Baltimore Sun

Miscarriag­e care gets complicate­d

Some doctors wary of running afoul of new abortion laws

- By Pam Belluck

Last year, a 35-year-old woman named Amanda, who lives in the Dallas-Fort Worth area, had a miscarriag­e in the first trimester of her pregnancy. At a large hospital, a doctor performed a surgical procedure often used as a safe and quick method to remove tissue from a failed pregnancy.

She awoke from anesthesia to find a card signed by the nurses and a little pink and blue bracelet with a butterfly charm, a gift from the hospital to express compassion for her loss. “It was so sweet because it’s such a hard thing to go through,” Amanda said.

Eight months later, in January, Amanda, who asked to be identified by her first name to protect her privacy, experience­d another first-trimester miscarriag­e. She said she went to the same hospital, Baylor Scott & White Medical Center, doubled over in pain and screaming as she passed a large blood clot.

But when she requested the same surgical evacuation procedure, called dilation and curettage, or D&C, she said the hospital told her no.

A D&C is the same procedure used for some abortions. In September 2021, in between Amanda’s miscarriag­es, Texas implemente­d a law banning almost all abortions after six weeks into pregnancy.

Following the June 24 reversal of Roe v. Wade, numerous states are enacting bans or sharp restrictio­ns on abortion. While the laws are technicall­y intended to apply only to abortions, some patients have reported

hurdles receiving standard surgical procedures or medication for the loss of desired pregnancie­s.

Amanda said the hospital didn’t mention the abortion law, but sent her home with instructio­ns to return only if she was bleeding so excessivel­y that her blood filled a diaper more than once an hour. Hospital records that Amanda shared with The New York Times noted that her embryo had no cardiac activity during that visit and on an ultrasound a week earlier. “She reports having a lot of pain” and “she appears distressed,” the records said.

“This appears to be miscarriag­e in process,” the records noted, but suggested waiting to confirm and advised a follow-up in seven days.

Once home, Amanda said, she sat on the toilet digging “fingernail marks in my wall” from the pain. She then moved to the bathtub, where her husband held her hand as they both cried. “The bathtub

water is just dark red,” Amanda recalled. “For 48 hours, it was like a constant heavy bleed and big clots.”

She added, “It was so different from my first experience where they were so nice and so comforting, to now just feeling alone and terrified.”

The hospital declined to discuss whether Texas’ abortion laws have had any impact on its medical care. In a statement, the hospital said, “our multidisci­plinary team of clinicians works together to determine the appropriat­e treatment plan on an individual case-bycase basis. The health and safety of our patients is our top priority.”

John Seago, president of Texas Right to Life, said he considers any obstacles miscarriag­e patients encounter to be “very serious situations.” He blamed such problems on “a breakdown in communicat­ion of the law, not the law itself,” adding “I have seen reports of doctors

being confused, but that is a failure of our medical associatio­ns” to provide clear guidance.

The uncertain climate has led some doctors and hospitals to worry about being accused of facilitati­ng an abortion, a fear that has also caused some pharmacist­s to deny or delay filling prescripti­ons for medication to complete miscarriag­es, providers and patients say.

Delays in expelling tissue from a pregnancy that is no longer viable can lead to hemorrhagi­ng, infections, and sometimes life-threatenin­g sepsis, obstetrici­ans say.

“In this post-Roe world, women with miscarriag­es may die,” said Dr. Monica Saxena, an emergency medicine physician at Stanford Hospital.

Medical experts define miscarriag­e as a pregnancy that ends naturally before 20 weeks’ gestation. Medical terminolog­y often calls miscarriag­e “spontaneou­s abortion,” a designatio­n that can increase patients’ or providers’ concerns about being targeted under bans. In medical records, Amanda’s second miscarriag­e was also labeled “threatened abortion: establishe­d and worsening.”

In typical early miscarriag­es, when cardiac activity has stopped, patients should be offered three options to expel tissue, said Dr. Sarah Prager, an obstetrics and gynecology professor at the University of Washington’s School of Medicine.

D&C is recommende­d when patients are bleeding heavily, are anemic, have blood-clotting issues or certain conditions that make them medically fragile, Prager said. Some other patients also choose D&C’s, considerin­g them emotionall­y easier than a lingering process at home.

Another option is medication — usually mifepristo­ne, which weakens the membrane lining the uterus and softens the cervix, followed by misoprosto­l, which causes contractio­ns. These same pills are used for medication abortion.

The third option is “expectant management”: waiting for tissue to pass on its own, which can take weeks. It is unsuccessf­ul for 20% of patients, who then need surgery or medication, said Prager, who co-authored miscarriag­e management guidelines for the American College of Obstetrici­ans and Gynecologi­sts.

When possible, patients should be allowed to choose the method because lack of choice compounds the trauma of losing a wanted pregnancy, doctors and patients said.

A study from two Dallas hospitals reported on 28 patients whose water broke or who had other serious complicati­ons before 22 weeks’ gestation, and who, because of Texas laws, didn’t receive medical interventi­on until there was an “immediate threat” to their lives or fetal cardiac activity stopped.

On average, the patients waited nine days, and 57% ended up with serious infections, bleeding or other medical problems, the report said. Another article, in the New England Journal of Medicine, said similar patients returned with signs of sepsis after doctors or hospitals decided Texas’ abortion law prevented them from intervenin­g earlier.

In such cases, Seago of Texas Right to Life said abortion bans might require delaying interventi­on.

Some women who have miscarried and are at risk of future losses say they are considerin­g moving from states that ban abortion or are rethinking life plans.

“We are not going to try and conceive anymore,” Amanda said. “We don’t feel like it’s safe in Texas to continue to try.”

 ?? NANCY NEWBERRY/THE NEW YORK TIMES ?? Amanda, in the Dallas-Fort Worth area of Texas, was denied surgery for a miscarriag­e.
NANCY NEWBERRY/THE NEW YORK TIMES Amanda, in the Dallas-Fort Worth area of Texas, was denied surgery for a miscarriag­e.

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