Unsafe abortion

INTRODUCTION — Access to safe abortion care is an essential component of comprehensive health care. In settings where abortion is restricted, patients access abortion outside of the formal healthcare system; this may be performed by an untrained clinician or be self-managed (self-managed abortion; SMA). SMA can be performed "safely" (usually through the internet with self-procured mifepristone and misoprostol) or "unsafely" (often with herbal preparations, self-inflicted trauma or uterine instrumentation, or toxic substances).

Safe abortion (typically performed with a combination of mifepristone and misoprostol, though other regimens may be used) is associated with few adverse events and the overall death rate from safe abortion is far less than the maternal mortality rate among live births in the United States. By contrast, unsafe abortion is associated with high morbidity and mortality.

Unsafe abortion is presented here. Safe abortion, including first- and second-trimester medication and procedural pregnancy termination, as well as septic abortion, are presented separately.

●(See "Overview of pregnancy termination".)

●(See "First-trimester pregnancy termination: Medication abortion".)

●(See "First-trimester pregnancy termination: Uterine aspiration".)

●(See "Overview of second-trimester pregnancy termination".)

●(See "Septic abortion: Clinical presentation and management".)

DEFINITIONS — The World Health Organization (WHO) defines "safe" abortion as abortion in countries where abortion law is not restrictive (ie, abortion is legally permitted for social or economic reasons, or without specification as to reason) or countries in which, despite restrictions, safe abortion is broadly available [1].

Conversely, "unsafe" abortion is performed by people lacking the necessary skills using a hazardous technique, and/or in an environment that does not meet minimum medical standards. Similar to WHO definitions, the Society of Family Planning (SFP) defines unsafe abortion as an abortion performed by an unskilled or untrained provider using unsafe (eg, ingesting toxic substances, abdominal trauma, intrauterine instrumentation) or less-studied (eg, herbal preparations, botanicals) methods to terminate a pregnancy [2]. (See 'Methods of unsafe abortion' below.)

The WHO has adopted a focus on safety to emphasize the procedure and its context rather than placing blame on the patients undergoing the procedure or emphasizing its legality [3].

EPIDEMIOLOGY — It is estimated that 25 million unsafe abortions occur worldwide each year, and historically 97 percent of these abortions occur in resource-limited countries [4]. The incidence is lower in resource-rich countries where there is often better access to contraception, and medication and procedural abortion. In both resource-limited and resource-rich settings, those most vulnerable to undergoing unsafe abortions are individuals who are younger, poorer, and lack partner support [5].

Unsafe abortions also occur in countries with legal abortion. For example, in a 2011 cross-sectional study in the United States including 9500 people undergoing abortion, 1.4 percent reported they had used a substance other than misoprostol to self-induce abortion [6]. This number is expected to increase as abortion restrictions increase [7,8].

METHODS OF UNSAFE ABORTION — Safe methods for abortion are discussed separately. (See "Overview of pregnancy termination".)

Unsafe, or less safe, methods may include [7,9-12]:

●Oral and injectable treatments – Oral and injectable treatments such as metal salts, phosphorus, lead, kerosene, turpentine, detergent solutions (eg, bleach), chloroquine, hormones (eg, gynaecosid), and numerous teas and herbal remedies (eg, vitamin C, parsley, Dong Quai, rose hips, gingerroot, chamomile, ruda [rue], Carachipita, arnica, bardana, sage, St. John's wort, black or blue cohosh, pennyroyal).

Patients may also attempt to use large doses of oral contraceptive pills or analgesic medications [13].

In a study including 30 patients in the United States who self-induced their abortions with medications, the most common methods were vitamin C, aspirin, laxatives, oral contraceptives, hormonal injections, and unspecified pills (not misoprostol) or injections [14].

●Preparations placed in the cervix, vagina, or rectum – Such preparations may include potassium permanganate tablets, herbal preparations, detergents, and enemas.

●Intrauterine instrumentation – Intrauterine instrumentation may include catheter insertion followed by infusion of alcohol, saline, or other solution, or insertion of foreign bodies. Penetration with sharp objects (eg, coat hanger, knitting needle) with potential for uterine perforation and use of unclean instruments (eg, unsterilized catheters) are methods that pose the highest risks for morbidity and mortality [9].

Transcervical introduction of compounds such as mixtures of soap, cresol, and phenol can cause renal toxicity, cardiac toxicity, and death [15].

●Trauma to the abdomen – Trauma may include self-inflicted blows to the abdomen, abdominal massage, jumping from an unsafe height, and lifting heavy weights. Traditional practitioners commonly use vigorous abdominal massage with the idea that this will result in disruption of the pregnancy; this has resulted in uterine rupture and other morbidity [16].

In one qualitative study including 14 individuals that attempted self-managed abortion (SMA) in the United States, approximately half used herbal substances; others used prescription or over-the-counter medications, and one attempted intrauterine instrumentation [17]. None used mifepristone or misoprostol.

MORBIDITY AND MORTALITY

●Morbidity – In resource-limited countries in 2015, it was estimated that seven million females (estimated rate of 6.9 per 1000) were treated for complications related to unsafe abortion [18,19].

In a systematic review of 43 studies evaluating patients hospitalized with abortion-related complications in areas where most abortions are unsafe (14 countries in Africa, six countries in Asia, four countries in Latin America), the type and median prevalence of complications were [20]:

•Hemorrhage – Severe 3 percent, nonsevere or unspecified 44.2 percent

•Anemia – 38.1 percent

•Infection – Severe 5.1 percent, nonsevere or unspecified 24 percent

•Trauma – Severe 7.2 percent, nonsevere or unspecified 5.5 percent

•Renal failure – 1.6 percent

Most patients had more than one complication. Such complications may lead to death or other long-term sequelae (eg, infertility).

Factors that increase morbidity at the time of unsafe abortion include [21]:

•Lack of provider skill

•Poor technique

•Unsanitary conditions for performing the procedure

•Lack of appropriate equipment

•Use of toxic substances

•Poor maternal health

•Higher gestational age

•Lack of access to postabortion care

In addition, social stigma, legal threats, and fear can prevent individuals who undergo unsafe abortion from accessing postabortion care, which is a critical aspect of reducing morbidity and saving lives.

●Mortality – Death due to unsafe abortion varies widely by setting and is subject to underreporting [20,22]. In resource-rich settings, it is estimated that 30 females die for every 100,000 unsafe abortions [23]. Mortality is higher in resource-limited settings (220 deaths per 100,000 unsafe abortions) and is even higher in certain regions (520 deaths per 100,000 unsafe abortions in sub-Saharan Africa).

Factors that increase morbidity also increase mortality and are described in detail above.

CLINICAL PRESENTATION — The clinical presentation after unsafe abortion may mimic that of safe abortion and pregnancy loss (miscarriage); however, providers generally do not need to differentiate between these entities to care for the patient [24]. (See "Pregnancy loss (miscarriage): Clinical presentations, diagnosis, and initial evaluation", section on 'Clinical presentations'.)

Such patients may present to several different types of facilities (eg, emergency department, outpatient clinic) and have a variety of presentations. Some patients present to confirm their abortion is complete, while others present because of complications they are unable to manage at home.

●Hemorrhage – Hemorrhage is the most common presentation after unsafe abortion and may present with symptoms suggestive of heavy blood loss (eg, feeling dizzy, faint, having loss of consciousness). Diaphoresis, pallor, dyspnea, tachycardia, hypotension, and orthostasis are often late signs of hemorrhage, especially in young healthy patients. (See "Overview of pregnancy termination", section on 'Hemorrhage'.)

Vaginal bleeding is often present in patients with retained products of conception (RPOC) or those with vaginal, cervical, and uterine lacerations from trauma (eg, insertion of a foreign body into the vagina and/or uterus). By contrast, intraabdominal bleeding is more common in patients with uterine perforation, abdominal trauma, or lacerations that occur laterally (particularly near vessels in the parametrial space).

●Infection – Infection may present with abdominal and/or pelvic pain, malodorous vaginal discharge, fever and chills, vaginal bleeding or spotting, or uterine or adnexal tenderness. Infection may also present as sepsis, septic shock, organ failure, and disseminated intravascular coagulation. (See "Overview of pregnancy termination", section on 'Infection/retained products of conception'.)

●Trauma/Injury – Abortion-related trauma (eg, insertion of a foreign body into the vagina and/or uterus, direct abdominal trauma) may result in injuries to the genital tract, including vaginal and cervical lacerations, uterine perforation, and chemical burns. Patients with lacerations or uterine perforation may present with hemorrhage or symptoms and signs of infection. Patients who have used or been administered local (ie, vaginal) toxic substances may present with chemical burns to the vagina.

●Drug toxicity – Patients may present with symptoms and signs (eg, physiologic excitation and/or depression) of drug toxicity. (See "General approach to drug poisoning in adults", section on 'Physical examination'.)

•Herbal preparations – Multiorgan failure has been observed in patients that ingest certain herbs such as ruda, Carachipita, arnica, and bardana. Hepatoxicity may occur with ingestion of pennyroyal or black cohosh (table 1). Pulmonary aspiration with chemical pneumonitis may occur with ingestion of turpentine. Death has been observed in patients that ingest ruda or Carachipita [25]. (See "Hepatotoxicity due to herbal medications and dietary supplements", section on 'Specific hepatotoxic herbs' and "Acute hydrocarbon exposure: Clinical toxicity, evaluation, and diagnosis", section on 'Hydrocarbon ingestion'.)

•Misoprostol – While misoprostol is overall a very safe medication, cases of poor misoprostol drug quality and toxicity at very high doses (eg, 3 to 8.5 mg) have been reported [26-30]. For comparison, the standard dose for medication abortion is 800 mcg, and cumulative doses of up to 2.2 mg administered over a period of 12 hours have been described with no serious adverse effects [31].

Manifestations of misoprostol toxicity may include high fever, shaking chills, abdominal cramping, vomiting, diarrhea, tremor, agitation, confusion, rhabdomyolysis, hypoxemia, and hypotension [28-30,32]. Symptoms develop soon after ingestion, as misoprostol is rapidly absorbed (it is completely absorbed from the stomach 1.5 hours after ingestion). One case of a pregnant adolescent was reported who experienced stomach and distal esophagus necrosis, upper gastrointestinal bleeding, sepsis, multiorgan failure, and ultimately death after ingesting 12 mg of misoprostol orally [33].

DIAGNOSTIC EVALUATION

History — A focused history is obtained, including date of last menstrual period, risk factors for ectopic pregnancy (table 2), and (for patients who disclose their pregnancy) if an intrauterine pregnancy has been confirmed previously. However, many patients will not disclose their pregnancy or unsafe abortion procedure, even in settings where abortion is legal [34]. Thus, clinicians should always consider the possibility of pregnancy during the initial medical assessment of a reproductive-age patients with a uterus.

It is important to initially limit questions to those that are necessary for evaluation and treatment of an unsafe abortion. For example, a clinician can chart that a patient is pregnant and is bleeding, without specifying if the pregnancy was desired [35]. In the United States, clinicians are not required to report an abortion to law enforcement authorities and disclosure may violate Health Insurance Portability and Accountability Act (HIPPA) privacy rules [36,37]. It is important to note that Black, Hispanic, and low-income individuals are more likely than White or high-income individuals to be targeted by the criminal justice system [38,39].

Physical examination — Hemodynamic stability is assessed and those with life-threatening hemorrhage and/or infection are identified. Physical examination should also assess for findings consistent with drug toxicity (eg, gastrointestinal distress, hyperthermia, tachycardia) [40]. This is discussed in detail separately. (See "General approach to drug poisoning in adults", section on 'Physical examination'.)

A complete pelvic examination is performed, although this may be deferred in unstable patients until after stabilization (eg, with vascular access and blood product replacement). Speculum examination is used to assess for cervical dilation, blood clot or tissue in the cervical os or vagina, active bleeding from the cervical os, sanguinopurulent and/or malodourous discharge, and vaginal or cervical lacerations. Bimanual pelvic examination is used to assess for cervical motion tenderness, deep vaginal lacerations, adnexal and/or abdominal tenderness, adnexal masses, and uterine enlargement, tenderness, and tone. A tender and/or boggy uterus is concerning for infection or retained products of conception (RPOC); cervical dilation and uterine enlargement may also be present with RPOC. By contrast, a vaginal or cervical laceration, or uterine perforation, should be suspected in the setting of heavy vaginal bleeding with firm uterine tone.

Laboratories — Laboratory studies may include the following: complete blood count; Rh blood type and crossmatching (for patients with heavy bleeding); quantitative beta human chorionic gonadotropin (hCG; if an intrauterine pregnancy has not been confirmed); comprehensive metabolic panel; lactate (if there is concern for sepsis or injury to the adjacent viscera [ie, bladder, bowel]); and toxicology screen (if there is concern for intentional or unintentional poisoning). (See "Ectopic pregnancy: Clinical manifestations and diagnosis", section on 'Human chorionic gonadotropin' and "General approach to drug poisoning in adults", section on 'Diagnosis of poisoning'.)

Rh testing, with administration of Rhogam to Rh negative individuals, is generally not needed for patients at early gestational ages (eg, <8 to <12 weeks). This is discussed in detail separately. (See "Overview of pregnancy termination", section on 'Alloimmunization prevention'.)

Imaging studies — Transvaginal ultrasound (by a clinician with expertise in gynecologic ultrasound) is the preferred initial imaging study in patients presenting with unsafe abortion. Ultrasound can evaluate for RPOC, ongoing intrauterine pregnancy, ectopic pregnancy, adnexal masses, hematometra, and intrabdominal bleeding.

However, for hemodynamically unstable patients, a bedside transabdominal ultrasound may be used to quickly assess for intraperitoneal hemorrhage.

MANAGEMENT

Hemorrhage — Initial management of patients with hemorrhage includes vascular access and blood product replacement. Intravenous fluids may be given to hypotensive patients but are generally avoided in patients with hemorrhage given the increased risk of coagulopathy from dilution of clotting factors and platelets. If disseminated intravascular coagulopathy (DIC) is suspected, treatment may also include administration of clotting factors and platelets. These are discussed in detail separately. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient" and "Evaluation and management of disseminated intravascular coagulation (DIC) in adults", section on 'Treatment'.)

For patients with hemorrhage in whom the suspicion for retained products is low:

●Initial management includes uterine massage, administration of a uterotonic agent (eg, misoprostol 400 mcg sublingually; methylergonovine 0.2 mg intramuscularly [IM]; carboprost 0.25 mg IM every 15 to 90 minutes, as needed, to a total cumulative dose of 2 mg [eight doses]), an intrauterine pack, and/or an intrauterine balloon. (See "Postpartum hemorrhage: Medical and minimally invasive management", section on 'Administer additional uterotonic medications' and "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device".)

●Subsequent management for hemodynamically unstable patients or in patients in whom bleeding is unable to be controlled with conservative measures, includes uterine artery embolization or hysterectomy. (See "Postpartum hemorrhage: Medical and minimally invasive management", section on 'Consider uterine or hypogastric artery embolization' and "Postpartum hemorrhage: Management approaches requiring laparotomy", section on 'Role of hysterectomy'.)

Management of patients with hemorrhage and suspected RPOC or hemorrhage due to trauma are described below. (See 'Retained products of conception' below and 'Trauma/injuries' below.)

Infection — Infection from unsafe abortion may be caused by RPOC, trauma, or nonsterile techniques and can result in sepsis, septic shock, organ failure, DIC, and future sterility.

Infection is usually due to Enterobacteriaceae, streptococci, staphylococci, and enterococci. Mixed infections, anaerobic organisms, and fungi also occur.

Management of such patients includes immediate initiation of broad-spectrum antibiotics and surgical evacuation of the uterus; this is discussed in detail separately. (See "Septic abortion: Clinical presentation and management", section on 'Management'.)

Trauma/injuries

Lacerations — Lower genital tract lacerations generally require surgical repair. Pressure (with a finger, sponge stick, or damp gauze pack) may be applied to sites of active bleeding while waiting for a gynecologist or other surgeon.

For patients with lacerations extending into the peritoneal cavity, laparotomy or laparoscopy may be needed to assess for other intra-abdominal trauma and for repair. (See "Evaluation and management of female lower genital tract trauma".)

Uterine perforation — For patients with suspected uterine perforation, there is a low threshold for surgical exploration, as uterine perforation cannot be confirmed or excluded with any imaging study, and it is often difficult to ascertain if there is injury to surrounding structures. In hemodynamically stable patients, laparoscopy may allow for initial assessment of intra-abdominal trauma and laparotomy may be avoided if bleeding is controlled and bowel, bladder, and blood vessels are intact. Laparotomy is generally needed for hemodynamically unstable patients or in whom there is a high suspicion for intra-abdominal organ injury. (See "Uterine perforation during gynecologic procedures", section on 'Management'.)

Chemical burns — For patients with chemical burns, the type and potency of the toxic agent and duration of contact primarily determine the degree of tissue destruction. As with drug toxicity, management of chemical burns can be complex, and we recommend clinicians consult with a medical toxicologist or poison control center about specific exposures. This is discussed in more detail elsewhere. (See "Topical chemical burns: Initial evaluation and management" and 'Drug toxicity' below.)

Retained products of conception — For hemodynamically unstable patients with hemorrhage and suspected RPOC, either based on clinical or ultrasound findings, uterine evacuation is performed with dilation and curettage or evacuation. For hemodynamically stable patients with vaginal bleeding and suspected RPOC, options include expectant management, medical management (eg, misoprostol), or surgical evacuation of the uterus. How to choose between treatment options, as well as their detailed descriptions, are described separately. If intrauterine instrumentation is performed, antibiotic prophylaxis is administered. (See "Retained products of conception in the first half of pregnancy", section on 'Management'.)

Not all patients with suspected RPOC require management. For asymptomatic patients in whom ultrasound examination demonstrates a thickened endometrium or enhanced myometrial vascularity (EMV), treatment may not be needed [41]. This is discussed in detail separately. (See "Retained products of conception in the first half of pregnancy", section on 'Asymptomatic patients with suspected RPOC'.)

Drug toxicity — Management of drug toxicity is generally supportive as patients may not know or disclose which medications or herbs they ingested. However, some patients may be critically ill and require life-saving treatments. (See "General approach to drug poisoning in adults" and "Initial management of the critically ill adult with an unknown overdose".)

For patients with misoprostol toxicity (eg, hyperthermia, tachycardia, metabolic acidosis, rhabdomyolysis), treatment includes removing any remaining tablets from the vagina or cheeks and supportive care until symptoms resolve, which takes approximately 12 hours [28,30,32,40,42]. If more expedient removal is needed and the misoprostol was taken orally or buccally, activated charcoal may be used, but misoprostol is completely absorbed from the stomach 1.5 hours after ingestion, so this is often not helpful. It is not known if misoprostol acid is dialyzable. However, because misoprostol is metabolized like a fatty acid, it is unlikely that dialysis would be appropriate treatment for overdosage [43]. Treatment of rhabdomyolysis is discussed elsewhere. (See "General approach to drug poisoning in adults" and "Prevention and treatment of heme pigment-induced acute kidney injury (including rhabdomyolysis)".)

For patients with mifepristone toxicity (rare), treatment may also include gastrointestinal decontamination [40]. As mifepristone has antiglucocorticoid activity, it can precipitate acute adrenal insufficiency or crisis, and steroid administration may be required in some patients.

Regional poison control centers in the United States are available at all times for consultation on patients who are critically ill, require admission, or have clinical pictures that are unclear (1-800-222-1222). In addition, some hospitals have clinical and/or medical toxicologists available for bedside consultation and/or inpatient care. Whenever available, these are invaluable resources to help in the diagnosis and management of ingestions or overdoses. Contact information for poison centers around the world is provided separately. (See "Society guideline links: Regional poison control centers".)

PREVENTION — The prevention of unsafe abortion requires a multifaceted approach including [44-47]:

●Expanded access to safe abortion. Historically, liberalization of abortion laws has resulted in increased access to safe abortion. In Romania, the 1989 repeal of laws banning contraception and abortion was associated with a 50 percent decrease in maternal mortality within one year [48]. In the United States, the number of abortion-related deaths fell after Roe v. Wade in 1973: from almost 40 per million live births in 1970 to 8 per million live births in 1976, in part due to the increased availability of legal abortion [49]. With increased restrictions in the United States and the overturn of Roe v. Wade in 2022, this rate is expected to increase again [8]. In contrast to the time before Roe v. Wade, safe self-managed abortion (SMA) using self-procured mifepristone and misoprostol may be a key component in ensuring safety. (See "First-trimester pregnancy termination: Medication abortion", section on 'Self-managed'.)

●Prevention of unintended pregnancy. This can be done by maintaining (or increasing) access to contraceptive services.

Victims of intimate partner violence are also at risk for unintended pregnancy and abortion, as well as other health consequences. A study by the World Health Organization (WHO) estimated that reducing intimate partner violence by 50 percent could potentially reduce unintended pregnancy by 2 to 18 percent and abortion by 4.5 to 40 percent, according to population-attributable risk estimates [50].

●Provision of high-quality postabortion medical care. Postabortion care is critical for reducing morbidity and mortality given early recognition and management of complications. Patients can also be offered contraception counseling at that time. (See "Contraception: Postabortion".)

●Reduction of restrictive abortion policies and stigma. Abortion is least safe where it is most restricted. In countries where abortion is highly restricted, only 25 percent of abortions are safe; by contrast, in countries where abortion is unrestricted, 87 percent of abortions are safe [4].

OTHER HEALTH CONSEQUENCES OF ABORTION RESTRICTION — In addition to unsafe abortion, abortion restriction may lead to other health consequences. Such consequences may include [51-54]:

●Delays in treatment for patients with ectopic pregnancy or septic abortion [55].

●Limitations in treatment options for patients with obstetric (eg, fetal anomalies, previability preterm prelabor rupture of membranes [PPROM] or chorioamnionitis, early onset pre-eclampsia with severe features) or other medical (eg, patients with cancer) conditions [56-60].

●Limited access to emergency contraception.

●Limited access to methotrexate or misoprostol for treatment of other medical conditions (eg, rheumatoid arthritis, pregnancy loss).

●Increased hesitancy to prescribe teratogenic agents (eg, isotretinoin, valproate) for treatment of other medical conditions (eg, moderate to severe acne vulgaris, focal or generalized seizures, bipolar disorder) [61,62].

●Limited access to assisted reproductive technology procedures (eg, in vitro fertilization [IVF]).

●Increasing requests for permanent sterilization procedures.

●Increasing rates of economic insecurity (eg, food and housing insecurity, loss of employment) [63,64] and children placed into foster care [65].

●Increasing rates of domestic violence.

●Exacerbation of pre-existing, or new onset of, mental health disorders [62,66].

●Increasing rates of suicide. In a longitudinal study including data from the US Centers for Disease Control and Prevention (CDC) between 1974 and 2016, increased enforcement of laws restricting access to abortion was associated with more than a fivefold increase in suicide rates among females ages 20 to 34 years (coefficient of interest 0.17, 95% CI 0.03-0.32) [67]. By contrast, rates of suicide are not increased in patients who undergo pregnancy termination. (See "Pregnancy termination and potential psychiatric outcomes", section on 'Suicide'.)

●Increased rates of maternal and infant mortality [68].

A registry has been established to better understand how clinical care has changed since Roe v. Wade was overturned; information about this registry is available online.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pregnancy termination".)

SUMMARY AND RECOMMENDATIONS

●Definition – Unsafe abortion is defined by the Society of Family Planning (SFP) as an abortion performed by an unskilled or untrained provider using unsafe (eg, ingesting toxic substances, abdominal trauma, intrauterine instrumentation) or less-studied (eg, herbal preparations, botanicals) methods to terminate a pregnancy. (See 'Definitions' above.)

●Methods of unsafe abortion – The four major methods of unsafe abortion are (see 'Methods of unsafe abortion' above):

•Oral and injectable treatments (eg, metal salts, phosphorus, lead, kerosene, turpentine, detergent solutions, chloroquine, hormones, and numerous teas and herbal remedies).

•Preparations placed in the cervix, vagina, or rectum (eg, potassium permanganate tablets, herbal preparations, enemas).

•Instrumentation of the uterus (eg, catheter insertion followed by infusion of alcohol, saline, or other solution; insertion of foreign bodies).

•Trauma to the abdomen.

●Morbidity and mortality – The most common complications from unsafe abortion include hemorrhage, anemia, infection, and trauma (eg, uterine perforation, vaginal and cervical lacerations, chemical burns). Complications may lead to death or other long-term sequelae (eg, infertility). (See 'Morbidity and mortality' above.)

●Presentation – Patients undergoing unsafe abortion may present to several different types of facilities, have a variety of presentations, and may disclose neither their pregnancy nor unsafe abortion procedure, even in settings where abortion is legal. (See 'Clinical presentation' above.)

●Management – Management includes stabilization of the patient, followed by treatment of the underlying complication (eg, hemorrhage, infection, injury). (See 'Management' above.)

•Hemorrhage – For patients with hemorrhage and in whom no retained products of conception (RPOC) are suspected, initial management includes uterine massage, administration of uterotonic agents (eg, misoprostol, methylergonovine, carboprost), an intrauterine pack, and/or an intrauterine balloon. Subsequent management for hemodynamically unstable patients or in patients in whom bleeding is unable to be controlled with conservative measures, includes uterine artery embolization or hysterectomy. (See 'Hemorrhage' above.)

•RPOC – For hemodynamically unstable patients with hemorrhage and suspected RPOC, uterine evacuation is performed with dilation and curettage or evacuation. For hemodynamically stable patients with vaginal bleeding and suspected RPOC, options include expectant management, medical management (eg, misoprostol), or surgical evacuation of the uterus. For asymptomatic patients in whom ultrasound examination demonstrates a thickened endometrium or enhanced myometrial vascularity, treatment may not be needed. (See 'Retained products of conception' above and "Retained products of conception in the first half of pregnancy", section on 'Management'.)

•Drug toxicity – Management of drug toxicity is generally supportive. While misoprostol is considered a very safe medication, cases of poor drug quality and toxicity at very high doses have been reported. Treatment of such patients involves removing any remaining tablets from the vagina or stomach and supportive care until symptoms resolve, which takes approximately 12 hours. (See 'Drug toxicity' above.)

●Prevention – The prevention of unsafe abortion requires a multifaceted approach including expanded access to safe abortion, prevention of unintended pregnancy, provision of high-quality postabortion medical care, and reduction of the stigma associated with abortion. (See 'Prevention' above.)