Medical Assessment After Self-Managed Abortion

M.A. is a 24-year-old patient who presents to my office two weeks after using abortion pills that she ordered online because abortion is now illegal in this state. M.A. reports that she took 200 mg of mifepristone orally 10 weeks after her last menstrual period. Twenty-four hours later, she took four misoprostol (Cytotec) pills buccally. When nothing happened, she stated that she took another misoprostol dose, after which she experienced heavy bleeding and cramping. Ten days later, she is still bleeding irregularly. She is wondering whether this is normal or whether she is still pregnant. How should I answer her questions? What are my legal risks in this situation?

The American politicolegal landscape surrounding abortion and routine pregnancy care has been changing rapidly since the 2022 Supreme Court of the United States issued its decision on Dobbs v. Jackson Women's Health Organization.¹

Patients and physicians face uncertainty about how abortion and miscarriage care may be accessed and what legal liability they may face. One grassroots response has included a dramatic increase in accessing medication abortion pills outside established health care systems, such as online pharmacies, telehealth visits with physicians from other countries, or even informal networks.^2,3 Patients commonly access resources such as Plan C, Mayday Health, and the Miscarriage + Abortion Hotline (833-246-2632). The hotline is staffed by more than 60 volunteer clinicians—mostly family physicians—and offers medical information via phone and text.²

Family physicians may be asked to evaluate patients who have self-managed an abortion or miscarriage without prior consultation. Studies of medication abortion provision through telemedicine have demonstrated that limited clinical evaluation before using medications for induced abortion is safe and effective; the sparse existing data around self-managed abortion echo these findings.⁴ Two clinical questions typically arise after self-managed abortion or miscarriage: Is the bleeding normal? and Is the abortion complete?

For the family physician, the medical assessment is identical regardless of whether the bleeding is spontaneous or induced. Treating a resolving miscarriage is the same as treating a self-managed medication abortion. Only clinically relevant information should be documented in the medical record, such as estimated gestational age, timing of bleeding, and any pregnancy symptoms before and after the bleeding.⁵ The use of pills to start this process does not affect subsequent treatment and may be omitted from the medical record.⁶

BLEEDING

It is rare for miscarriages or abortions to result in life-threatening bleeding.⁷ Physicians can assess anemia or bleeding as they would for any other medical scenario that might result in symptomatic anemia by asking patients about feeling faint, whether they have maintained hydration during the process, and about the number of pads that they are soaking through. Physicians who evaluate these patients in their office can consider checking a point-of-care hemoglobin level or obtaining a complete blood count. Bleeding is considered worrisome if the patient is soaking through more than two large pads per hour for two consecutive hours (e.g., four large pads in two hours); this occurrence is rare. Figure 1 provides an approach that can help physicians triage phone calls about bleeding.⁸