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Wednesday, June 19, 2024

The Fall of Roe Makes Complex Pregnancies Even Riskier

Doctors who care for pregnant people often have to make time-sensitive decisions when lives are on the line. But in the wake of the US Supreme Court’s Dobbs decision, which overturned the national right to abortion, time is no longer on their side.

Many states have now implemented tough restrictions that don’t necessarily ban doctors from performing any abortions, but make them wait until a “medical emergency” or “life-threatening” event happens—and what these terms mean is not well-defined. These delays can endanger patients who are experiencing incomplete miscarriages (when a miscarriage begins, but some tissue from the pregnancy remains in the uterus) or ectopic pregnancies (in which the fertilized egg implants somewhere other than the uterus). In many cases, terminating the pregnancy is the safest option. But without the blanket protection once provided by Roe, physicians in these states may not be able to provide appropriate care in a timely manner.

Katrina Green, an emergency medicine physician who practices in Tennessee, has seen many of these pregnant patients who, she says, “present very critically ill. Time is of the essence in getting them to an operating room, stat. We don’t have time to call a lawyer and find out: Am I going to go to jail for doing my job?”

For example, during an incomplete miscarriage, if the parent’s body cannot evacuate the rest of the tissue on its own, the standard of care can include a process called dilation and curettage (also known as a D&C). This is a uterine aspiration—a procedure in which tissue remaining from the pregnancy is removed. Here, Green says, timing is important. “What we are trained to do—what is supposed to happen, evidence-based, scientific medicine here—is to do the D&C upfront,” she says. “The longer the products of conception sit there in the uterus, the more likely there is going to be an infection.”

And if that infection becomes very serious, it can lead to sepsis—when bacteria from the infection travel into the bloodstream. That can make the D&C, or other procedures to remove remaining pregnancy tissue, riskier. “Surgeons like to have a stable patient on the operating table,” Green adds. “The outcomes are so much worse when you’re septic.”

Or sometimes, in the process of providing emergency care, a doctor will uncover information that makes abortion no longer an option in that state. Diagnosing an incomplete miscarriage relies on a variety of factors, says Stacy De-Lin, a physician and the associate director of a Planned Parenthood in New York. While many patients present with heavy bleeding, some do not—and physicians can then look at hormone levels or an ultrasound to determine if an incomplete miscarriage has occurred or is inevitable. One of the problems, though, is when “at the time we diagnose that, there may still be a fetal heartbeat,” De-Lin says.

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Several states (including Georgia, South Carolina, and Texas) explicitly outlaw abortions after a fetal heartbeat is detected—sometimes with exceptions in the cases of rape or incest or if the pregnant person’s life is in danger. If a doctor detects a heartbeat in these states, they often must wait until the heartbeat goes away or the pregnant person’s condition worsens enough to be considered life-threatening. “What I’m seeing and hearing from my colleagues across the country is that patients are being told to go home and wait until they are bleeding or until they have signs of an infection, like a fever, which can be really dangerous for the pregnant person,” says Amy Addante, an obstetrician and gynecologist in Illinois.

This situation can also arise when treating ectopic pregnancies; in some edge cases, the fetus can grow to the point where cardiac activity is detected. But, in all cases, an ectopic pregnancy “can never result in childbirth,” De-Lin says emphatically, since the fetus cannot survive outside of the uterus. The standard of care for an ectopic pregnancy is to end it as soon as possible, either through surgery or by administering methotrexate, a drug that stops the cluster of fetal cells from further dividing.

To diagnose an ectopic pregnancy, physicians will look at trends of beta HCG levels—a hormone present in a pregnant person’s blood or urine that, when charted over time, can help determine whether a pregnancy is abnormal. They will also look at ultrasound: If the fetus is explicitly detected to be outside of the uterus, then an ectopic pregnancy is quickly diagnosed.

But as Jennifer Kerns, an obstetrician and gynecologist at UC San Francisco, says, not all these cases are “clear-cut.” In some instances, physicians are unsure whether the pregnancy is a failed intrauterine pregnancy (where fetal viability is not detected inside the uterus), an ectopic pregnancy that just wasn’t detected yet on the ultrasound, or another type of abnormal pregnancy. In this situation, having a viable pregnancy is exceedingly rare, and it can be dangerous for it to progress. To diagnose what went wrong, the doctor can proceed with a uterine aspiration, then look at the removed tissue underneath a microscope. But because this method counts as an abortive procedure, states with tough post-Roe laws are making it harder for doctors to use it as a diagnostic tool.

“Some people are going to feel quite nervous about providing evidence-based medical care, which might be a uterine aspiration, for a condition that could possibly be an ectopic pregnancy, as part of the diagnostic procedure that you do to understand if it’s an ectopic or not,” Kerns says. “Delaying that care is really putting the person at risk of serious morbidity and mortality.”

Without intervention and removal of the ectopic pregnancy, the tissue can “keep growing and can actually cause the fallopian tube to rupture, and it can cause really catastrophic, life-threatening, intra-abdominal bleeding,” says Addante.

Despite these serious consequences, Addante is concerned that, under the guidelines of state laws that followed Roe’s overturn, physicians will be “very reluctant to offer what is really standard-of-care medicine, because they’re afraid of the criminal liability that they might hold.” Restricting abortive procedures unless there is a “medical emergency” or the life of the pregnant person is threatened is very nebulous. It makes it hard for doctors to know when medical intervention becomes OK, particularly when trying to diagnose whether something is a failed intrauterine pregnancy or an ectopic pregnancy. “If it is an intrauterine pregnancy, and you haven’t 100 percent proven that it was a failed intrauterine pregnancy, in today’s world you might be accused of interrupting a normal intrauterine pregnancy,” Addante says. “This is where having to think defensively really interferes with clinical judgment.”

While some state laws contain written exceptions for medical emergencies (including miscarriages or ectopic pregnancies), the overall lack of clarity can cause physicians to proceed cautiously rather than intervene immediately to mitigate risk, De-Lin says. She points out that these regulations seem to be written only with healthy patients and healthy pregnancies in mind. They don’t “leave any room for the broad array of pregnancy-related conditions that may be dangerous to the health of the person carrying the pregnancy,” she says.

Thinking defensively, waiting to intervene until the patient presents with severe medical complications—these are factors that are suddenly, horribly, becoming real situations. Another problem, De-Lin says, is time: Patients who travel across state lines to seek a diagnosis at her clinic sometimes must return to their home states the next day, limiting her ability to provide long-term care if their pregnancy develops serious problems. “There are certain cases where it’s hard to tell if it’s just an early pregnancy, is it an ectopic, is it a miscarriage?” she says. “We need some time and monitoring to figure those things out.” She notes that although she tries to coordinate follow-up care with other Planned Parenthoods across the country, “it is a logistical nightmare sometimes.”

Addante previously worked in Missouri, at a time when state had a 72-hour waiting period between initial counseling and when a patient was allowed to have an abortion. She sometimes had to decide whether the patient was sick enough to waive that waiting period. “One of the most difficult things I have ever experienced as a provider is having to look at a patient and say: ‘I cannot take care of you, not because I don’t know how to but because I am not allowed to,’” she says. “It’s devastating.”

Missouri now bans all abortions except in medical emergencies, and Addante worries about her former colleagues, some of whom, she says, have been told not to counsel patients on all treatment options—which can include abortive procedures. That, Addante says, “just violates every oath we took in this field.”

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