Clinical Pearls & Morning Reports
Published March 11, 2020
As U.S. abortion laws become increasingly restrictive, people will decide to end pregnancies without clinical supervision. Health care providers must become familiar with the normal course of self-managed abortion with medications and its rare complications, as well as complications of unsafe methods. Read the NEJM Review Article here.
Q: What medications are most often used for self-managed abortion?
A: Worldwide, people increasingly choose misoprostol or a combination of mifepristone and misoprostol to end pregnancies on their own. These drugs are the most extensively studied, safe, and effective agents for clinician-supervised abortion and miscarriage management, as well as for self-managed abortion. After taking the medications, patients have bleeding, cramping, and expulsion of pregnancy tissue at home. The World Health Organization recommends both regimens, preferring those with mifepristone where available.
Q: How widespread are laws that criminalize self-managed abortion in the United States?
A: In addition to becoming familiar with the necessary clinical care after self-managed abortion, doctors should consider their larger role in a legally restrictive environment. Seven states criminalize self-managed abortion, and 24 others have laws that can be interpreted as doing so. However, no state mandates that health care providers report suspected or confirmed self-managed abortion, including for minors. When a facility’s policies — or possibly future laws — restrict needed intervention (e.g., when uterine evacuation is prohibited because of fetal cardiac activity), prompt consultation with lawyers or ethicists may be needed.
A: Patients who have used mifepristone and misoprostol to end pregnancies on their own may be clinically indistinguishable from those who have had uncomplicated spontaneous pregnancy loss. Similarly, patients with complications of self-managed medication-induced abortion and those with complications of miscarriage may have identical clinical presentations. As such, caregivers can usually give care without knowing whether the abortion is self-managed or spontaneous. Although doctors must prepare for acute presentations related to trauma, hemorrhage, or sepsis, growing use of medications for abortion (in contrast to mechanical methods) means that most patients with abortion-related symptoms are in stable condition. Diagnosis and treatment center on determining whether clinically important bleeding or infection is present and whether ectopic pregnancy can be ruled out.
A: Some signs and symptoms associated with complications of abortion may be the same as the signs and symptoms that occur during the normal course of an uncomplicated medication-induced abortion. For example, dizziness can signify either hypovolemia due to hemorrhage or a vagal reaction as tissue passes through the cervix. Low-grade fever can be a typical reaction to misoprostol or may indicate infection. Nausea and vomiting can be due to misoprostol or can be a result of serious infection or bowel injury from uterine perforation. Patients may report tissue passage even if the pregnancy itself has not passed; decidualized endometrium can shed even with ongoing pregnancy. Some presentations suggest a specific diagnosis more readily. For example, severe cramping without bleeding suggests hematometra (accumulation of blood in the uterus) or possibly infection. In contrast, cramping accompanied by bleeding suggests incomplete abortion.