Pregnant women who present to the emergency department (ED) with complaint of severe abdominal pain after self-managed medical abortion should be evaluated for ruptured ectopic pregnancy, suggests a case report published in the New England Journal of Medicine.¹

The 22-year-old patient developed severe pain in abdomen 6 weeks following a self-induced medical abortion with a combination of mifepristone and misoprostol for which she presented to the ED. The woman was 5 weeks pregnant and had no previous births. A pelvic USG performed in the ED revealed a small amount of intra-abdominal bleeding and an empty uterus. This led to the assumption that the pregnancy was terminated and the probability of rupture of a hemorrhagic cyst. However, the patient revisited the ED after a week with severe pain. A diagnostic laparoscopy was done, which revealed a right tubal ectopic pregnancy, which was removed without more complications.²

Ectopic pregnancy is a significant cause of morbidity during the first trimester of pregnancy. It is also a potential life-threatening complication. Several risk factors have been identified such as pelvic inflammatory disease (PID), periconceptional smoking, pelvic surgery, IUDs and previous ectopic pregnancy

This case report elucidates the association between induced abortion and ectopic pregnancy and highlights induced medical abortion as a risk factor for ectopic pregnancy. Severe abdominal pain after a medical self-induced abortion is a “red flag” for further evaluation including hCG to confirm complete abortion. A decrease of ~50% in beta-hCG within 24 hours denotes complete termination of pregnancy.³ Although the risk is very low, clinicians managing such patients should be aware of this association and have a high index of suspicion for ruptured ectopic pregnancy in patients 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”²

References

1. Beshar I, et al. Discovery of an ectopic pregnancy after attempted self-managed abortion. N Engl J Med. 2023 Jan 19;388(3):278-279. doi: 10.1056/NEJMc2214213.
2. Amanda DAmbrosio. https://www.medpagetoday.com/obgyn/abortion/102689. Dated Jan. 18, 2023, Accessed on Jan. 19, 2023.
3. Creinin MD, et al. Change in serum beta-human chorionic gonadotropin after abortion with methotrexate and misoprostol. Am J Obstet Gynecol. 1996 Feb;174(2):776-8. doi: 10.1016/s0002-9378(96)70463-5.