In Texas, abortion laws prevent coverage for miscarriages
As the Supreme Court appears poised to return abortion regulation to the states, recent experience in Texas shows that medical care for miscarriages and dangerous ectopic pregnancies would also be at risk if restrictions become widespread. .
A texas law passed last year lists several drugs as abortion-inducing drugs and largely bans their use for abortion after the seventh week of pregnancy. But two of those drugs, misoprostol and mifepristone, are the only drugs recommended in 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 pregnancy tissue – the same approach as for an abortion.
“The challenge is that treating an abortion and treating a 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 need any additional care, other than emotional support, said Dr. Tony Ogburn, who chairs the OB-GYN department at the University of Texas-Rio Grande Valley School of Medicine. But in other situations, he said, providers may need to intervene to stop the bleeding and make sure no pregnancy tissue remains, as a protection against infection.
dr. Lauren ThaxtonOB-GYN and assistant professor at Dell Medical School at the University of Texas at Austin, has heard of local patients who miscarried and couldn’t get a pharmacy to fill their misoprostol prescription.
“The pharmacy said, ‘We don’t know whether or not you’re using this medication for abortion,'” she said.
Thaxton, who supervises obstetrics and gynecology residents who have seen these patients, said sometimes the prescribing clinic does intervene, but it takes longer for the patient to get the medication. Other times patients don’t report the problem and miscarry on their own, she says, but without medication they risk further bleeding.
Under another new Texas abortion law, a person who “aids or abets” an abortion after heart activity can be detected – usually around six weeks – can be fined up to minus $10,000 per occurrence. Anyone can bring a civil action, which poses a dilemma for doctors and other providers. How do they follow the latest guidelines when many others — from other healthcare professionals to friends and family members — may question their intent: are they helping treat a miscarriage or facilitating an abortion?
Sometimes patients don’t realize they’ve lost their pregnancy until they come in for a checkup and no heart activity can be detected, said Dr. Emily Briggs, a family doctor who gives birth at New Braunfels, Texas. At this point, the patient may choose to wait for the bleeding to begin and for the pregnancy tissue to be naturally released, Briggs said.
For some, it’s too difficult, given the emotions surrounding pregnancy loss, she said. Instead, the patient can choose medication or a surgical evacuation procedure, which Briggs says may be necessary anyway to prevent a patient from becoming septic if some tissue remains in the eye. ‘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 creates reluctance for doctors to meet the standard of care for a patient has a cascade of adverse effects for both the patient and everyone else,” Esplin said.
This is an emotional and legal dilemma that potentially faces not only obstetricians and midwives, but also family physicians, emergency physicians, pharmacists and anyone else who may be involved in health care. pregnancy. And Ogburn, who noted he was speaking personally and not for medical school, worries fears about Texas laws have already delayed care.
“I wouldn’t say that’s true for our practice,” he said. “But I’ve certainly heard discussions among doctors that they’re very hesitant to do any kind of surgery until they’re absolutely sure it’s not a viable pregnancy – even if the amount of bleeding would warrant intervention because it is life threatening to the mother.”
John Seago, Legislative Director of Texas right to life, describes this type of hesitation as “an awful misunderstanding of the law”. Even before the two bills were passed, existing Texas law stated that the act was not an abortion if it involved the treatment of an ectopic pregnancy – which most often occurs when the pregnancy develops. into the fallopian tube — or to “remove a dead, unborn child whose death was caused by spontaneous abortion,” he said, pointing to the law. Another area of Texas law cited by Seago provides an exception to state abortion restrictions if the mother’s life is in danger or she is at “serious risk of substantial impairment of a major bodily function” unless an abortion is performed.
“It’s a pro-life position to allow doctors to make these life-and-death decisions,” Seago said. “And that can mean, in certain circumstances, protecting the mother in that situation and the deceased child.”
But interpreting the laws still poses challenges to care. At least several Austin-area OB-GYNs received a letter from a pharmacy in late 2021 saying it would no longer refill the drug methotrexate for an ectopic pregnancy, citing recent Texas laws, the report said. Dr. Charlie Brown, an Austin-based obstetrician-gynecologist who provided a copy to KHN. Methotrexate is also listed in Texas law passed last year.
An ectopic pregnancy develops in about 2% of reported pregnancies. Methotrexate or surgery are the only two options listed in medical guidelines to prevent 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 law professor at the Dedman School of Law at Southwestern Methodist University in Dallas, understands why some members of the Texas pharmaceutical community might be nervous. “The penalties are quite draconian,” he said, noting that someone could be found guilty of a crime.
However, Mayo said her reading of the law allows the use of methotrexate to treat an ectopic pregnancy. In addition, he said, other Texas laws and the Roe vs. Wade decision provides an exception to authorize abortion if the life of a pregnant person is in danger.
Because Texas laws include a stipulation that there must be an intent to induce an abortion, Mayo said he would advise physicians and other clinicians to closely document the rationale for medical care, whether to treat a miscarriage or an ectopic pregnancy.
But Prager thinks laws in Texas — and possibly 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 file a malpractice suit,” she said. “They absolutely can do it.”
Texas providers are still adjusting to other ripple effects that affect patient care. Dr. Jennifer Liedtke, a family physician in Sweetwater, Texas, who delivers about 175 babies a year, no longer sends misoprostol prescriptions to the local Walmart. Since the new laws came into effect, Liedtke said, the pharmacist has repeatedly refused to supply the drug, citing the new law – despite Liedtke writing the prescription to treat a miscarriage. Walmart officials did not respond to multiple requests for comment.
Since pharmacists go through this Walmart, Liedtke decided to send these prescriptions to other pharmacies rather than trying to sort out the misunderstanding again each time.
“It’s hard to form a relationship to say, ‘Hey, look, I’m not using this for elective abortion,'” she said. “‘I’m just using it because it’s not a viable pregnancy.'”