By Randall K. O’Bannon, Ph.D. NRL Director of Education & Research
Ectopic Pregnancy, where the developing child implants outside the uterus, occurs in some 1-2 percent of pregnancies, experts tell us. They can be particularly dangerous if not detected and addressed, as the continued growth of the child may eventually lead to the rupture of the fallopian tube and the death of both mother and child.
This is one of the reasons for early ultrasounds, to confirm the child’s safe implantation in the uterus, and one of the reasons why the sending of abortion pills by mail to women who have not been professionally screened by a physician is particularly dangerous.
Correspondence published in the January 19, 2023 issue of the New England Journal of Medicine (NEJM) related the story of a 22-year-old who attempted a “self-managed” abortion with mifepristone and misoprostol she got over the internet [https://www.nejm.org/doi/full/10.1056/NEJMc2214213]. Those are the drugs many U.S. and foreign groups (and soon many U.S. pharmacies) are now selling online and shipping to women’s homes.
The patient was just over 5 weeks pregnant when she showed up at the emergency room with severe abdominal pain. Because she had taken the abortion pills six days earlier, ER doctors presumed, after a pelvic ultrasound showed an empty uterus and a modest amount of bleeding, that she had simply had an abortion and that the bleeding, the pain, and other symptoms she was experiencing were just due to the rupture of a cyst.
When that patient returned another six days later, however, in more pain than before, a more extensive examination revealed that the patient had suffered the rupture of her right fallopian tube from an ectopic pregnancy. That was removed and the doctor says there were no further complications.
There are a couple of important things to note about this case.
First, note how doctor and patient expectations related to the chemical abortion caused them to miss important evidence of an ectopic pregnancy. Because they expected pain and bleeding from the chemical abortion and didn’t find evidence of pregnancy in the uterus with the ultrasound, they assumed the pain and bleeding were just the expected side effects that come with these abortions.
If the patient had not taken mifepristone and misoprostol—the two drugs that make up a “medication abortion” regimen– the doctors would probably have looked more carefully and might have recognized the signs of ectopic pregnancy from the beginning.
Second, though the patient survived in this case, the circumstances were clearly set up so that such an outcome was not guaranteed. Had she waited longer, if she had simply tried and “tough it out,” if she had not returned when she did and challenged the original diagnosis she received, she may well have died.
This is not theoretical. In a June 30, 2021 Postmarketing Adverse Events report, the U.S. Food and Drug Administration (FDA) indicated that it had records of similar circumstances occurring 97 times. On at least two occasions they proved fatal.
Third, telemedical prescriptions and online sales of these drugs with overnight mail delivery are very likely to make things worse.
Though abortion advocates like the doctor publishing this correspondence attribute the increase in “self-managed” or “Do-It-Yourself” (DIY) abortion to increasing restrictions on abortion (Beshar in MedPage Today, 1/18/23), this neglects the major role that the abortion industry has played in pushing and promoting telabortion and home delivery of abortifacients, without the sort of safeguards needed to guard against outcomes like this one.
The attitude of those industry experts who have been pushing these “self-managed” and telemedical abortions appears to be just to heighten awareness of your Emergency Room staff to be on the lookout for such things. Asked about the case, Daniel Grossman, an advocate of the “No-Test” chemical abortion protocol who argues that these can be done without any formal medical tests, says “We always have to be alert to someone having an ectopic pregnancy if they have not had a prior confirmation of intrauterine pregnancy” (MedPage Today, 1/18/23).
The problem is, of course, that this is after-the-fact. After the woman has already received and taken the abortion pills and has been given assurances that her pain and bleeding are normal parts of the chemical abortion process. If she gets to the emergency room in time and the doctor has the medical intuition and wisdom to look past the obvious (but wrong) answer, her ectopic pregnancy may be discovered before it ruptures.
But the crisis could have been averted at the beginning with better, more direct initial screening.
One of the reasons that the FDA insisted for so long that patients needed to pick up their abortion pills in person was to ensure that the woman was professionally screened for conditions such as ectopic pregnancy.
Ideally, this would be done with ultrasound, with technicians specifically looking for signs of ectopic pregnancy. But at a minimum, the doctor could perform a professional exam and check with patients face-to-face as to whether they had any signs or symptoms of an extra-uterine pregnancy.
Supposedly, even with the FDA’s dropping of the in-person distribution requirement, these questions will still be asked by clinicians prescribing these by telemedicine, given that this is a condition of FDA certification. But how careful this screening may be, particularly if left to some low-level functionary designated to handle online sales, is an open question.
It certainly is not something to be expected of the rogue foreign operators selling their knock-off abortion pills who have refused to commit to the FDA’s certification program.
Exactly where and how this woman got her abortion pills is unknown. What we do know is that she was not adequately screened before receiving her pills and that it nearly cost her life.
If these pills are going to become readily available by mail or for pickup at a woman’s local pharmacy, expect more cases like this one.