Chapter 3. Recommendations and best practice statements across the continuum of abortion care

Incomplete abortion management: Recommendations 35-38 (3.5.2)

3.5.2 Incomplete abortion

Incomplete abortion is defined by clinical presence of an open cervical os and bleeding, whereby all products of conception have not been expelled from the uterus, or the expelled products are not consistent with the estimated duration of pregnancy. Common symptoms include vaginal bleeding and abdominal pain. Uncomplicated incomplete abortion can result after an induced or spontaneous abortion (i.e. miscarriage); the management in both cases is the same. Incomplete abortion may be managed expectantly, medically or surgically (vacuum aspiration). Managing uncomplicated incomplete abortion with vacuum aspiration (when uterine size is less than 14 weeks) includes recognizing the condition, assessing uterine size, the actual procedure and pain management.

CLINICAL SERVICES Recommendation 35 and 36: Management of incomplete abortion

35. For incomplete abortion at < 14 weeks: Recommend either vacuum aspiration or medical management.

36a. For the medical management of incomplete abortion at < 14 weeks uterine size: Suggest the use of 600 μg misoprostol administered orally or 400 μg misoprostol administered sublingually.

36b. For the medical management of incomplete abortion at ≥ 14 weeks uterine size: Suggest the use of repeat doses of 400 μg misoprostol administered sublingually, vaginally or buccally every 3 hours.*

Remarks:

  • The decision about the mode of management of incomplete abortion should be based on the individual’s clinical condition and preference for treatment.
  • Expectant management of incomplete abortion can be as effective as misoprostol; it can be offered as an option on the condition that the woman, girl or other pregnant person is informed of the longer time for expulsion of the pregnancy tissue and the increased risk of incomplete emptying of the uterus.
  • Recommendation 35 was extrapolated from research conducted in women with reported spontaneous abortion.

* Misoprostol can be repeated at the noted interval as needed to achieve success of the abortion process. At gestational ages ≥ 14 weeks, providers should use caution and clinical judgement to decide the maximum number of doses of misoprostol in pregnant individuals with prior uterine incision. Uterine rupture is a rare complication; clinical judgement and health system preparedness for emergency management of uterine rupture must be considered with advanced gestational age.

Source: Recommendation 35 carried forward from WHO (2012) where it was Recommendation 10 (19). The wording has been revised to amend the gestational age from “13 weeks or less” to “before 14 weeks” (< 14 weeks). Recommendations 36a and 36b carried forward from WHO (2018) where they were Recommendations 1A and 1B (120). The gestational ages have also been updated to change the cut-off point from 13 weeks to 14 weeks.

SERVICE DELIVERY Recommendation 37: Medical management of uncomplicated incomplete abortion with misoprostol at gestational ages < 14 weeks

Type of health worker Recommendation Rationalea
Community health workers (CHWs) Recommend No direct evidence was found for this option, but some indirect evidence was found that CHWs can use simple tools and checklists to determine gestational age (based on patient history), and to assess eligibility for and the outcome of medical abortion (low to moderate certainty). CHWs are often involved in advising women seeking abortion care (moderate-certainty evidence). In general, CHW interventions are acceptable and have proved feasible in many contexts. The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a
Pharmacy workers

Pharmacists

Recommend Although insufficient evidence was found for the safety and effectiveness of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a In addition, the skills required for managing incomplete abortion with misoprostol are similar to those for provision of medical abortion at < 12 weeks, which is a recommended task for these health workers (see Recommendation 28).
Traditional and complementary medicine professionals Recommend   Evidence was found for the safety and effectiveness of these professionals providing medical abortion at gestational ages < 12 weeks (low certainty), and the skills required for managing incomplete abortion with misoprostol are similar. In addition, the skills and knowledge for this task (according to the competency framework) align with the competencies of this type of health worker.a
Auxiliary nurses/ANMs Recommend Evidence was found for the safety and effectiveness of these health workers providing medical abortion at gestational ages < 12 weeks (moderate certainty), and the skills required for managing incomplete abortion with misoprostol are similar.
Nurses Recommend Indirect evidence was found for the safety, effectiveness and acceptability of nurses providing medical abortion (moderate certainty), and the skills required for managing incomplete abortion with misoprostol are similar. The option is feasible and has the potential to increase equitable access to quality abortion care.
Midwives Recommend Evidence was found from a low-resource setting for the safety and effectiveness of this option (moderate to high certainty). Women’s overall satisfaction with the provider was high when midwives manage incomplete abortion (moderate-certainty evidence). This option is feasible and has the potential to increase equitable access to quality abortion care.
Associate/advanced associate clinicians Recommend Moderate-certainty indirect evidence was found for the safety and effectiveness of medical management of incomplete abortion by midwives, and moderate-certainty evidence was also found for the safety and effectiveness of medical abortion provision by health worker types with similar or less comprehensive basic training. Additionally, direct evidence was found that these clinicians can assess gestational age (by uterine size) as part of provision of manual vacuum aspiration. This option is feasible and the potential to increase equitable access to quality abortion care is high.
Generalist medical practitioners

Specialist medical practitioners

Recommend Within their typical scope of practice,b therefore no assessment of the evidence was conducted.
Source: Recommendation updated from WHO (2015) (23).

Note on updating of the recommendation: This was an existing recommendations for which evidence relating to traditional and complementary medicine professionals (previously “suggest”), pharmacists and pharmacy workers (both previously “recommend against”) and community health workers (previously “within the context of rigorous research”) was reviewed using GRADE methodology, since the other health workers already had a strong recommendation for this task. After review, the recommendations were upgraded to “recommend” for all of the reviewed health worker categories. A summary of the evidence is presented in Supplementary material 3, EtD framework on Medical management of incomplete abortion.

a For this and all health worker recommendations, given the limited evidence for many of the health worker–task combinations, the discussions of the expert panel focused on the competency framework in WHO’s 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women’s values and preferences.

b For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.

No requirement for location (on-site vs off-site).

Implementation considerations
  • Restrictions on prescribing authority for some categories of providers may need to be modified or other mechanisms put in place for making the medicines available for these providers within the regulatory framework of the health system.
  • The evacuation of retained products is a signal function of basic emergency obstetric care (EmOC); thus training and implementation of these tasks can be integrated with EmOC services.

SERVICE DELIVERY Recommendation 38: Vacuum aspiration for management of uncomplicated incomplete abortion at gestational ages < 14 weeks

Type of health worker Recommendation Rationalea
Traditional and complementary medicine professionals Recommend Evidence was found for the effectiveness of these professionals carrying out components of the task, such as assessing uterine size with bimanual examination as part of medical abortion provision (very low certainty). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a These professionals perform other transcervical procedures (e.g. IUD insertion) in some settings. This option has the potential to increase equitable access to quality abortion care in regions where these professionals constitute a significant proportion of the health workforce.
Auxiliary nurses/ANMs Suggest

Condition: In contexts where established health system mechanisms involve auxiliary nurses/ANMs in providing basic emergency obstetric care, and where referral and monitoring systems are strong.

Insufficient direct evidence was found for the safety and effectiveness of this option. However, the option of this type of health worker delivering emergency obstetric care (which includes removing retained products as a signal function) or post-abortion care using manual vacuum aspiration has been shown to be feasible in programmes in several low-resource settings.
Nurses Recommend Evidence was found for the safety and effectiveness of these health workers providing vacuum aspiration for induced abortion (low certainty), and the skills required for the management of uncomplicated incomplete abortion with vacuum aspiration are similar. The option is feasible, including in low-resource settings.
Midwives Recommend Indirect evidence was found for the safety and effectiveness of these health workers providing vacuum aspiration for induced abortion (moderate certainty), and the skills required for the management of uncomplicated incomplete abortion with vacuum aspiration are similar. The option is feasible, including in low-resource settings.
Associate/advanced associate clinicians Recommend Indirect evidence was found for the safety and effectiveness of these clinicians providing of vacuum aspiration for induced abortion (moderate certainty), and the skills required for the management of uncomplicated incomplete abortion with vacuum aspiration are similar.
Generalist medical practitioners

Specialist medical practitioners

Recommend Within their typical scope of practice,b therefore no assessment of the evidence was conducted.
Source: Recommendation updated from WHO (2015) (23).

Note on updating of the recommendation: This was an existing recommendation for which evidence relating to traditional and complementary medicine professionals and for auxiliary nurses and auxiliary nurse midwives was reviewed using GRADE methodology. After review, only the recommendation for traditional and complementary medicine professionals was upgraded from “suggest” to “recommend”. For all the other health worker categories, the recommendations remain unchanged from the previous guidance. A summary of the evidence is presented in Supplementary material 3, EtD framework on Vacuum aspiration for management of incomplete abortion.

a For this and all health worker recommendations, given the limited evidence for many of the health worker–task combinations, the discussions of the expert panel focused on the competency framework in WHO’s 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women’s values and preferences.

b For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.

In a health-care facility.

Implementation considerations
  • The skills required for the provision of both MVA and EVA are similar, so the recommendations above apply to both. MVA is more commonly used and more likely to be used in primary care settings.
  • Uncomplicated incomplete abortion can result after an induced or spontaneous abortion (i.e. miscarriage). The management is identical and the above recommendations apply to both.
  • The evacuation of retained products is also a signal function of basic emergency obstetric care (EmOC) and training and implementation can be integrated with EmOC services.

KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO MANAGEMENT OF INCOMPLETE ABORTION

  • States must ensure adequate access to essential medicines in an affordable and non-discriminatory manner.
  • Regardless of whether abortion is legal, States are required to ensure access to post-abortion care where it is needed.
  • Post-abortion care must be available on a confidential basis, including in situations where abortion is illegal.
  • Post-abortion care must be available without the threat of criminal prosecution or punitive measures. States must not require health workers to report persons suspected of undertaking unlawful abortion, or require them to provide any potentially incriminating information during or as a prerequisite to receiving post-abortion care.

For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.