USA: Sepsis after attempted self-induced abortion

A case report in the Western Journal of Emergency Medicine raises some useful questions about the practice of self-induced abortion in parts of the developed world, where abortion is legal and generally available. 

The authors note:

‘While unsafe abortions have become rare in the United States, the practice persists. We present a 24-year-old female with a 21-week twin gestation who presented to the emergency department with complications of an attempted self-induced abortion. Her complicated clinical course included sepsis, chorioamnionitis, fetal demise, and a total abdominal hysterectomy with bilateral salpingo-oophorectomy for complications of endomyometritis. We discuss unsafe abortions, risk factors, and the management of septic abortion. Prompt recognition by the emergency physician and aggressive management of septic abortion is critical to decreasing maternal morbidity and mortality.’

As Kelly Culwell, MD, MPH, of IPPF notes, this case report is interesting for a number of reasons. One is that it highlights the unusual character of such events in countries like the USA: ‘Of the approximately 20 million unsafe abortions that occur globally each year, all but half a million are estimated to occur in developing countries. [1] In countries like the United States, which liberalized its abortion law nationally in 1973, septic abortion cases after self-induced abortion are now rare enough to be presented as published case reports, as in this article.’ Although the woman suffered from serious complications and the consequent loss of her uterus and ovaries, because she received prompt treatment she did not die.

The case is also unusual, writes Culwell, because it appears in an academic journal about emergency medicine rather than a journal of reproductive health. ‘As clinical academic articles tend not to describe the social circumstances around the case, we don’t know what lead to this woman having attempted a self-induced abortion. Was she unable to find a safe abortion provider? Did she only discover she was pregnant after her first trimester and was then unable to find a provider who offered second trimester procedures? Was she unable to afford the cost of the procedure, which is not covered in US military facilities, like the site of this report? Did she fear the stigma of seeking abortion care and fear a service in a safe clinical setting would not be confidential?’ Without understanding the particular circumstances surrounding this woman’s self-induced abortion, it is difficult to draw general conclusions about why she undertook this course of action. 

However, as Culwell concludes: ‘What is clear is that even in a country with a less restrictive abortion law, there still exist obstacles that prevent women from obtaining high quality safe abortion care. And even when faced with obstacles – many of which are erected purposefully to limit women’s access to safe abortion – a woman who has decided that she cannot continue a pregnancy may resort to any means necessary in order to end that pregnancy, even if it means risking death.’ While events such as these should be recognised as rare, they nonetheless provide a useful counter to complacent assumptions that all women who need abortions can readily access them, particularly in later gestations.

[1] Sedgh G et al. (2007) Induced abortion: estimated rates and trends worldwide. Lancet (9595):1338-1345.

The Back Alley Revisited: Sepsis after Attempted Self-Induced Abortion. Saultes TA, Devita D, Heiner JD. Madigan Army Medical Center, Department of Medicine, Tacoma, WA, USA. Western Journal of Emergency Medicine. 2009 November; 10(4): 278–280.

Discussed in IPPF Abortion Abstract 212, 9 February 2010.