The NICE guideline on abortion care provides clear, evidence-based recommendations for the safe and effective delivery of abortion services within the legal framework of the Abortion Act 1967. While most procedures occur in specialist settings, primary care clinicians play a critical role in supporting access, informed decision-making, follow-up, and post-abortion care.

Patient-Centered Decision Making

At the heart of the guideline is the principle that patients have the right to participate in informed decisions about their care. This aligns with both NICE’s patient empowerment standards and the 2015 Montgomery ruling, which emphasizes that patients must be provided with all necessary information to make decisions about their treatment.

Implication for GPs: Ensure patients understand their options, including types of abortion, where procedures can take place, and potential emotional and physical outcomes.

Aspect	Details & Relevance
Abortion Act 1967	Regulates lawful conditions and locations for abortion in England, Scotland, and Wales.
Health and Social Care Act 2008	Requires providers to register with the Care Quality Commission (CQC); abortion is a regulated activity.
Additional Standards	GPs should be aware of the guidance from the Department of Health, BMA, RCN, and RCOG.

Medicines Use and Licensing

The guidance includes recommendations involving off-label use of mifepristone and misoprostol. While these uses are evidence-based and endorsed by NICE, they are not within the official UK marketing authorisations.

Medicine	Licensed Use	Off-label Use Highlight
Mifepristone	Approved for specific gestational windows and regimens.	Used in various regimens outside these parameters, particularly in later gestations.
Misoprostol	Approved for limited regimens.	Dosing varies widely depending on gestation and procedure type.

Medical abortion involves a combination of mifepristone and misoprostol, each with distinct but complementary actions. Understanding their mechanisms helps primary care clinicians counsel patients and explain the process confidently.

Mifepristone (Anti-progesterone)

Aspect	Details
Action	Competitive antagonist of progesterone receptors
Effect	Detaches the pregnancy from the uterine lining by disrupting progesterone support to the endometrium
Additional	Softens the cervix and sensitizes the uterus to prostaglandins (misoprostol)

Misoprostol (Prostaglandin E1 Analogue)

Aspect	Details
Action	Binds to prostaglandin receptors in the uterus
Effect	Induces uterine contractions → expulsion of pregnancy tissue
Additional	Also used to prepare cervix for surgical procedures; routes: oral, buccal, sublingual, vaginal

Providing Information – NICE Key Messages

NICE stresses the importance of comprehensive, non-directive, and empathetic communication to support informed decisions around abortion. Clinicians should:

• Reassure that abortion does not increase risks of infertility, breast cancer, or mental health issues.

• Offer balanced information on medical vs surgical abortion using NICE Patient Decision Aids.

• Ensure early, clear explanations of the procedure, including expected pain and bleeding.

• Use a range of accessible formats, including real patient experiences.

• Provide contraception information on request.

• For medical abortions, explain that pregnancy products may be visible during expulsion.

• Advise on what symptoms need medical attention and where to get help.

• Discuss options for handling pregnancy remains if relevant.

• In cases of fetal anomalies, provide clear referral pathways and ongoing emotional support.

Choice of Procedure

Women should be offered a choice between medical and surgical abortion up to 23+6 weeks, with specific considerations for later gestations:

• Offer medical or surgical abortion up to 23+6 weeks, and for post-23+6 weeks, abortion is only legal if feticide is performed at or before 23+6 weeks, as clarified in 2019 (1.6.1).
• Use decision aids to help women choose (1.6.2).

Step	What NICE Recommends	Why It Matters in Primary Care
1. Choice of method (≤23+6 wks)	Offer choice of medical or surgical abortion up to 23+6 weeks; surgical only after this with feticide ≤23+6 wks. Use decision aids	Supports informed consent and patient-centred referrals; use aids in discussions.
2. Early abortion (< definitive scan)	Permit abortion before yolk sac visible on ultrasound if no ectopic symptoms; inform re: ectopic risk, ensure follow-up	Enables quicker care when ectopic is unlikely; primary care can triage and monitor.
3. Home expulsion (≤10 wks)	Up to 9+6 weeks: complete home expulsion; at 10 weeks, clinic misoprostol then home expulsion	Offers convenience and autonomy; GPs can reassure safety and remote follow-up.
4. Medical abortion regimens	≤10 wks: interval treatment (24–48 h). ≤9 wks: simultaneous dosing option. 10+1–23+6 wks: loading misoprostol + repeated dosing every 3 h  24+ wks onward: adjust dose intervals (every 3/4/6 h) based on gestation	Key for counselling on procedure timeline, efficacy and safety.
5. Cervical priming (surgical)	Misoprostol or mifepristone before surgical abortion: dosing depends on gestation; use osmotic dilators ≥14 weeks	Helps structure referral letters and pre-op counselling.
6. Anaesthesia options	Offer local, conscious sedation, deep sedation or GA; prefer IV sedation and propofol + opioid for GA	Aid patients in understanding procedure experience and risks.
7. Follow-up & support	≤10 wks: offer self- or remote assessment with pregnancy test. All abortions: explain aftercare, emotional responses, access to support and counselling	GPs provide essential follow-up, reassurance, and mental health support.
8. Contraception access	Provide full range of reversible contraception same day; implants/IUD at abortion, DMPA with caution	Prevents unintended pregnancy; GPs can follow through.

Expulsion at Home – NICE Recommendations

Gestation	Recommendation	Primary Care Relevance
Up to 9+6 weeks	Offer home expulsion; mifepristone and misoprostol may be taken at home or clinic within legal limits	Inform patients of home option, safety evidence, and legal criteria
10+0 weeks	Offer home expulsion after taking misoprostol in clinic/hospital	Explain partial in-clinic dosing and manage expectations

Medical Abortion Procedures – Stepwise by Gestation

Gestation Range	Regimen	Primary Care Notes
Up to 10+0 weeks	Standard: 24–48 hour interval between mifepristone and misoprostol. Optional: same-day dosing ≤9+0 weeks with risks explained.	Support informed choice; advise on follow-up protocols (1.14.1–1.14.2).
10+1 to 23+6 weeks	200 mg mifepristone → 800 mcg vaginal or 600 mcg sublingual misoprostol → 400 mcg every 3 hours until expulsion. Shorter intervals optional with caveats.	Guide patient expectations and understand duration implications.
After 23+6 weeks	Dose intervals adjusted by gestation; monitor for uterine sensitivity and rupture risks.	Essential for safe referrals and communicating procedural urgency.

Surgical Abortion – Overview for Primary Care

Surgical abortion involves the physical removal of the pregnancy from the uterus using suction or surgical instruments. It is a safe, effective, and quick procedure, typically completed within minutes. NICE NG140 supports surgical abortion at any gestation up to 23+6 weeks, and beyond that if feticide has been carried out ≤23+6 weeks. The procedure choice depends on gestational age, patient preference, medical eligibility, and local service availability.

Primary care teams should be able to explain this option, support patient decision-making, and prepare referrals with awareness of pre-procedure needs like cervical priming and anaesthesia options.

Aspect	Details
Availability	Can be performed up to 23+6 weeks; later only with prior feticide
Pre-procedure Cervical Priming	Needed ≥14 weeks; options include misoprostol, mifepristone, or osmotic dilators based on gestation
Anaesthesia	Local anaesthesia, conscious sedation, deep sedation, or general anaesthesia depending on setting and preference
Duration	Typically <10 minutes; same-day discharge
Primary Care Role	Discuss options, provide early counselling, refer appropriately, manage aftercare and contraception

Anti-D Prophylaxis – Update Summary (NICE NG140, May 2025)

Gestation	Recommendation	What This Means for Primary Care
Up to 11+6 weeks	Do NOT offer anti-D prophylaxis to rhesus D negative individuals	No need to test Rh status or provide anti-D in early abortions (medical or surgical). Aligns with WHO guidance.
12+0 weeks and over	Ensure Rh testing and anti-D is ready at time of abortion – no delays	Confirm anti-D availability without causing any delay to abortion care. Matches RCOG best practice.

Why It Matters

• Improves access by removing unnecessary steps for early abortions.

• Streamlines care and aligns with WHO and RCOG standards.

• Reduces variation and need for further research in this area.

Summary of Key Points

The NICE guideline NG140 on abortion care focuses on improving accessibility, safety, and quality of services. Key points include ensuring legal compliance, informed consent, accessible services with minimal delays, comprehensive information provision, choice of abortion methods, infection prevention, VTE prophylaxis, and detailed procedures for medical and surgical abortions at different gestational ages. The guideline also emphasizes training for healthcare professionals, follow-up care, and support for special populations, while ensuring privacy and avoiding stigma.

Reference: https://www.nice.org.uk/guidance/ng140/chapter/Recommendations#choice-of-procedure-for-abortion