Article Text

Download PDFPDF
Surgical or medical abortion of pregnancies between 13+0 and 23+6 weeks’ gestation? A systematic review and new NICE national guidelines
  1. Mia Schmidt-Hansen1,
  2. Patricia A Lohr2,
  3. Sharon Cameron3,
  4. Elise Hasler1
  1. 1 National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
  2. 2 British Pregnancy Advisory Service (BPAS), Stratford upon Avon, UK
  3. 3 Sexual and Reproductive Health Services, NHS Lothian, Edinburgh, UK
  1. Correspondence to Dr Mia Schmidt-Hansen, National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London SE1 1SZ, UK; MSchmidt-Hansen{at}


Background Abortion in the second trimester may be performed surgically or medically. The objective of this systematic review was to examine the effectiveness, safety and acceptability/satisfaction of surgical compared with medical abortion of pregnancy between 13+0 and 23+6 weeks’ gestation for a new national guideline.

Methods We searched Embase, Medline and the Cochrane Library on 4 March 2019. We included randomised controlled trials (RCTs; any size) and non-randomised comparative studies with n≥100 in each arm, published in English from 1985. Risk-of-bias was assessed using the Cochrane Collaboration checklist for RCTs. Meta-analysis of risk ratios (RRs)

used the Mantel-Haenszel method. The quality of the evidence was assessed using GRADE.

Results Two RCTs (n=140) were included. ‘Incomplete abortion requiring surgical intervention’ was clinically significantly higher with medical than surgical methods (RR=4.58, 95% CI 1.07 to 19.64). ‘Abortion completed by the intended method’ was statistically, but not clinically, significantly lower after medical than surgical methods, but was marked by high between-study heterogeneity (RR=0.88, 95% CI 0.79 to 0.98). To the extent that ‘haemorrhage requiring transfusion/≥500 mL blood loss’, ‘uterine injury’, ‘cervical injury requiring repair’ and ‘infection reported within 1 month of abortion’ were reported, they did not differ significantly between methods. Depending on measurement method, ‘patient satisfaction/acceptability’ was either clinically significantly higher or comparable after surgical than medical methods. The quality of this evidence was limited by low event rates and attrition bias.

Conclusion Based on this evidence and consensus, women should be offered the choice of medical or surgical methods of abortion between 13+0 and 23+6 weeks’ gestation, unless not clinically appropriate.

  • abortion
  • family planning service provision

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors PAL, SC, EH and MSH conceived and designed the review and wrote the protocol. EH devised and undertook the search strategy. MSH screened the search results and performed the data extraction and 'risk of bias' assessment of the included studies. MSH devised and performed the analysis strategy. PAL and SC interpreted the results. PAL, MSH, SC and EH wrote the first draft of different sections of the full review. All the authors critically revised the first draft of the review and approved the final version of the review.

  • Funding This article presents a systematic review undertaken as part of the 2019 National Institute for Health and Care Excellence (NICE) guideline on ‘Abortion Care’. This work was undertaken by the National Guideline Alliance (NGA) at the Royal College of Obstetricians and Gynaecologists (RCOG), which received funding from NICE. The funding body (NICE) did not play any direct role in the study design; the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The views expressed in this publication are those of the authors and not necessarily those of the NGA, RCOG or NICE. All researchers involved in this work were independent from the funding body at the time of completing this work.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.