Clinicians in the emergency department (ED) and primary care settings should be prepared to spot complications of self-managed abortion, according to a case report.

A patient who had attempted self-managed abortion presented to the ED with a ruptured ectopic pregnancy that went undetected, reported Isabel Beshar, MD, of Stanford University in California, and colleagues.

They explained in a correspondence to the New England Journal of Medicine that the 22-year-old patient was just over 5 weeks pregnant when she presented to the ED with severe abdominal pain 6 days after taking the abortion medications mifepristone (Mifeprex) and misoprostol. The patient had no prior births.

ED physicians initially performed a pelvic ultrasound, which showed that the patient had an empty uterus and small-volume intra-abdominal bleeding. Because of the patient’s history of medication abortion, clinicians presumed that the pregnancy was terminated and that the patient’s condition was due to a hemorrhagic cyst rupture.

But another 6 days later, the patient returned to the ED with even more pain. A diagnostic laparoscopy revealed that the patient had a ruptured right tubal ectopic pregnancy that was removed without further complications.

Many states have restricted abortion since the Supreme Court ruling on Dobbs v. Jackson Women’s Health Organization, with at least 13 states banning most of the procedures entirely. Increased abortion restrictions are pushing many patients to self-managed abortion, Beshar told MedPage Today.

Initial evidence shows that self-managed abortion, defined as any action taken to end a pregnancy outside of the formal healthcare system and including the use of abortion medications, has become more common since the Dobbs decision. Daily requests to Aid Access — an online abortion pill provider — jumped from an average of 80 requests a day before the Supreme Court ruling to more than 200 after the decision came down last June, a recent study found.

“Looking ahead, more people will opt to manage their pregnancies outside of the formal medical system,” Beshar said in an email. “The healthcare system has not yet adjusted to this paradigm shift, and this case reflects the current uncertainty around management.”

Beshar added that some people in states that restrict abortion care may not feel comfortable revealing their decision to self-manage, due to “legitimate fear of criminalization.” She said that providers should consider obtaining an ultrasound and assess beta human chorionic gonadotropin (hCG) levels for women presenting with a history of medication abortion, or even those with a positive pregnancy test and pain. “Above all, providers should maintain patient confidentiality and trust,” she added.

Beshar and colleagues stated in the report that clinicians should have increased concerns of ectopic pregnancy in patients with a recent medical abortion who:

• Do not have prior confirmation of intrauterine pregnancy
• Do not have a previous ectopic pregnancy or tubal surgery
• Do not have an intrauterine device
• Do not have an ultrasound showing abdominal free fluid

Daniel Grossman, MD, director of the University of California San Francisco (UCSF) Advancing New Standards in Reproductive Health, was not involved with this case report, but told MedPage Today that as patients present for follow-up care in EDs and primary care settings after attempting to end their pregnancies, it’s “important that clinicians know what’s normal after medication abortion.”

Symptoms such as severe abdominal pain days after a termination can be a red flag for clinicians that patients may need follow-up care, including hCG tests to confirm termination, Grossman said.

“We always have to be alert to someone having an ectopic pregnancy if they have not had a prior confirmation of intrauterine pregnancy,” he added. Grossman encouraged providers to ask patients who present with abnormal symptoms if they’ve had a prior ultrasound to confirm their pregnancy.

Ectopic pregnancy is a “rare, but very serious complication” of pregnancy that is not limited to patients seeking abortion care, Grossman said. The incidence of ectopic pregnancy among patients seeking abortion care is very low, approximately 0.07 per 1,000, Beshar’s group noted. But they added that despite the low risk, ruptured ectopic pregnancy remains an important cause of pregnancy-related morbidity and mortality that clinicians should be aware about.

“While self-managed abortion has been shown to be safe and effective, it does not include some of the same safety checks for rare, but potentially serious, complications such as ectopic pregnancy,” Beshar said. “Healthcare providers caring for people after a self-managed abortion should keep in mind these small risks.”

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