In the wake of the U.S. Supreme Court's decision to overturn Roe v. Wade in June 2022, access to surgical abortion became increasingly restricted in several states, pushing many women to pursue medication abortions.
But the case of a 22-year-old who took mifepristone and misoprostol -- bought on the internet to end a pregnancy -- serves as a cautionary tale.
She was about six weeks pregnant based on her last menstrual period and developed severe abdominal cramps six days after taking mifepristone.
She thought she had had a "regular" pregnancy, but after increased pain and two visits to the emergency department, doctors instead diagnosed a life-threatening ruptured ectopic pregnancy. An ectopic pregnancy occurs when a fertilized egg grows outside of the uterus, usually in the fallopian tube. It requires immediate surgery.
The danger is that in its earliest stages, when medical abortion pills are indicated, a woman may not know that a pregnancy is ectopic.
Fortunately, this woman was treated without complications.
While rare, this situation could occur more frequently due to abortion restrictions, according to Dr. Isabel Beshar, co-author of a research letter describing the case in the Jan. 19 issue of the New England Journal of Medicine.
"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," said Beshar, a resident at Stanford University School of Medicine in California.
A medication abortion involves two drugs: mifepristone and misoprostol, which can end an early pregnancy. Mifepristone blocks the hormone progesterone needed for pregnancy, and misoprostol brings on cramping and bleeding to empty the uterus. More than half of U.S. abortions are now done using pills rather than surgery, according to the Guttmacher Institute, a research group that supports abortion rights.
Access to medical abortion has increased in the wake of the Dobbs decision that overturned Roe v. Wade. Now, retail pharmacies like CVS and Walgreens can fill prescriptions for mifepristone, and the U.S. postal service will continue to deliver these medications to people with a prescription. Recent research shows that medical first-trimester abortions are safe and effective.
Google searches for medication abortion surged after the Dobbs decision, Beshar said. "Looking ahead, more people will opt to manage their pregnancies outside of the formal medical system," she said.
“The health care system has not yet adjusted to this paradigm shift, and this case reflects the current uncertainty around management," Beshar noted. "With time, we anticipate health care providers will become more comfortable assessing people after self-managed abortion."
Risk factors for ectopic pregnancy include a history of prior ectopic pregnancy, sexually transmitted infections or previous surgery on the fallopian tubes, the two tubes that connect the ovaries to the uterus, she said.
“People with these risk factors should consider speaking with a physician before self-managing an abortion," Beshar said. However, this isn’t always an option as doctors can face prosecution for discussing abortion in some states with bans.
Outside experts agree that this case serves as a cautionary tale.
This story "outlines just one reason why abortion bans and restrictions are so harmful," said Dr. Jen Villavicencio. She is the lead for equity transformation at the American College of Obstetricians and Gynecologists.
"While medication abortion is safe and effective, there are some instances in which it may be contraindicated or in which a different treatment protocol would be more appropriate," she said.
"This patient did the right thing by seeking medical attention when something didn’t feel right. Too many patients will not have that opportunity or will be penalized for doing so," Villavicencio said.
Signs of an ectopic pregnancy
It can be hard to tell the difference between ectopic pregnancy symptoms and typical pregnancy symptoms early on, Villavicencio said. Early signs of an ectopic pregnancy may include abnormal vaginal bleeding, low back pain, mild pain in the abdomen or pelvis, or mild cramping on one side of the pelvis.
"If that ectopic pregnancy continues without treatment, more serious symptoms may develop, which would include sudden severe pain in the abdomen or pelvis, shoulder pain, weakness, dizziness or fainting," Villavicencio said. If this occurs, go to an emergency room, she said.
"Because of the Dobbs decision, we will see more patients without access to abortion and without access to gynecologic and obstetric care," Villavicencio said. "Data show that abortion restrictions do not decrease the rate of unintended pregnancies, so it is likely that we will see more people forced to self-manage their abortions."
Dr. Eran Bornstein agreed. He is vice chair of obstetrics and gynecology at Lenox Hill Hospital in New York City.
"Although this is an overall uncommon scenario, given the potential catastrophic outcome of undiagnosed ruptured ectopic pregnancy, efforts to minimize such cases is crucial," he said.
"Clinical scenarios in which a pregnant person, and especially one with underlying risk factors for ectopic pregnancy, self-manage abortion without confirming it is an intrauterine pregnancy [a normal pregnancy inside the uterus] is likely to result in more complications from undiagnosed ectopic pregnancy, as the authors presented," Bornstein said.
Women who are at high risk to develop ectopic pregnancies should have an early ultrasound to confirm the location of the pregnancy and assure it is not an ectopic pregnancy, he said.
"I would generally recommend taking the pills only after ultrasound confirmation of intrauterine pregnancy to avoid potential complications from misdiagnosis and wrong treatment," Bornstein said.
The American College of Obstetricians and Gynecologists provides more on ectopic pregnancies.
SOURCES: Isabel Beshar, MD, MPH, resident, Stanford University School of Medicine, Stanford, Calif.; Eran Bornstein, MD, vice chair, obstetrics and gynecology, Lenox Hill Hospital, New York City; Jennifer Villavicencio, MD, MPP, lead, equity transformation, American College of Obstetricians and Gynecologists, Washington, D.C.; New England Journal of Medicine, Jan. 19, 2023