Management of miscarriages in the wake of Dobbs v. Jackson

With Roe v. Wade overturned, there have been questions and concerns about the impact the ruling will have on patient access to care and medications associated either directly or indirectly with abortion procedures in the US. Specifically, the management of miscarriages could be affected by the Dobbs v. Jackson decision.

Management of miscarriages could be riskier

FDA-approved drugs like mifepristone and misoprostol have been used to induce early-stage abortions. These drugs are also critical players in helping pregnant patients manage missed and incomplete miscarriages—an essential element of care when, according to the Mayo Clinic, “10 to 20 percent of known pregnancies end in miscarriage.”

Mifepristone, like any other FDA-approved drug, has undergone a rigorous development, clinical trial, and approval process before it reached the market. Mifepristone “is available only under an FDA-approved Risk Evaluation and Mitigation Strategy (REMS) program,” according to its developer, GenBioPro.

As another example, methotrexate, when used with misoprostol, treats ectopic pregnancies: non-viable and deadly instances of fertilization within the fallopian tube. Ectopic pregnancies occur in 1 out of every 50 pregnancies.

After the Dobbs v. Jackson ruling, these drugs are reportedly being denied to patients both dealing with acute pregnancy complications, as well as treating non-pregnancy-related issues like autoimmune diseases or long COVID. Methotrexate, for example, is often used to treat conditions and diseases such as axial spondyloarthritis, ankylosing spondylitis, psoriatic arthritis, lupus, Sjogren’s vasculitis, and juvenile idiopathic arthritis (JIA). Reports are surfacing across the social media landscape that patients’ prescriptions are not being filled because they are of childbearing age.

The American College of Rheumatology responded on Twitter, saying it was “aware of the emerging concerns surrounding access to needed treatments such as [methotrexate] after the recent decision in Dobbs v. Jackson Women’s Health Organization.”

The impact on maternal care and mortality

Both missed or incomplete miscarriages, as well as ectopic pregnancies, can cause rapid sepsis in reproductive organs, blood loss, and death. The denial of these drugs will undoubtedly increase the already high maternal mortality rate in the US.

Miscarriages and intentional abortions are indistinguishable when a patient is admitted for care, which puts doctors and patients in a dangerous legal position in states where abortion procedures are illegal. Additionally, in states with fetal heartbeat laws, a pregnant patient who is in the process of having a miscarriage cannot have it medically managed until any vital sign is extinguished, including in situations of ectopic pregnancy, as the Texas Tribune has reported.

This puts pregnant patients at risk of becoming mortally ill as access to vital care is delayed.

“I want this Committee to understand the far-reaching ripple effects of abortion bans,” Kristyn Brandi, MD, MPH, FACOG and Board Chair Physicians for Reproductive Health in New Jersey, explained to a full US Senate Health, Education, Labor, and Pensions committee hearing on Reproductive Care in a Post-Roe America: Barriers, Challenges, and Threats to Women’s Health, on July 13, 2022.

“I remember having a patient with a ruptured ectopic pregnancy, who was talking to me in the ER quickly as we were rushing her to the operating room for surgery. It took us only 10 minutes or so from meeting her to starting her surgery. Just before we began, her blood pressure suddenly dropped dramatically – she was dying. We rushed to complete her procedure safely, finding several liters of blood in her belly along with a ruptured fallopian tube which held her 7-week pregnancy. I am so glad she came to the hospital when she did, that we identified this ectopic pregnancy so quickly, and that we were able to intervene before it was too late,” explained Dr. Brandi.

She discussed the potentially far-reaching impact on access to medical care: “We have heard people question whether bans on abortion will impact care like ectopic pregnancy management even when they shouldn’t, or whether bans on abortion will impact care such as in vitro fertilization (IVF). Or if miscarriage management will be allowed, which uses the same medicines and procedures as abortion care.”

There have already been reports that doctors in states with the most aggressive anti-abortion legislation and trigger laws in place have felt obligated to delay lifesaving care or even turn patients away altogether because of legal restrictions.

Leah Torres, writing for Slate, highlighted what was already happening in Alabama: “I saw a patient in active miscarriage (bleeding, passing clots, cramping) who had just had an office visit with her primary physician. She was forced to wait more than 48 hours in order to get the results of her bloodwork. Doctors will sometimes check a patient’s levels of HCG, or human chorionic gonadotropin, to help distinguish miscarriages from ongoing pregnancies or ectopic pregnancies.”

In Kentucky – one of the 22 states that had trigger laws to ban abortion in all or most cases when Roe was overturned – patients are crossing state lines to Indiana, where abortion is legal up to the 22nd week of pregnancy.

“Though Kentucky allows exceptions for abortion when it will save a mother’s life, conflicting state and federal guidance has left doctors struggling to figure out how the bans — and exemptions — apply,” reported Bloomberg. “In pregnancy emergencies, doctors have to weigh how rapidly a patient’s health is deteriorating and make snap decisions to prevent a situation from becoming fatal.” All too often in Kentucky, patients are denied care completely. The trend of making patients wait longer than necessary for care is one that is consistent in states with bans on abortion procedures.

As the Texas Medical Association (TMA) said in a letter to regulators, “Delayed or prevented care in this scenario creates a substantial risk for the patient’s future reproductive ability and poses serious risk to the patient’s immediate physical wellbeing.” In a state as large as Texas, which is also surrounded by states with anti-abortion laws (Oklahoma, Alabama, and Lousiana)—with the exception of New Mexico—driving to get emergency care is simply not a viable or safe option.

With 22 states targeting abortion coverage, the problem of accessing emergency (and other types of) care affects a massive swath of the child-bearing patient population in the US.

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