Introduction
Abortion is an essential healthcare.1 The Supreme Court’s overturning of Roe v. Wade by the Dobbs v. Jackson Women’s Health Organization decision in June 2022 has provoked rapid and diverse responses across the USA, with many implications. Twelve states have already enacted laws that essentially prohibit abortion, outside of very limited exceptions.2 Another 14 states have prepared legislation hostile to abortion, with laws written but not yet implemented including strict bans limiting abortions as early as 6 weeks after conception.3 Nearly 60% of people who can become pregnant—around 40 million—now find themselves in states hostile to abortion.4 Despite proclamations from politicians about the importance of protecting the legality of abortion, the right to seek a legal abortion has not been codified into federal law. Widespread hostility to abortion has shifted the landscape in ways that are increasingly pushing many pregnant people to turn to alternative means by which to obtain essential healthcare.
When conducted under safe conditions, abortion is an extremely effective and safe procedure. Unsafe abortions are defined by the WHO as “a procedure for terminating a pregnancy that is carried out either by persons lacking the necessary skills or in an environment that does not conform to minimum medical standards, or both.” Globally, unsafe abortions are a leading cause of maternal mortality and morbidity, stemming from hemorrhage, infection, sepsis, genital trauma, and necrotic bowel.5 Restricting a woman’s access to abortion does not prevent abortion but simply leads to more unsafe abortions.6 Abortions can be procedural or medical, with the latter referring to abortion by medication, which is the most common form of pregnancy termination in the USA in 2022. As the ability to obtain an abortion becomes more challenging in many states, self-managed abortions (SMAs) are likely to increase. SMAs are defined as activities undertaken to end a pregnancy that take place outside of a formal healthcare setting.7 In the USA, SMAs are most commonly performed using medications that have low overall complication rates.8
Acute care surgeons face an increased likelihood of seeing patients with complications from both SMAs and forced pregnancy, especially in underserved areas of reproductive and maternity care throughout the USA, such as the case of our 31-year-old patient. Given the overall safety of SMAs, acute care surgeons will more commonly be tasked to manage complications in patients forced to continue a pregnancy to delivery, against the patient’s will. Acute care surgeons have an ethical and legal duty to provide care to these patients, especially in “obstetrician and gynecology (OB/GYN) deserts,” which already exist in much of the country and are likely to be exacerbated by legislation banning abortion.
This article will discuss how acute care surgeons can treat the complications of SMAs, both medical and procedural. We will also address the effects of and complications stemming from forced pregnancy that are a direct effect of changing laws, impacting all physicians and society broadly. We think that the Dobbs decision will be incredibly harmful to our patients, their families, communities, and even surgeons, and should be denounced by the profession.