Ripple effect of abortion restrictions confounds miscarriage care

While the Supreme Court appears poised to return abortion regulation to the states, recent experience in Texas illustrates that medical care for unsafe miscarriages and ectopic pregnancies would also be threatened if restrictions became widespread.

A Texas law passed last year lists several drugs as abortion-inducing drugs and largely prohibits their use for abortion after the seventh week of pregnancy. But two of those drugs, misoprostol and mifepristone, are the only ones recommended in the American College of Obstetricians and Gynecologists’ guidelines for treating a patient after an early pregnancy loss. The other miscarriage treatment is a procedure described as surgical uterine evacuation to remove the pregnancy tissue, the same approach as for an abortion.

“The challenge is that treatment for abortion and treatment for miscarriage are exactly the same,” said Dr. Sarah Pragerprofessor of obstetrics and gynecology at the University of Washington in Seattle and an expert in early pregnancy loss.

Miscarriages occur in about 1 in 10 pregnancies. Some people experience pregnancy loss at home and don’t require additional care other than emotional support, said Dr. Tony Ogburn, chairman of the department of obstetrics and gynecology at the University of Texas-Rio Grande Valley School of Medicine. But in other situations, he said, providers may need to intervene to stop bleeding and make sure no pregnancy tissue remains, to protect against infection.

Dr. Lauren Thaxton, an obstetrician-gynecologist and assistant professor at the University of Texas-Austin Dell School of Medicine, has already heard of local patients who have had miscarriages and were unable to get a pharmacy to fill their misoprostol prescription. . “The pharmacy has said, ‘We don’t know whether or not you might be using this abortion medication,'” she said..

Thaxton, who oversees obstetrics and gynecology residents who have cared for these patients, said sometimes the prescribing clinic is involved, but it takes longer for the patient to get the medication. Other times, patients don’t report the problem and abort on their own, she said, but without medication they risk additional bleeding.

Under another new Texas abortion law, someone who “aides or abets” an abortion after cardiac activity can be detected, usually around six weeks, may be subject to a fine of at least $10,000 per occurrence. Anyone can bring such a civil action, posing a dilemma for doctors and other providers. How do they follow the latest guidelines when others, from medical professionals to friends and family, may question their intent: Are they helping care for a miscarriage or facilitating an abortion?

Sometimes patients don’t realize they’ve miscarried until they come in for a checkup and no cardiac activity is detected, said Dr. Emily Briggs, a family physician who delivers in New Braunfels, Texas. At that point, the patient may choose to wait until the bleeding begins and the pregnancy tissue naturally sheds, she Briggs said. For some, that’s too difficult, given the emotions surrounding pregnancy loss, she said. Instead, the patient may choose medication or a surgical evacuation procedure, which Briggs says may still be necessary to prevent the patient from becoming septic if any tissue remains in the uterus.

But now in Texas, new laws are creating uncertainties that may deter some doctors and other providers from offering optimal miscarriage treatment.

These situations can create significant moral distress for patients and providers, said Bryn Esplin, a bioethicist and assistant professor of medical education at the University of North Texas Health Sciences Center in Fort Worth. “Any law that makes physicians hesitant to uphold a patient’s standard of care has a cascade of deleterious effects for both the patient and everyone else,” Esplin said.

It’s an emotional and legal dilemma potentially facing not only obstetricians and midwives, but also family physicians, emergency physicians, pharmacists, and anyone else who may be involved in pregnancy care. And Ogburn, who noted that he was speaking personally and not on behalf of the medical school, worries that fears about the Texas laws have already delayed attention.

“I wouldn’t say this is true for our practice,” he said. “But I’ve certainly heard discussions among doctors that they’re very reluctant to do any kind of intervention until they’re absolutely certain it’s possibly not a viable pregnancy, even though the amount of bleeding would warrant intervention because it’s life threatening. mother’s life.”

John Seago, legislative director of Texas Right to Life, described this kind of hesitation as “a terrible misunderstanding of the law.” Even before the passage of the two bills, existing Texas law stated that the law is not an abortion if it involves the treatment of an ectopic pregnancy, which most commonly occurs when the pregnancy grows in the fallopian tube, or to “remove a dead body, unborn child whose death was caused by miscarriage,” he said, pointing to the statute. Another area of ​​Texas law that Seago cited provides an exception to the state’s abortion restrictions if the mother’s life is in danger or if she is at “serious risk of substantial impairment of a major bodily function” unless perform an abortion.

“It’s a pro-life position to allow doctors to make those life-and-death decisions,” Seago said. “And that can mean, in certain circumstances, protecting the mother in this situation and the child dying.”

But the interpretation of the laws still generates challenges for care. At least several Austin-area OB/GYNs received a letter from a pharmacy in late 2021 saying it would no longer fill the drug methotrexate for ectopic pregnancy, citing recent Texas laws, said Dr. Charlie Brown, Austin doctor. primary obstetrician-gynecologist who provided a copy to KHN. Methotrexate is also listed in the Texas law passed last year.

Ectopic pregnancy develops in approximately 2% of reported pregnancies. Methotrexate or surgery are the only two options listed in medical guidelines to prevent the fallopian tubes from rupturing and causing dangerous bleeding.

“Ectopic pregnancies can kill people,” said Brown, district president of the American College of Obstetricians and Gynecologists, representing Texas.

Tom Mayo, a professor of law at Southern Methodist University Dedman School of Law in Dallas, understands why some in the Texas pharmaceutical community may be nervous. “The penalties are pretty draconian,” he said, noting that someone could be convicted of a serious crime.

However, Mayo said that his reading of the law allows the use of methotrexate to treat an ectopic pregnancy. In addition, she said, other Texas laws and the Roe v. Wade provide an exception to allow abortion if the life of a pregnant person is in danger.

Because Texas law includes a provision that there must be an intent to induce an abortion, Mayo said it would recommend that doctors and other clinicians carefully document the rationale for medical care, whether to treat a miscarriage or a pregnancy. ectopic.

But Prager thinks laws in Texas, and perhaps soon elsewhere, could increase doctors’ vulnerability to medical malpractice lawsuits. Consider the patient whose miscarriage care is delayed and develops a serious infection and other complications, Prager said. “And they decide to sue for negligence,” he said. “They absolutely can do that.”

Texas providers are still adjusting to other side effects that affect patient care. Dr. Jennifer Liedtke, a family physician in Sweetwater, Texas, who sees about 175 babies a year, no longer sends misoprostol prescriptions to the local Walmart. Since the new laws took effect, Liedtke said, the pharmacist repeatedly refused to provide the drug, citing the new law, even though she Liedtke wrote the prescription to treat a miscarriage. Walmart officials did not respond to multiple requests for comment.

Since pharmacists rotate at that Walmart, Liedtke decided to send those prescriptions to other pharmacies instead of trying to resolve the misunderstanding each time.

“It’s hard to build a relationship to say, ‘Hey, look, I’m not going to use this for an elective abortion,'” she said. “‘I’m only using this because it’s not a viable pregnancy.'”

KHN (Kaiser Health News) is a national newsroom that produces detailed journalism on health issues. Along with Policy Analysis and Polling, KHN is one of the three main operational programs of KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization that provides information on health issues to the nation.

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