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As the Supreme Court appears ready to repeal abortion rules in the states, recent experience in Texas shows that medical care for abortions and dangerous ectopic pregnancies would also be threatened if sanctions become more widespread.
A Texas law passed last year lists several drugs as abortion-inducing drugs and greatly restricts their use for abortion after the seventh week of pregnancy. But two of those drugs, misoprostol and mifepristone, are the only drugs recommended in the guidelines of the American College of Obstetricians and Gynecologists to treat a patient after an early pregnancy loss.
Treatment for other abortions is a procedure that has been described as surgical removal of the uterus to remove tissue from the pregnancy – the same procedure for abortion.
“The challenge is that abortion treatment and abortion treatment are exactly the same,” said Dr. Sarah Pragar, a professor of obstetrics and gynecology at the University of Washington in Seattle and an expert in early pregnancy damage.
Abortions occur in about 1 in 10 pregnancies. Dr. Tony Ogburn, chairman of the OB-GYN department at the Valley School of Medicine at Texas-Rio Grande, said some people experience pregnancy loss at home and do not need extra care without emotional support. But in other situations, she said, providers may have to intervene to stop the bleeding and ensure that no pregnancy tissue remains, as a guard against infection.
Dr. Lauren Thaxton, an OB-GYN and assistant professor at Dale Medical School at the University of Texas-Austin, has already heard of local patients who are having abortions and have not found a pharmacy to fill their misoprostol prescription.
“We don’t know if you are using this drug for abortion purposes,” the pharmacy said.
Thaxton, who oversees obstetric-gynecology residents who have seen these patients, said that sometimes the prescribed clinic will intervene, but it takes longer for the patient to get the medication. Other times patients don’t report the problem and have abortions on their own, he said, but without medication they run the risk of excessive bleeding.
Under another Texas abortion law, anyone who “assists or promotes” abortion after cardiac activity can be identified – usually for about six weeks – with a fine of at least $ 10,000 per event. Anyone can bring that civil action, creating a confusion for physicians and other providers. How can they follow the latest guidelines when so many other people – from other medical professionals to friends and family members – question their motives: Are they helping or taking advantage of abortion care?
Sometimes patients do not realize that they have lost a pregnancy and cardiac activity cannot be detected until they arrive for a checkup, says Dr. Emily Briggs, a family physician who gave birth in New Brownfells, Texas. At that point, the patient can wait until the bleeding starts and the pregnancy tissue is released normally, Briggs said.
For some people, it’s very difficult because of the emotions surrounding the loss of pregnancy, she said. Instead, the patient may choose to have the drug or surgery removed, which Briggs said may prove necessary to somehow prevent the patient from becoming septic if some tissue remains in the uterus.
But now in Texas, new laws are creating uncertainty that could prevent some doctors and other providers from providing the best abortion treatment.
These situations could create significant ethical crises for patients and providers, said Brian Esplin, a biotheist and assistant professor of medical education at the University of North Texas Health Science Center at North Texas Health Science Center in Fort Worth. “Any law that makes physicians hesitant to maintain the quality of a patient’s care has a detrimental effect on the patient but on everyone else,” Esplin said.
This is a mental and legal dilemma that could potentially be faced not only by maternity and midwives, but also by family physicians, emergency physicians, pharmacists and anyone else who may be involved in pregnancy care. And Ogburn, who noted that he is speaking privately and not for medical school, is concerned that fears about Texas law have already delayed care.
“I wouldn’t say that’s true for our practice,” he said. “But I have certainly heard discussions among physicians that they are reluctant to intervene in any way until they are fully convinced that it is probably not an effective pregnancy – although the amount of bleeding will warrant intervention because it is a threat to the mother’s life.”
John Sigo, legal director of Texas Right to Life, described this kind of dilemma as “a terrible misunderstanding of the law.” Even before two bills were passed, existing Texas law states that the law is not an abortion if it involves the treatment of an ectopic pregnancy – which usually occurs when the pregnancy grows in the fallopian tube – or “to remove a dead, unborn child whose death is due to a spontaneous abortion.” He pointed to the law. Another area of Texas law that Sego cites exceptions to the state’s abortion ban is if the mother’s life is in danger or she is “at significant risk of substantial loss of a major bodily function” if the abortion is not performed.
“It’s a pro-life position to allow doctors to make those life-and-death decisions,” Sigo said. “And that could mean protecting the mother and the child in certain situations.”
But interpretation of the law still poses a challenge to care. At least several OB-GYNs in the Austin area received a letter from a pharmacy in late 2021 stating that it would no longer supplement the drug methotrexate for ectopic pregnancies, citing recent Texas law, Dr. Charlie Brown said, adding that Austin-based obstetrics and gynecology Expert who provided a copy to KHN. Methotrexate is also listed in the Texas Act passed last year.
Ectopic pregnancies develop in approximately 2% of reported pregnancies. Methotrexate or surgery to prevent fallopian tube rupture and dangerous bleeding are the only two alternative medical guidelines listed.
“Ectopic pregnancies can kill people,” said Brown, a district chair at the American College of Obstetricians and Gynecologists representing Texas.
Tom Mayo, a law professor at Deadman School of Law at Southern Methodist University in Dallas, understands why anyone in the Texas pharmacy community can be nervous. “Penalties are quite severe,” he said, adding that anyone could be convicted of a crime.
However, Mayo said the law allows her reading to use methotrexate to treat an ectopic pregnancy. He also said other Texas laws and regulations Rowe vs. Wade The decision to allow an abortion when the life of a pregnant person is in danger provides an exception.
Since Texas law includes a condition that there must be an intent to induce an abortion, Mayo said she would advise physicians and other physicians to closely document the rationale for medical care, whether treating abortion or ectopic pregnancy.
But Prague believes that Texas law – and perhaps elsewhere – could increase the vulnerability of physician abuse cases. Consider a patient whose abortion care is delayed and creates a serious infection and other complications, Pragar said. “And they decided to sue for misconduct,” he said. “They can absolutely do that.”
Texas providers are still adapting to other ripple effects that affect patient care. Dr. Jennifer Lidt, a family doctor in Sweetwater, Texas, who gives birth to about 175 babies a year, no longer sends Misoprostol prescriptions to the local Walmart. Since the new law went into effect, Liedtke says, pharmacists have repeatedly refused to dispense drugs, citing the new law – despite Liedtke writing prescriptions for abortion treatment. Walmart officials did not respond to a request for comment.
Since pharmacists go through that Walmart, instead of trying to resolve the misunderstanding anew each time, Lidot decides to send those prescriptions to other pharmacies.
“It’s hard to build a relationship to say,‘ Hey look, I’m not using it for an elective abortion, ’” he said. “I’m using it because it’s not an effective pregnancy.”
KHN (Kaiser Health News) is a national newsroom that creates in-depth journalism about health issues. It is an editorially independent operating program KFF (Kaiser Family Foundation).