Abortion — MSF Essential obstetric and newborn care

What this guideline says

GMJ summary

This section of the MSF Essential Obstetric and Newborn Care guideline provides comprehensive clinical guidance on managing abortion (spontaneous miscarriage or induced termination) occurring before 22 weeks of pregnancy. The guideline emphasises that in countries with legal restrictions, unsafe induced abortions performed under poor conditions often lead to life-threatening complications including trauma, bleeding, and severe infection.

The document covers diagnosis of threatened, missed, incomplete, and septic abortion, with differential diagnoses including ectopic pregnancy and cervical pathology. Management strategies are differentiated by gestational age (before or after 13 weeks) and clinical presentation, offering both medical management with misoprostol (with or without mifepristone) and instrumental evacuation options. The guideline prioritises manual vacuum aspiration over sharp curettage as less traumatic and painful.

Special attention is given to septic abortion management, requiring immediate antibiotic therapy and uterine evacuation regardless of gestational age, with specific dosing regimens for amoxicillin/clavulanic acid, gentamicin, ampicillin, and metronidazole. Precautions for patients with previous uterine scars, grand multiparity, or uterine overdistention include reduced misoprostol doses and close monitoring for uterine rupture.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Missed abortion before 13 weeks: misoprostol 600 micrograms sublingually or 800 micrograms vaginally, repeat every 3 hours if needed (maximum 3 doses total), or manual vacuum aspiration
2. Missed abortion 13–22 weeks: mifepristone 200 mg PO followed 1–2 days later by misoprostol 400 micrograms every 4–6 hours, or misoprostol alone at the same dose
3. Incomplete abortion before 13 weeks: manual vacuum aspiration preferred, or misoprostol 400 micrograms sublingually or 600 micrograms PO single dose
4. Incomplete abortion 13–22 weeks: misoprostol 400 micrograms sublingually every 3 hours until expulsion; instrumental evacuation if haemorrhage present
5. Patients with ≥2 previous uterine scars, grand multiparity, or uterine overdistention: reduce misoprostol to 200 micrograms every 6 hours and monitor closely for uterine rupture
6. Septic abortion: immediate antibiotics (amoxicillin/clavulanic acid 1 g IV every 8 hours plus gentamicin 5 mg/kg IM once daily, or triple therapy with ampicillin, metronidazole, and gentamicin) and urgent uterine evacuation
7. Continue IV antibiotics until fever resolves (minimum 48 hours), then complete 5 days with oral therapy; treat very severe infections for 10 days
8. Manual vacuum aspiration under local anaesthesia is the method of choice for instrumental evacuation: technically easier, less traumatic, and less painful than curettage

Tetanus prophylaxis

Table extracted from the guideline

Source: Médecins Sans Frontières, Abortion — MSF Essential obstetric and newborn care. Reproduced in summary form.

From the guideline

Verbatim

“Aspiration under local anaesthesia is the method of choice. It is technically easier to perform, less traumatic and less painful than curettage.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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