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Complications of Unsafe and Self-Managed Abortion Lisa H The new england journal of medicine Review Article Edward W. Campion, M.D., Editor Complications of Unsafe and Self-Managed Abortion Lisa H. Harris, M.D., Ph.D., and Daniel Grossman, M.D. hen abortion is legally restricted or otherwise inaccessi- From the Department of Obstetrics and ble, girls, women, and those who care about them look outside formal Gynecology and the Department of 1 Women’s Studies, University of Michigan, medical care to end pregnancies. Worldwide, people increasingly choose Ann Arbor (L.H.H.); and the Department W of Obstetrics, Gynecology, and Repro- misoprostol or a combination of mifepristone and misoprostol to end pregnancies on their own (referred to as self-managed abortion).2-4 These medications are ductive Sciences, Advancing New Stan- dards in Reproductive Health (ANSIRH), safer and more effective than older, invasive techniques of self-managed abortion, and the Bixby Center for Global Repro- and patients who have used these medications may be clinically indistinguishable ductive Health, University of California, from those who have had uncomplicated spontaneous pregnancy loss.1-5 Similarly, San Francisco, San Francisco (D.G.). Ad- dress reprint requests to Dr. Harris at patients with complications of self-managed medication-induced abortion and lhharris@ med . umich . edu. those with complications of miscarriage may have identical clinical presentations. N Engl J Med 2020;382:1029-40. As U.S. abortion laws become increasingly restrictive, people will decide to end DOI: 10.1056/NEJMra1908412 pregnancies without clinical supervision. Health care providers must become fa- Copyright © 2020 Massachusetts Medical Society. miliar with the normal course of self-managed abortion with medications and its rare complications, as well as complications of unsafe methods. This review pro- vides the information clinicians need to prepare for an increasingly restrictive legal climate for abortion. Ultimately, we conclude that appropriate care is centered on two clinical concepts. First, because medication-induced abortion and spontane- ous abortion are clinically similar processes, care can usually be given without knowledge of whether the abortion is self-managed or spontaneous. Second, be- cause medication-induced abortion is safe, many patients who seek care will re- quire only confirmation that their abortion is complete or outpatient intervention for incomplete abortion. In contrast, those using unsafe methods may need life- saving critical care for sepsis, hemorrhage, pelvic-organ injury, or toxic exposures. The hallmark of skilled care in this new era will be judicious use of intervention in most cases and readiness for aggressive treatment when needed. Appropriate care also involves understanding that women’s legal safety — their risk of prosecution — may be the biggest threat to their well-being. Seven states criminalize self-managed abortion, and 24 others have laws that can be inter- preted as doing so.6 However, no state mandates that health care providers report suspected or confirmed self-managed abortion, including for minors.6 Indeed, reporting may violate patients’ privacy rights and result in penalties for those who report. Reporting is also problematic because caregivers are more likely to report women of color and low-income women than white or affluent women in similar circumstances.7 When patients present with bleeding in pregnancy and caregivers involve the police, patients may face detention and prosecution, regardless of whether they induced the abortion. Background Before 1973, when abortion was illegal in most U.S. states, approximately 800,000 illegal abortions took place annually, although the clandestine nature of illegal n engl j med 382;11 nejm.org March 12, 2020 1029 The New England Journal of Medicine Downloaded from nejm.org at Universite de Strasbourg on March 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. The new england journal of medicine abortion makes enumeration imprecise.8 As ac- States, at least for now, 2 to 7% of patients seek- cess to legal abortion increased after Roe v. Wade, ing this service report efforts to self-induce abor- morbidity and mortality from illegal abortion tion.26,27 They do so for a variety of reasons, includ- declined by a factor of nearly 8.9 Similar precipi- ing those related to privacy, cost, distance from tous declines in mortality occurred with the legal- clinics, and a preference for self-managed care.28 ization of abortion in Romania and South Africa.10 Not all methods of self-managed abortion are Before U.S. legalization of abortion, some effective or safe. Women in the United States women found relatively safe methods of self- report using herbs, including rue, sage, St. John’s managed abortion; others used dangerous means, wort, and black or blue cohosh, among other such as vaginal or cervical insertion of imple- understudied methods generally thought to be ments, objects, or caustic substances.11 Some ineffective.28 Toxic reactions and even death have women were able to obtain safe surgical abor- been reported with some of these substances, tion care — for example, with lay caregivers of especially rue.29 In rare cases, women in the the Jane Collective. Other women underwent United States have also reported the use of other surgery performed by inadequately trained pro- means, such as vaginal insertion of implements viders. Pelvic-organ injuries, hemorrhage, dan- or objects or abdominal trauma to try to disrupt gerous clostridial infections, and sepsis resulted, their pregnancy.30 leading to emergency hysterectomies and some- Data are limited on self-managed abortion times death. Doctors working in hospitals at during the second trimester. The mifepristone– that time recall the regularity with which pa- misoprostol combination is probably the safest tients presented with life-threatening complica- method.13 The research gap here is important, tions,12 and some hospitals had entire clinical since approximately two thirds of deaths world- wards dedicated to septic abortion. wide from unsafe abortion involve attempts after More recently, women worldwide have been the first trimester.31 managing abortion with the use of mifepristone If U.S. abortion law is further restricted, and misoprostol or with misoprostol alone. some of the nearly 1 million people seeking These drugs are the most extensively studied, abortion care annually will travel for medically safe, and effective agents for clinician-super- supervised, legal care. However, since 75% of vised abortion and miscarriage management, as patients seeking abortion are poor or low- well as for self-managed abortion13-21 (Table 1). income,26 many will need alternatives. Some will After taking the medications, patients have self-induce abortion using safe medications that bleeding, cramping, and expulsion of pregnancy they have obtained themselves. Others, lacking tissue at home. The World Health Organization access or relying on misinformation, will use recommends both regimens, preferring those dangerous methods. Emergency-department (ED) with mifepristone where available.13 With clini- physicians, obstetrician–gynecologists, family cal supervision, major complications associated physicians, and internists will have a role in all with the combination of mifepristone and miso- these care paths. They will need to know where prostol (those requiring hospitalization, surgery, abortion care is legally available and be familiar or blood transfusion) are rare, occurring in 0.3% with resources to assist patients (see Table S1 in of cases. Mortality is approximately 0.65 deaths the Supplementary Appendix, available with the per 100,000 medication-induced abortions, mak- full text of this article at NEJM.org). They will ing medical abortion more than 13 times as safe also need to understand the normal course of as childbirth in the United States.22-24 medication-induced abortion and be prepared to Evidence from Ireland, Peru, and other coun- manage its rare complications. Finally, along tries indicates that using these medications with subspecialist consultants, they will need to outside of clinician supervision is also effective effectively manage the life-threatening compli- and associated with a low rate of complica- cations of unsafe abortion methods. tions.2-4 In Latin America, where abortion has Although prevention of undesired pregnancy historically been legally restricted, the increase should remain a public health focus, restrictions in self-managed abortion with misoprostol has on funding for contraceptive services make ac- been associated with reduced maternal mortal- cessing family planning even harder for people ity.25 Though abortion is legal in the United with low incomes, contributing to an increase in 1030 n engl j med 382;11 nejm.org March 12, 2020 The New England Journal of Medicine Downloaded from nejm.org at Universite de Strasbourg on March 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. Table 1. Common Medication Regimens for Induced Abortion, Miscarriage, and Incomplete Abortion.* Downloaded fromnejm.orgatUniversite deStrasbourgonMarch14,2020.Forpersonaluseonly.Nootheruses withoutpermission. Overall Ongoing Clinical Scenario Medication Regimen Success† Pregnancy‡ Comments % of cases Induced abortion At ≤10 wk of gestation Mifepristone, 200 mg administered orally, followed 97 0.7 Failure increases
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