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Monday, April 15, 2024

Pregnancy Has Risks. Without 'Roe,' More People Will Face Them

Somehow in the debate about abortion and the onset of human life, the physical reality of pregnancy has been disregarded. It isn’t just an inconvenient interlude. Pregnancy places a strain on the body, sometimes in life-altering or even perilous ways. It burdens the heart—in a literal sense. If the US Supreme Court overturns Roe v. Wade, allowing states to ban or strictly limit abortion, the number of pregnancies carried to term will rise, and so will the number of people facing the health risks of pregnancy.

The abortion conversation centers on fetal development, from the first pulsing cardiac cells to viability. Here’s what happens to the woman: By four weeks of pregnancy, her blood volume begins to rise, expanding 50 percent by the time of delivery. The heart beats faster to pump that extra blood, much of it flowing to the uterus, placenta, and kidneys. The kidneys expand in size, volume, and filtration. Blood clotting becomes stronger, peaking before delivery, the body’s way of protecting against hemorrhage, which has always been a leading cause of childbirth-related death. But as a result of the extra clotting, compared to non-pregnant women of reproductive age, pregnant women have five times the risk of deep vein thrombosis, a painful and potentially life-threatening clot, usually in the legs. They are three times more likely to have a stroke; the risk is even higher for Black women.

In 2020, 861 women died from pregnancy-related causes, most commonly from cardiovascular events. About 60,000 women had serious childbirth-related complications, a figure that doesn’t count severe conditions that arise prenatally or in the postpartum months. About 7 percent of women develop gestational diabetes and about the same portion have gestational hypertension, which can lead to immediate as well as lifelong health problems.

Karen Florio knew all those facts well when she became pregnant at age 33. As a maternal fetal medicine doctor in Kansas City, Missouri, specializing in cardio-obstetrics, she has helped many women navigate scary medical scenarios. On occasion, she has counseled others on the option of terminating a pregnancy due to life-threatening complications. But she could not imagine that she would soon be lying in the hospital, facing her own life-or-death struggle.

Florio had been the proverbial picture of health. Before becoming pregnant, she completed an Ironman triathlon. She played college softball. She had no preexisting conditions. Then at 28 weeks of pregnancy, her blood pressure spiked to 147/97. (Normal blood pressure is 120/80 or less.) She’d noticed that her face was puffy, and that her weight gain seemed a bit high considering her careful diet. These turned out to be signs of preeclampsia, or persistent high blood pressure during pregnancy or postpartum, which occurs in 5 percent to 8 percent of all births. “I think I missed all the signs because it never occurred to me that I could get preeclampsia, even though that’s [a condition] I take care of all the time,” she says.

As Florio’s blood pressure rose to 160/100, she developed headaches and spots in her vision. When her baby was delivered by C-section at 31 weeks, mother and child ended up in separate ICUs. The preeclampsia led to brain swelling known as posterior reversible encephalopathy syndrome, or PRES.

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Florio recovered. Today, she is back to her triathlete workouts, and her 8-year-old son is healthy. But her heart still sometimes races—something it hadn’t done before, and a harbinger of cardiac issues she might have in her future. “The heart never really goes back to normal,” she says. She decided not to have another child because of the increased risks she would face.

Her state, Missouri, has a trigger law that will go into effect if Roe is struck down, banning all abortions “except in cases of medical emergency.” Legally, it would be up to the physician or health provider to prove that a person is facing an emergency. Twelve other states have trigger laws that would ban or limit abortion access and five have pre-Roe bans that would go into effect if Roe is overturned. Some remove consideration of the health of the mother, and certain “no exception” bans force women to continue pregnancies after rape or incest, or block terminations even in the event of miscarriage.

In states with strict anti-abortion laws, delayed care could create a new type of pregnancy risk. An analysis by researchers at the Washington University in St. Louis found that states with the most restrictive abortion laws from 2009 to 2017 had higher rates of maternal mortality. The study wasn’t designed to identify a cause, but the authors speculated on possible reasons: Less restrictive states might offer more resources to support women’s health. Or in more restrictive states people with high-risk pregnancies that they can’t terminate may be more likely to die from complications.

Even before the draft US Supreme Court opinion that would gut Roe became public, medical experts have been raising an alarm about a rise in cardiovascular complications. Pregnancy is often called “nature’s stress test” because the physical strain can reveal heart-related conditions that have long-term implications. In 2021, a Lancet commission on women and cardiovascular disease pointed to many under-recognized risks, including of peripartum cardiomyopathy, a form of heart failure that occurs in late pregnancy or postpartum. The American Heart Association has used its “Go Red for Women” campaign to publicize that “heart disease is the No. 1 killer of new moms.”

Stroke can come on suddenly and unpredictably. Some people have rising blood pressure after delivery, which creates a silent danger at a time when women are less likely to be following up on their medical care. (And they may have lost insurance; 12 states have taken no action to expand Medicaid to cover the postpartum year, despite federal incentives.)

Affecting about 45 per 100,000 pregnant or postpartum women, stroke isn’t common—but it isn’t exceedingly rare, either. About half of the cases result in permanent debilitation. “It can be devastating,” says Louise D. McCullough, a stroke expert and chief of neurology at Memorial Hermann Hospital in Houston. “These are young women. If they’re disabled or die, it has a huge impact on the family.”

One recent case resonates for McCullough: A 26-year-old woman with an uneventful first pregnancy developed a severe headache a few weeks after childbirth. By the time she arrived at the hospital, she had a massive brain hemorrhage from a clot, known as cerebral vein thrombosis. Clot-busting treatment temporarily saved her life, but she died of complications a few months later. Monitoring blood pressure, even postpartum, and acting fast when a problem arises can make a life-altering difference, McCullough says. “It’s important to recognize that pregnancy can be a dangerous time for women,” she says.

Why does pregnancy so often trigger serious health conditions? To get some insights into cardiovascular effects, the nuMoM2b study is following about 4,500 mothers for years beyond their pregnancies. Conducted at eight medical centers around the US and funded by the National Institutes of Health, the study focuses on the relationship between “adverse pregnancy outcomes,” such as gestational hypertension or preterm birth, and the mother’s future cardiovascular health. (The concept is similar to the famous Framingham Heart Study, which has been running since 1948 and led to new understandings of cardiovascular risks.) So far, researchers have found key markers in the first trimester that may be predictive—higher triglycerides, high-sensitivity C-reactive protein, and blood glucose were associated with hypertension two to seven years after delivery.

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Eugene Declercq, a maternal health researcher at the Boston University School of Public Health, has been tracking severe maternal morbidity—serious complications of pregnancy—to better understand the risks of maternal death. It’s a big problem: Half of pregnancy-related deaths happen within the year after birth, when they might not be recognized as linked to the pregnancy at all. And medical events that happen outside the hospital need more attention, says Declercq. “The rate of maternal deaths at the hospital have gone down,” he says. “It’s the deaths in the community—prenatal and postpartum—that are driving the continued increase.”

It’s hard to know how many more people would die post-Roe if they must continue their pregnancies because they can’t access an abortion, although a sociologist at the University of Colorado, Boulder, estimates maternal deaths will rise by 21 percent—and for Black women, who are most at risk, by 33 percent. Overall, unplanned pregnancies result in worse outcomes for mothers and babies, in part because of delays in prenatal care. Even with current abortion restrictions in the US, almost 40 percent of births are unintended or unwanted—a number that will clearly rise if states are allowed to ban abortions.

“What I’d like to see is for those states that are so anxious to put restrictions in to say, ‘And by the way, we’re going to really improve support for pregnant women,’” says Declercq. He isn’t optimistic. Of the 12 states that haven’t expanded Medicaid coverage to more low-income adults, seven have trigger laws or previous abortion bans that automatically go into effect if Roe is struck down. In others, state lawmakers have vowed to impose a ban or tighter restrictions. Boosting the health status of women, pregnant or otherwise, isn’t part of their post-Roe plan.

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