Understanding your options: surgical abortion vs medical abortion

Making the decision to have an abortion can be challenging, and choosing which type of abortion procedure is best for your circumstances can add to the confusion. In this article we discuss the differences between surgical abortion and medical abortion, in order to help you better understand the choices available to you.

Surgical abortion

Surgical abortion is one of the most commonly performed and safest surgical procedures in Australia, with up to 80,000 women undergoing the procedure every year.¹ Most commonly performed in the first trimester, up to 14 weeks’ gestation, surgical abortion has a low complication rate when carried out during this time. While surgical abortion can be performed in the second trimester (up to 20 weeks in most states, and up to 24 weeks in Victoria); this does involve a more complex surgical procedure.

A surgical abortion in the first trimester is most often carried out under ‘twilight sedation’, although the option of a local anaesthetic is available. Once the anaesthetic has taken effect, the doctor inserts a small tube into the uterus and, applying gentle suction, removes the contents and lining of the uterus. This is why a surgical abortion is often called a ‘suction curette’.

The procedure itself takes around 10 minutes; however, from the point of arrival at the clinic, to preparation for the surgery and recovery from the anaesthetic, having a surgical abortion can take 4 – 5 hours. After the anaesthetic has worn off and you have received your aftercare advice, you will need to be driven home.

The risks of surgical abortion

Surgical abortion is one of the safest operations carried out in Australia; however, all surgery carries some risks. Although complications can occur in an estimated 3% of cases, major complications are rare. Below is a list of the risks associated with surgical abortion:

1. Incomplete abortion is the most common complication (up to 2%)², and occurs when a small piece of the pregnancy or lining remains in the uterus. This may result in problematic bleeding or cramping and a repeat procedure may be required.
2. Ongoing pregnancy is uncommon (1 in 500)² but is more likely in procedures performed under 6 weeks.
3. Infection is uncommon (less than 1%)². You will usually be given or prescribed antibiotics with your procedure to reduce the risk.
4. Damage to the cervix is uncommon and rarely has longstanding effects.
5. Perforation of the uterus, where the surgical instruments make a hole in the wall, is potentially the most serious complication but fortunately is rare with an experienced surgeon.
6. Haemorrhage following a surgical abortion in the first trimester is rare.

Women who experience heavy bleeding, fever or severe pain or discomfort following a surgical abortion must consult a doctor as soon as possible.

Why choose surgical abortion?

Overall, surgical abortion is a very safe and highly successful option for termination of pregnancy in the first trimester. The advantages of choosing a surgical abortion are:

• It can be performed later in the pregnancy than a medical abortion;
• The procedure itself takes only a matter of minutes;
• It usually involves only one visit to the clinic;
• There’s usually less bleeding and cramping than with a medical abortion;
• Medical staff are present throughout the procedure;
• It can be performed under twilight sedation, which reduces awareness and pain;
• It has a very low complication rate and a high success rate;
• You can continue to breastfeed, whereas you will need to cease breastfeeding during a medical abortion.

Medical abortion

Medical abortion has been more widely available in Australia since 2012, and is a non-surgical abortion option, available to most women up to 63 days gestation. Choosing between a medical or surgical abortion is very much dependent on your circumstances and personal preference.

For many women, the availability of medical abortion in Australia has meant greater privacy and less invasiveness in accessing a termination. The more recent introduction of medical abortion via teleconsultation has also made early termination more readily available to women living in rural and regional areas or without access to an abortion clinic.

Medical abortion is available once a pregnancy is detected via ultrasound (usually around 5 weeks) up to 9 weeks (63 days) gestation. The abortion is achieved using a combination of two medications which work together to terminate a pregnancy.

1. The first medication is administered by your doctor, or taken by you at home. This medication is an anti-hormone, which acts by blocking the effects of progesterone – the hormone needed for a pregnancy to continue.
2. 24 to 48 hours after taking the first medication, you take the second medication buccally (which means you place the tablets between the cheek and gum for 30 minutes before swallowing any remaining fragments with water).

The second medication opens the cervix and assists the uterus to expel the pregnancy. This should occur between 30 minutes to 24 hours after taking the second medication, but most women can expect to experience some vaginal bleeding, cramps and to pass some pregnancy tissue within 4 hours.

Before being prescribed the medication for medical abortion you must have an ultrasound to determine that you are no more than 9 weeks (63 days) pregnant and to exclude ectopic pregnancy (a pregnancy in the tubes).

Almost all women are suitable for a medical abortion, although there are a few medical conditions that may mean you are not suitable. If you have a bleeding disorder or are on blood thinning medications, if you have adrenal gland problems or are taking corticosteroid medications, such as prednisone, a medical abortion is unsuitable for you. Your doctor will take a medical history to make sure that you are eligible for a medical abortion. You will also need to able access emergency medical care during the time you are having the medical abortion.

The risks of medical abortion

Medical abortion is a safe and effective method of terminating a pregnancy up to 9 weeks’ gestation; however, like surgical abortion, medical abortion carries some risks:

1. Incomplete abortion is the most common complication (1-4%)² and occurs when the pregnancy is not completely expelled from the uterus, causing cramping or heavy bleeding. A surgical procedure may be required if the bleeding or cramping is not settling.
2. Ongoing pregnancy occurs in less than 1% of cases ². A surgical abortion will usually be recommended.
3. Infection is uncommon (less than 1%).²
4. Excessive bleeding severe enough to require a blood transfusion occurs in around 1 in 1,000 cases.²

What to expect after taking the second medication

Vaginal bleeding and cramping is normal and usually starts within a few hours of taking the second medication (misoprostol). The amount of bleeding and cramping varies from patient to patient.

• Bleeding lasts on average 10 to 16 days³ and it is usual for bleeding to be heavier than a normal period for 2 to 3 days.
• Side effects of the medication can also include nausea, vomiting, diarrhoea and chills or fever but these are usually mild and short lived.

Contact the MSI Australia aftercare service if:

• You are soaking more than 2 maxi pads per hour for more than 2 hours;
• You have severe cramps or pain uncontrolled by pain medication;
• You have fever, chills, severe pain or other side effects which continue more than 24 hours after taking misoprostol;
• You have any concerns after taking the medication.

If bleeding does not occur, some patients may require a repeat dose of misoprostol, or another method of termination may be suggested. You should contact your doctor as soon as possible if this occurs.

Why choose a medical abortion?

If your pregnancy is under 9 weeks’ gestation and you prefer not to undergo surgery, then a medical abortion is a good option. Other reasons women choose medical abortion over surgical abortion include:

• It requires no anaesthetic;
• The procedure is non-invasive;
• There is greater privacy than with a surgical abortion;
• As a non-surgical procedure, there are no surgical risks associated with medical abortion;
• You are at home and can have the support of friends and/or family if you choose;
• It can feel ‘more natural’, as it is similar to having a heavy period or miscarriage.

What’s best for you?

Above all, the decision to have a surgical or medical abortion is up to you and has to take into account your particular circumstances, medical history and personal preference. If you are unsure about what is the right option for you, it’s always best to talk to your doctor or make an appointment for a telephone consultation with one of our pre-care nurses.

If you’d like to talk to an experienced and supportive professional about your decision to have an abortion, we provide free over-the-phone pregnancy options counselling.

For more information about surgical or medical abortion, visit our abortion services page.

To make an appointment or to discuss your options, contact MSI Australia.

Sources and references

¹ Better Health abortion procedures information
² Lohr P et al. Abortion: Clinical Review. BMJ 2014; 348:f7553
³ MS Health medical abortion product information