Managing Ongoing Pregnancy After Early Medical Abortion: A Northern Ireland Perspective

Early medical abortion (EMA) using mifepristone and misoprostol is a safe and effective method of ending a pregnancy before 12 weeks of gestation. Since abortion services were established in Northern Ireland following decriminalisation through the Northern Ireland (Executive Formation etc.) Act 2019 and the adoption of the Abortion (Northern Ireland) Regulations 2020, EMA has become the predominant method of abortion care. In 2024 and 2025, 94.6% of abortions were performed under Ground A (pregnancy not exceeding 11 weeks and 6 days), while 89.1% took place before 10 weeks’ gestation.

Current best practice recommends administration of 200mg oral mifepristone followed 24-48 hours later by 800 micrograms of misoprostol administered vaginally, buccally or sublingually. If expulsion has not occurred after three hours, an additional dose of 400 microgram of misoprostol is recommended. Nevertheless, no medical intervention is entirely without complications and risks. There is approximately a 1-2% risk of an ongoing viable pregnancy following EMA, requiring further counselling and clinical care. Post-abortion follow-up is therefore an important component of abortion care, and women should be advised to contact their abortion provider if there is no bleeding following completion of the mifepristone and misoprostol regimen, or in the event of a positive low-sensitivity pregnancy test three weeks after the abortion.

In cases of unsuccessful EMA a pregnant person who wishes to continue to proceed with abortion care can opt to procced with medical treatment in hospital or opt for surgical management without conditionality up to 23+6 weeks of gestation. A new certification process is not necessary if the EMA has been commenced under Ground A of the Regulations. If the woman opts for medical termination of pregnancy greater than 12 weeks of gestation, she is admitted to hospital for mifepristone and misoprostol as a hospital inpatient. If the woman opts for surgical abortion, she is referred to the South-Eastern Health and Social Care Trust, which acts as the commissioned regional surgical centre in Northern Ireland. Women and pregnant people are pre-assessed and counselled in preparation for a day-case procedure, known as dilatation and evacuation (D&E) under general anaesthetic.

The management of an ongoing viable pregnancy beyond 12 weeks following unsuccessful EMA differs substantially between Northern Ireland and the Republic of Ireland both legally and in clinical practice. The Republic of Ireland operates under the Health (Regulation of Termination of Pregnancy) Act 2018, following the repeal of the 8^th amendment. Whilst abortion is legally available before 12 weeks’ gestation in both the Republic of Ireland and Northern Ireland, the position differs substantially when an early medical abortion is unsuccessful, and an ongoing viable pregnancy is identified beyond 12 weeks. As discussed in Northern Ireland, women can receive continuous treatment under Ground A or be reassessed under the legal grounds applicable after 12 weeks and proceed to definitive treatment. In contrast, the Republic of Ireland has no equivalent legal provision specifically addressing women with an ongoing pregnancy following unsuccessful EMA. Once the pregnancy exceeds 12 weeks’ gestation, abortion is only lawful under the limited statutory grounds set out in sections 9, 10 and 11 (see Box 1). Consequently, women who do not meet these grounds cannot access the care required to complete the abortion within the Republic of Ireland. As a result, women will experience markedly different management of unsuccessful EMA depending on what side of the border they receive care.

Northern Ireland’s regional model demonstrates how collaboration between all five Health and Social Care Trusts can provide local access to abortion care while maintaining specialist surgical expertise within a dedicated regional centre. This networked approach aligns closely with the principles set out in the RCOG Best Practice in Abortion Care, ensuring that care does not end when medication is prescribed but continues until treatment has been safely and successfully completed.

As abortion services continue to evolve and collaborate across both Northern Ireland and the Republic of Ireland, there is an opportunity to learn from each other’s experiences. Creating referral pathways between North and South, expanding specialist training and maintaining integrated multidisciplinary services will help ensure that women experiencing the uncommon circumstance of an unsuccessful early medical abortion receive the high-quality, compassionate care they deserve.

Box 1. Comparison of abortion law in Northern Ireland and the Republic of Ireland

Lyndsay Creswell, Consultant Obstetrician and Maternal and Fetal Medicine Subspecialist, South Eastern Health and Social Care Trust, Ulster Hospital, Northern Ireland

References

1. Information & Analysis Directorate, Department of Health. Northern Ireland Abortion Statistics 2024/25. Published 2025
2. Royal College of Obstetricians and Gynaecologists. Best Practice in Abortion Care. London: RCOG; 2022.
3. Royal College of Obstetricians and Gynaecologists. Best Practice in Post-Abortion Care. London: RCOG; 2022.
4. World Health Organization. Abortion Care Guideline. Geneva: WHO; 2022.
5. Abortion (Northern Ireland) (No. 2) Regulations 2020.
6. Health (Regulation of Termination of Pregnancy) Act 2018 (Republic of Ireland).