Your medical team cannot tell if you had a self-managed abortion
What you need to know to protect yourself
Police arrested Lizelle Herrera in Texas for allegedly performing a self-induced abortion. Thankfully, she is now out on bail. There are no further details at this time and which law she is accused of breaking is unclear.
This is awful on so many levels. Abortion should not be criminalized, and while we don’t know everything that transpired, there is an alarming trend of health care workers reporting people who may have had abortions or even miscarriages to the police. With that in mind, I want to provide some practical, factual information about self-managed abortions and seeking medical care afterwards.
This is not medical advice or legal advice, just some ideas that I find interesting and that other people might find interesting too.
For starters, here are the medication abortion regimens recommended by the American College of Obstetricians and Gynecologists (ACOG) for up to 70 days in the pregnancy (10 weeks).
No one can tell if you had a medical abortion or are miscarrying. If it happened yesterday or two weeks ago or last year, we doctors can’t tell. If you are having bleeding complications or an infection, two of those most likely complications that would take you to an emergency room with a self-managed medical abortion (albeit they are rare), we OB/GYNs still can’t tell if you are bleeding or have an infection from a miscarriage or from a medication abortion.
In addition, if you show up at a medical office for any reason your medical providers don’t need to know that you have ever had an abortion. If you are in a state like Texas and have had 2 previous abortions, you can say they were miscarriages if you like or even leave them out.
Given doctors and nurses and social workers have previously reports patients to the police, here is some more information should anyone ever be in the situation where they have self-managed an abortion and need medical care.
If someone took misoprostol
The success rate for a misoprostol induced abortion up to 70 days into the pregnancy is 87%. While misoprostol is a little less effective than misoprostol plus mifepristone, it is cheaper and easier to get. The dose is 800 mcg (usually four 200 mcg tablets) placed vaginally, under the tongue, or placed against the cheek. This is repeated every 3 hours up to 3 times.
Could the hospital do a blood test and find misoprostol? Good question, and the answer is no. Misoprostol is quickly metabolized to misoprostol acid, which is rapidly removed from the blood. After a single 400 mcg dose is taken orally or placed under the tongue the misoprostol acid essentially gone by 120 minutes and by 350 minutes with vaginal administration. After three doses of 800 mcg every three hours it should be completely gone from the system within 12 hours after the last dose, if not sooner.
As abortion usually happens within several hours after the last dose, chances are if you have to go to the hospital there will be no misoprostol acid in your blood. In addition, even if some zealous district attorney wants to go testing for misoprostol acid, it is not a readily available test. So the chance that a hospital will store a blood sample correctly to test for this later is very unlikely.
The real concern here is undissolved tablets in the vagina if the vaginal route is chosen. This rarely happens, but one can still be there several hours later. I’ve definitely found one six or hours later. If a tablet were found on a vaginal exam, that could be problematic. This can be avoided by taking the misoprostol under the tongue (sublingually) or by putting it in the mouth against the cheek and letting it dissolve (buccally). This diagram shows how to take it buccally:
It seems advisable for people who live in areas with restrictive abortion laws and where abortion has been criminalized to not use a vaginal route for a self-managed misoprostol abortion.
This drug is taken orally and used in combination with misoprostol, which is taken 12-24 hours later. The success rate is 94-98%. The misoprostol can be taken vaginally or sublingually or buccally. Again, if you are worried about legal issues, sublingually or buccally is the safest. A self-managed abortion with mifepristone and misoprostol is very safe.
Mifepristone takes longer to be removed from the blood, possibly up to several days. My expert tells me that there is no commercially available blood test, but some research labs may be able to do this testing, but whether this could be organized or not isn’t known. It seems highly unlikely that mifepristone levels could be obtained.
Also, whether someone took mifepristone and misoprostol vs. misoprostol alone medically doesn’t matter. Doctors and nurses do not need to know if you took this medication to care for you, just like they don’t need to know if you took misoprostol and you do not need to tell them. This is not legal advice, but withholding this information will not affect the medical decisions your health care providers are making about your care.
There are a variety of herbal medications that people may find recommended as abortifacients. In one study of women who reported they had previously attempted a self-managed abortion, 38% said they had tried herbal methods. These methods were less effective than self-managed abortion with misoprostol. Some of these herbal methods are ineffective with no biologically plausible way they could induce abortion, but some can work and unfortunately the more effective ones are also more likely to have toxic effects
Herbal abortifacients typically work by stimulating contractions of the uterus or by being directly toxic to cells, like the placenta and fetus. Some of these chemicals can damage the heart, kidneys, or liver. Most of these products are understudied, so the risk isn’t really known. In addition to the potential toxicity of the abortifacient, unless you grew the herb yourself you don’t really know what you are taking. Products that you buy from someone else may be contaminated with a potentially even more harmful herb or with an unknown pharmaceutical.
One of the most concerning herbal abortifacients is pennyroyal, which is an oil obtained from the leaves of the Mentha pulegium. The active ingredient is pulegone, which also gives it a minty smell. It is believed that it works as an abortifacient by irritating the uterus and causing uterine contractions. The problem is pulegone is also toxic to the liver and there are several reports of liver failure and more than 20 deaths have been reported in the past 30-40 years. As we don’t know how many people have taken pennyroyal or how many have become seriously ill, it’s hard to calculate the risk.
If you have attempted a self-managed herbal abortion and are bleeding heavily, or are having a serious heart or liver or kidney complication, there may be specific situations where knowing if you took an herbal product could help the medical team better manage your medicare care. For example, you would be more likely to get on the transplant list if your doctors know why your liver is failing. As supplements are a growing cause of liver failure, liver specialists will ask a lot about any herbal medications. An ethical one only wants to help you, but as we’ve seen not all health care providers are ethical.
Admittedly, these situations are rare, and to make things more complicated you may not even know what you took as these products are often adulterated. How to address this uncommon situation isn’t something that is possible to answer in this forum, but if you took an herbal medication to induce an abortion and you are sick enough to be admitted to the hospital and you are asked about herbal medications, it will likely be helpful for your medical team to know what you took, but they don’t need to know why you took it. People take supplements for all kinds of reasons, and while this is most definitely not legal advice, people do take all kinds of supplements for well-being or sleep.
These are strange awful times in many states and having to write this post is quite deflating. But there is where we are and we will likely be here for a while. And until we get somewhere else, your medical team can’t tell if you performed a self-managed abortion or had a miscarriage.
If you are interesting in helping out:
Medication abortion up to 70 days of gestation. ACOG Practice Bulletin No. 225. American College of Obstetricians and Gynecologists. Obstet Gynecol 2020;136:e31–47.
Anderson IN, et al. Pennyroyal Toxicity: Measurement of Toxic Metabolite Levels in Two Cases and Review of the Literature. Ann Internal Med 1996, April.
Tang, O., Gemzell-Danielsson, K. and Ho, P. (2007), Misoprostol: Pharmacokinetic profiles, effects on the uterus and side-effects. International Journal of Gynecology & Obstetrics, 99: S160-S167.
Raymond EG et. al. Efficacy of Misoprostol Alone for First-Trimester Medical Abortion: A Systematic Review. Obstet Gynecol. Obstet Gynecol. 2019 Jan; 133(1): 137–147.
Ciganda C, Laborde A. Herbal Infusions used for Induced Abortion. Journal of Toxicology, 2003. 41.