Management of Termination of Pregnancy at Primary Health Care Level: Gestation up to 12 Weeks and 0 Days

General measures

Medicine treatment

Referral

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O04.9

GENERAL MEASURES

• Confirm pregnancy with urine pregnancy test.
• Determine gestational age with ultrasound. If ultrasound is unavailable, use dates (LMP) and bimanual (pelvic) examination.
• If unsure of dates, or examination disagrees with dates, or uterus palpable abdominally, or the woman is obese or difficult to examine, arrange pre-procedure ultrasound.
• Ultrasound is mandatory if suspected ectopic pregnancy – refer if uncertain.
• Counselling.
• Outpatient procedure by nursing staff with specific training.
• Screen for STIs (if treatment needed, do not delay TOP).
• Arrange Pap smear if needed.
• Check HIV status, Hb and blood group (Rh).
• Counsel and start contraception post TOP, before leaving facility. Arrange contraception follow-up.

MEDICINE TREATMENT

Medical TOP - if gestation ≤ 12 weeks and 0 days:

• Mifepristone, oral, 200 mg, immediately as a single dose.

LoE:IIIb⁴

Followed 24–48 hours later by:

• Misoprostol, SL, 800 mcg by self-administration at home*.
  • If expulsion does not occur within 4 hours of misoprostol administration, a second dose of misoprostol 400 mcg, oral/PV may be given.
  • *From >9 weeks to ≤ 12 weeks- return to the facility within 48 hours to take misoprostol on-site (early morning) due to the risk of heavy bleeding.

LoE:IIIb⁵

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Note:
Bleeding may persist for up to 1 week. If there is no bleeding after the second dose of misoprostol, the woman must return to the facility as soon as possible as there is a possibility of an incomplete procedure or ectopic pregnancy.

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LoE:IIIb⁶

For pain:
After administration of mifepristone, start:

• Paracetamol, oral, 500 mg to 1 g, 4 to 6 hourly as required (to a maximum of 4 g in 24 hours).
  • Maximum dose: 15 mg/kg/dose.

LoE:IVb⁷

ADD
After expulsion is complete:

• Ibuprofen, oral, 400 mg 8 hourly with or after a meal, as needed for 2 to 3 days.

LoE:IVb⁸

OR

TOP using manual vacuum aspiration (MVA) - if gestation ≤ 12 weeks and 0 days:

• Misoprostol, PV, 400 mcg 3 hours before vacuum aspiration of the uterus.

LoE:IVb⁹

Routine analgesia for vacuum aspiration:

• Morphine, IM, 0.1 mg/kg 30 minutes before aspiration procedure, to a maximum of 10 mg (Doctor prescribed).

LoE:IVb¹⁰

Alternatively, consider paracervical block if trained in technique. See the: Adult Hospital Level STGs and EML, TOP: Management of pregnancies up to the twelfth week of gestation (12 weeks and 0 days)

Oral analgesia as required for 48 hours:

• Paracetamol, oral, 500 mg to 1 g 4 to 6 hourly as required (to a maximum of 4 g in 24 hours).
  • Maximum dose: 15 mg/kg/dose.

LoE:IVb¹¹

AND

• Ibuprofen, oral, 400 mg 8 hourly with or after a meal, as needed for 2 to 3 days.

LoE:IVb¹²

Contraception:

Counsel all women on effective contraception, especially long-acting reversible methods.

All methods can be given at the time of the procedure, with the exception of the IUCD at a medical TOP.

LoE:IVb¹³

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Review all patients after 7 days: if bleeding persists, arrange urgent ultrasound.

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REFERRAL

• If gestation ≥12 weeks and 1 day.
• If gestation uncertain.
• If any signs or symptoms of ectopic pregnancy or other early pregnancy complications.
• Co-morbid conditions (heart disease, asthma, diabetes, anaemia, clotting disorder, seizure disorder, substance abuse, hypertension).
• Large fibroids (may interfere with determining gestation age and/or MVA).
• Any signs of sepsis (tachycardia, hypotension, pyrexia, tachypnoea, offensive vaginal discharge).
• If gestation ≥ 9 weeks and 1 day and MVA not available or declined, refer.

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2025-9_Version 1.0_26 March 2026

Chapter 6: Obstetrics and Gynaecology_6.3.1 Management of Termination of Pregnancy at Primary Health Care Level: Gestation up to 12 Weeks and 0 Days