PRE-PROCEDURE MEDICATIONS
Prophylactic Antibiotics
There is strong evidence for the universal use of routine antibiotic prophylaxis in people undergoing uterine aspiration for abortion (Ahmed 2022), and moderate evidence for universal use for early pregnancy loss (Islam 2021). Although the overall risk of infection with abortion is low, people receiving antibiotics were 0.6 times as likely to experience post-abortion uterine infection compared to those receiving placebo in a Cochrane review (Low 2012). This protective effect was evident in people with and without risk factors (history of PID, positive CT, or pre-procedural BV).
Evidence supports dosing up to 12 hours prior to uterine aspiration for maximal effect, and using the shortest possible course to give the lowest risk of adverse reactions and antibiotic resistance (SFP 2025). Data do not support post-procedure antibiotics (SFP 2025).
Recommended antibiotic prophylaxis regimen prior to uterine aspiration include a single dose of the following (ACOG 2018):
- Preferred:
- Doxycycline 200 mg PO
- Alternate:
- Metronidazole 500 mg PO
- Azithromycin 500 mg PO
Cervical Preparation for Aspiration Procedures
Misoprostol and other methods of cervical preparation for uterine aspiration have been well researched. While cervical preparation with misoprostol is generally safe and may decrease procedure time, it is not routinely recommended for uterine aspiration < 10-12 weeks gestation due to increased waiting time, bleeding, cramping, other side effects, and minimal benefit for ease of dilation (Ipas 2022, Kapp 2010). Cervical preparation may be considered in adolescents and for whom initial dilatation is challenging (Allen 2016).
- Preferred: (Meirik 2012, NAF 2024, Sääv 2015)
- Misoprostol 400 mcg buccally or vaginally 2-3 hours pre-procedure,
- or Misoprostol 400 mcg sublingual 1-2 hours pre-procedure
- Alternates:
For further information about cervical preparation for procedures > 14 weeks gestational duration, see Ch. 12: Incremental Expansion of Abortion Care.
Rh-D Immunoglobulin (IG)
Rho-D (Rh-D) alloimmunization may jeopardize the health of a subsequent pregnancy. While past guidelines recommended all people seeking abortion be tested and receive Rh-D immune globulin (anti-D immunoglobulin or RhIG) if Rh negative, new evidence supports that this is unnecessary for pregnancies < 12 weeks duration (Horvath 2023, WHO 2022). Flow cytometry studies show first trimester fetal red blood cell exposure remains below the calculated threshold for maternal Rh sensitization until ≥ 12 weeks of pregnancy (Chan 2021, Hollenbach 2019).
- For those < 12 weeks gestation: Rh testing and RhIG are not recommended during uterine aspiration, medication abortion, or early pregnancy loss (ACOG 2024, NAF 2024, SFP 2022, WHO 2022).
- Rh testing must be offered to people with unknown Rh status ≥ 12 weeks gestation and RhIG must be offered to those who are Rh negative (and who may experience future pregnancies) for prevention of sensitization.
Additionally:
- Rh documentation may be accomplished by onsite testing if CLIA (Clinical Laboratory Improvement Amendments) certified, outside source (such as previous lab result or blood donation card), or self-report. Individuals can self-test with independent labs on demand (Quest, LabCorp) or eldon cards ordered online, with variable reliability.
- A person > 12 weeks gestation declining Rh testing or anti-D IG should sign an informed waiver, including those who desire no future children. Document discussion and waiver for Rh testing as appropriate.
- When RhIG indicated:
- 12 – 18 wks: 100 mcg IM/IV (SFP 2022)
- Anti-D antibodies may be present if someone received an anti-D IG injection within the last 3 months or was sensitized from a prior pregnancy.
- For indications for recurrent RhIG (e.g. a person > 12 weeks with an episode of vaginal bleeding, followed by a planned uterine aspiration), a second injection is indicated only if the previous injection was > 3 weeks prior (Bichler 2003).
- No anti-D IG is indicated for individuals already Rh sensitized.