and 63 days of amenorrhoea
-
200 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 1 mg gemeprost vaginally, between 50 days and 63 days of amenorrhoea
-
200 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 800 micrograms misoprostol vaginally, up to and including 63 days of amenorrhoea
-
600 mg orally for medical abortion for medical reasons, followed 36 to 48 hours later by prostaglandin administration, beyond the first trimester
-
200 mg orally for cervical priming, 36 to 48 hours before first trimester surgical abortion.
All other uses of mifepristone are off label. See NICE's information on prescribing medicines.
In September 2019, misoprostol for medical abortion only has a UK marketing authorisation for:
-
400 micrograms orally as an initial dose for medical abortion of developing intrauterine pregnancy, 36 to 48 hours after 600 mg mifepristone orally, up to and including 49 days of amenorrhoea
-
800 micrograms vaginally as an initial dose for medical abortion of developing intrauterine pregnancy, 36 to 48 hours after 200 mg mifepristone orally, up to and including 63 days of amenorrhoea.
All other uses of misoprostol (including for cervical priming and for abortion at later gestations) are off label. See NICE's information on prescribing medicines.
1.11.1
For women who are having a medical abortion between 24+0 and 25+0 weeks' gestation, consider 200 mg oral mifepristone, followed by 400 micrograms misoprostol (vaginal, buccal or sublingual) every 3 hours until delivery.
1.11.2
For women who are having a medical abortion between 25+1 and 28+0 weeks' gestation, consider 200 mg oral mifepristone, followed by 200 micrograms misoprostol (vaginal, buccal or sublingual) every 4 hours until delivery.
1.11.3
For women who are having a medical abortion after 28+0 weeks' gestation, consider 200 mg oral mifepristone, followed by 100 micrograms misoprostol (vaginal, buccal or sublingual) every 6 hours until delivery.
1.11.4
Be aware that:
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the uterus is more sensitive to misoprostol as pregnancy advances
-
risk factors for uterine rupture include a pre-existing uterine scar, increased gestational age and multiparity.
1.12 Cervical priming before surgical abortion
In September 2019, mifepristone for abortion only has a UK marketing authorisation for:
-
600 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 400 micrograms misoprostol orally or 1 mg gemeprost vaginally, up to and including 49 days of amenorrhoea
-
600 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 1 mg gemeprost vaginally, between 50 days and 63 days of amenorrhoea
-
200 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 1 mg gemeprost vaginally, between 50 days and 63 days of amenorrhoea
-
200 mg orally for medical abortion of developing intrauterine pregnancy, followed 36 to 48 hours later by 800 micrograms misoprostol vaginally, up to and including 63 days of amenorrhoea
-
600 mg orally for medical abortion for medical reasons, followed 36 to 48 hours later by prostaglandin administration, beyond the first trimester
-
200 mg orally for cervical priming, 36 to 48 hours before first trimester surgical abortion.
All other uses of mifepristone are off label. See NICE's information on prescribing medicines.
In September 2019, misoprostol for medical abortion only has a UK marketing authorisation for:
-
400 micrograms orally as an initial dose for medical abortion of developing intrauterine pregnancy, 36 to 48 hours after 600 mg mifepristone orally, up to and including 49 days of amenorrhoea
-
800 micrograms vaginally as an initial dose for medical abortion of developing intrauterine pregnancy, 36 to 48 hours after 200 mg mifepristone orally, up to and including 63 days of amenorrhoea.
All other uses of misoprostol (including for cervical priming and for abortion at later gestations) are off label. See NICE's information on prescribing medicines.
Up to and including 13+6 weeks
1.12.1
For women who are having a surgical abortion up to and including 13+6 weeks' gestation, offer cervical priming with:
-
400 micrograms sublingual misoprostol, given 1 hour before the abortion or
-
400 micrograms vaginal misoprostol, given 3 hours before the abortion.
If misoprostol cannot be used, consider cervical priming with 200 mg oral mifepristone, given 24 to 48 hours before the abortion.
1.12.2
Explain to women that cervical priming:
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reduces the risk of incomplete abortion for women who are parous
-
makes dilation easier for women who are parous or nulliparous
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may cause bleeding and pain before the procedure.
Between 14+0 and 23+6 weeks
1.12.3
For women who are having a surgical abortion between 14+0 and 23+6 weeks' gestation, offer cervical priming.
1.12.4
For women who are having a surgical abortion between 14+0 and 16+0 weeks' gestation, consider:
-
osmotic dilators or
-
buccal, vaginal or sublingual misoprostol or
-
200 mg oral mifepristone, given the day before the abortion.
1.12.5
For women who are having a surgical abortion between 16+1 and 19+0 weeks' gestation, consider:
1.12.6
For women who are having a surgical abortion between 19+1 and 23+6 weeks' gestation, offer osmotic dilators. In addition, consider:
1.12.7
For women who are having a surgical abortion between 14+0 and 23+6 weeks' gestation and are having cervical priming with osmotic dilators, consider inserting the osmotic dilators the day before the abortion.
1.12.8
Do not offer misoprostol for cervical priming if the woman has had an osmotic dilator inserted the day before the abortion.
Terms used in this guideline
Fetal anomaly
Defined as pregnancies falling within section 1(1)(d) of the 1967 Abortion Act. This covers pregnancies where 2 medical practitioners are of the opinion that 'there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped'. This is referred to as ground E in the HSA1 form.
Feticide
Feticide is the injection of digoxin or potassium chloride into the fetus, or an injection of digoxin into the amniotic cavity, to stop the fetal heart before an abortion.