Abortion is one of the safest and most common outpatient procedures performed in the United States. One in four women have an abortion in their reproductive lifetime.1 Yet restrictive abortion laws have skyrocketed, making access limited for many despite abortion being legal. Between 2017 and 2020, 227 laws restricting abortion access were enacted compared to 29 laws expanding access.2 The June 24 Supreme Court decision on the Dobbs v. Jackson Women’s Health Organization case overturned the landmark decision in Roe v. Wade, removing constitutional protection of abortion.
Explore This IssueACEP Now: Vol 41 – No 08 – August 2022
The fall of Roe will create a state-by-state patchwork of those who have access to abortion services and those who do not. After this decision, it is expected that emergency departments (ED) will see an increase in patients who have a newly diagnosed pregnancy, are suffering from miscarriages or pregnancy-related complications, have accessed abortions locally or across state lines, or have self-managed their abortions. This article aims to review important aspects of the clinical management and counseling of these patients and outlines how the ED can collaborate effectively with their obstetrics and gynecology (OB/GYN) colleagues.
Your Patient is Diagnosed with an Intrauterine Pregnancy
Emergency physicians should be knowledgeable about clinical next steps for patients who are still making or have already made decisions about their early pregnancy. If providing patients with clinic referrals, emergency physicians should beware of crisis pregnancy centers (CPCs). These centers are usually staffed by non-medical personnel, are meant to dissuade patients from seeking abortions through misinformation and intimidation, and currently outnumber abortion clinics by three to one in some states and as high as nine to one in others.3,4 Plan in conjunction with your OB/GYN department to ensure the ED has a vetted list of both prenatal and family planning clinics to offer patients for follow-up.
Your Clinically Stable Patient is Considering Abortion
Emergency physicians should have basic knowledge regarding both up-to-date medication abortion and surgical abortion methods. In addition, they should be aware of restrictions on these options in the state in which they practice. Medication abortion, taken up to 10 weeks gestation, consists of the medication abortion pill—mifepristone 200mg—followed by misoprostol 800 µg 24–48 hours later. This method is 98 percent effective and is used by an estimated 60 percent of those who choose abortion early in pregnancy.5 Ninety five percent of patients should expect bleeding and cramping within 24 hours of taking misoprostol.
The alternative to medication abortion is a surgical option by either manual uterine aspiration (MUA) or electrical vacuum aspiration, also called dilation and curettage (D&C) or dilation and evacuation (D&E). These procedures can be performed in outpatient clinical settings and carry minimal risk. D&Cs are typically used up to 14 weeks gestation with D&E procedures being utilized beyond the second trimester.
The legal landscape for patients who wish to pursue abortion is both complicated and changing rapidly. Emergency physicians and patients alike need to understand the abortion laws in their states of practice, as obtaining an abortion can be time sensitive based on weeks of gestation. Abortions are safer, less expensive, and more likely to be available and legal earlier in pregnancy. Discharge papers should include the weeks of gestation as determined by ultrasound to facilitate the patient’s ability to pursue abortion based on state specific constraints.
What are Self-Managed Abortions?
Patients may disclose that they have self-managed an abortion. Self-managed abortions (SMA) are defined as abortions obtained outside formal health care systems, which most commonly include self-sourced medications (mifepristone and/or misoprostol, often obtained online), but the term can also include the use of herbs, blunt abdominal trauma, or the introduction of instruments into the intrauterine cavity. Research has shown that SMA with mifepristone and misoprostol can be safe and effective, and people who have SMAs are able to date their pregnancy and use these medications appropriately without the need to seek care at a medical facility.6 Approximately seven percent of U.S. women have attempted SMA at some point in their lifetime although SMA rates tend to be higher in states with greater abortion restrictions.7 SMA is considered a crime in three states: Oklahoma, South Carolina, and Nevada (after 22 weeks).8
Your Patient Had an Abortion or is Miscarrying
Following today’s SCOTUS ruling, it is likely there will be an increase in patients seeking care in your ED following SMA, abortions obtained outside their usual physician (and possibly out of state), or a pregnancy-related issue such as miscarriage. SMAs are clinically indistinguishable from miscarriages; between 500,000–900,000 women seek care in the ED with miscarriage-related concerns each year.9,10 Out of fear of criminalization, patients may not disclose if they initiated the abortion themselves.
Apart from stabilizing patients with significant bleeding, the standard work-up for every patient should include an ultrasound to determine if there are retained products of conception, an ongoing intrauterine pregnancy (evidenced by a yolk sac or embryo), or an ectopic pregnancy (many patients with SMA will not have had an ultrasound to exclude ectopic pregnancy), a complete blood count if concern for severe hemorrhage, type and screen, and beta hCG level. Traditionally, type and screen for Rh status has been necessary, however, newer data suggest that Rhogam is unnecessary under 12 weeks gestation.11 However, if there is any question regarding the gestational duration, giving Rhogam should always be the default. If an ultrasound reveals nonviable retained products of conception and the patient’s bleeding is stable (i.e., less than two pads per hour for two hours in a row) an additional 800mcg vaginal or buccal dose of misoprostol can be given in the ED or prescribed to be taken at home. If the patient is clinically unstable or having significant vaginal bleeding, they may require uterine aspiration to stop the bleeding, so consult your OB/GYN team. For more complex miscarriages, such as those in the second trimester (e.g., pre-viable preterm rupture of membranes or significant bleeding with ongoing fetal cardiac activity), timely involvement of OB/GYN colleagues for escalation of care will be necessary.
If there is concern for a septic abortion and the patient has a fever, lower abdominal tenderness, purulent vaginal discharge, or signs of sepsis with retained products of conception, prompt evaluation by the OB/GYN team should occur. If a patient has an acute peritoneal abdomen, consider possible uterine perforation or bleeding from a possible non-disclosed abortion procedure or mechanical SMA attempt, obtain imaging, and involve consultants early.
It is important to provide a safe and judgment free space for patients. Physicians do not have any obligation to disclose whether a patient had a SMA. Remember that doing so may lead to criminalization of the patient in some states. Akin to caring for ED patients with opiate use disorder or alcohol intoxication, our primary role is to care for the patient at hand, to maintain patient confidentiality and compliance with HIPAA laws, and supporting the patient’s confidence and trust in the medical system.
How Emergency Physicians Can Work with Their OB/GYN Departments to Prepare
Emergency departments are already busy places and while it is unclear currently how many patients will travel for abortion care, over 68,000 patients sought abortion care out-of-state in 2017. Increasingly restrictive state laws will likely put more pressure on patients to travel. Lack of access to their regular care providers leaves the ED as a main source of medical care, and patients who continue to have vaginal bleeding or complications from abortions may bounce back to the ED for repeat visits.
With few exceptions, post-abortion patients will have identical needs to those with first trimester miscarriage, so this is the time to invest in collaborative streamlined miscarriage care with your OB/GYN colleagues. Suggested steps:
- Identify an OB/GYN and emergency physician champion to lead an interdepartmental grand rounds.
- If manual uterine aspiration is not already offered in your ED, consider establishing a protocol to make it available at the bedside. This is becoming standard of care in the ED in the U.S. and is typically provided by OB/GYN consultant teams in ED for miscarriage patients with unstable bleeding or inadequate follow up. MUAs provide definitive management and are 97 percent effective at uterine evacuation after a single procedure which can help decrease ED bounce backs. The procedure compares favorably to misoprostol alone. MUAs are also very safe and have a much lower risk profile than many procedures commonly performed in the ED. MUAs decrease cost, length of stay, and operating room resource utilization.12
- Invite your Legal or Risk Management teams to review the need for continued commitment to patient privacy, autonomy, and HIPAA compliance to assure physicians and emergency department staff avoid reporting patients who have had abortions.
- Involve nursing leadership in planning decisions and meet with nursing and tech staff separately to hear any concerns.
In light of the June 24 SCOTUS ruling and as abortion restrictions progress in some states, it is increasingly important for emergency physicians to be well-versed in pregnancy, abortion, and miscarriage management and to collaborate with OB/GYN colleagues in order to provide compassionate, patient-centered care, minimize trauma, and prevent criminalization of patients.
Read ACEP’s statement on this SCOTUS ruling here.
Read Regs & Eggs special edition on EMTALA requirements here.
Dr. Koyama (@kiddoc47) is a pediatrician specializing in Pediatric Emergency Medicine and Adolescent Medicine.
Lauren Paulk (@laurenbpaulk) is Senior Research Counsel at If/When/How, where she focuses on in-depth legal research in support of If/When/How’s litigation and policy team and state and grassroots advocates.
Dr. Quinley (@KQ_MD) is a practicing emergency physician and currently works in two community clinical teaching hospitals in the Northern California Bay Area, and provides educational lectures and support to the Highland Hospital Emergency Medicine Residency.
Dr. Zahedi-Spung, is a Maternal Fetal Medicine specialist with Regional Obstetrical Consultants in Chattanooga, TN and an Instructor for the University of Tennessee Department of Obstetrics and Gynecology.
- Jones RK, Jerman J. Population Group Abortion Rates and Lifetime Incidence of Abortion: United States, 2008–2014. Am J Public Health. 2017 Dec;107(12):1904–9.
- Gaj EB, Sanders JN, Singer PM. State Legislation Related to Abortion Services, January 2017 to November 2020. JAMA Intern Med. 2021 May 1;181(5):711–3.
- Bryant AG, Narasimhan S, Bryant-Comstock K, Levi EE. Crisis pregnancy center websites: Information, misinformation and disinformation. Contraception. 2014 Dec 1;90(6):601–5.
- Swartzendruber A, English A, Greenberg KB, Murray PJ, Freeman M, Upadhya K, et al. Crisis Pregnancy Centers in the United States: Lack of Adherence to Medical and Ethical Practice Standards; A Joint Position Statement of the Society for Adolescent Health and Medicine and the North American Society for Pediatric and Adolescent Gynecology. J Pediatr Adolesc Gynecol. 2019 Dec 1;32(6):563–6.
- Cohen RH, Teal SB. Medication for Early Pregnancy Termination. JAMA [Internet]. 2022 Jun 2 [cited 2022 Jun 8]; Available from: https://doi.org/10.1001/jama.2022.6344.
- Conti J, Cahill EP. Self-managed abortion. Curr Opin Obstet Gynecol. 2019 Dec;31(6):435–40.
- Ralph L, Foster DG, Raifman S, Biggs MA, Samari G, Upadhyay U, et al. Prevalence of Self-Managed Abortion Among Women of Reproductive Age in the United States. JAMA Netw Open. 2020 Dec 1;3(12):e2029245.
- Self-Managed Abortion: Know Your Rights [Internet]. [cited 2022 Jun 5]. Available from: https://www.reprolegalhelpline.org/sma-know-your-rights/
- Miller CA, Roe AH, McAllister A, Meisel ZF, Koelper N, Schreiber CA. Patient Experiences With Miscarriage Management in the Emergency and Ambulatory Settings. Obstet Gynecol. 2019 Dec;134(6):1285–92.
- Benson L, Magnusson S, Gray KE, Quinley KE, Kessler L, Callegari L. Early pregnancy loss in the emergency department, 2006–2016. J Am Coll Emerg Physicians Open. 2021.
- Abortion Care Guidlines [Internet]. Geneva: World Health Organization; 2022 [cited 2022 Jun 1]. 210 p. Available from: https://www.who.int/publications/i/item/9789240039483
- Blumenthal PD, Remsburg RE. A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 1994 Jun;45(3):261–7.