Last yr, a 35-year-old woman named Amanda, who lives within the Dallas-Fort Value area, had a miscarriage in the primary trimester of her pregnancy. At a big hospital, a health care provider performed a surgical treatment often used as a secure and quick method to remove tissue from a failed pregnancy.
She awoke from anesthesia to seek out a card signed by the nurses and just a little pink and blue bracelet with a butterfly charm, a present from the hospital to precise compassion for her loss. “It was so sweet since it’s such a tough thing to undergo,” Amanda said.
Eight months later, in January, Amanda, who asked to be identified by her first name to guard her privacy, experienced one other first-trimester miscarriage. She said she went to the identical hospital, Baylor Scott & White Medical Center, doubled over in pain and screaming as she passed a big blood clot.
But when she requested the identical surgical evacuation procedure, called dilation and curettage, or D&C, she said the hospital told her no.
A D&C is similar procedure used for some abortions. In September 2021, in between Amanda’s two miscarriages, Texas implemented a law banning just about all abortions after six weeks into pregnancy.
Following the reversal of Roe v. Wade, quite a few states are enacting bans or sharp restrictions on abortion. While the laws are technically intended to use only to abortions, some patients have reported hurdles receiving standard surgical procedures or medication for the lack of desired pregnancies.
Amanda said the hospital didn’t mention the abortion law, but sent her home with instructions to return provided that she was bleeding so excessively that her blood filled a diaper greater than once an hour. Hospital records that Amanda shared with The Recent York Times noted that her embryo had no cardiac activity during that visit and on an ultrasound every week earlier. “She reports having plenty of pain” and “she appears distressed,” the records said.
“This appears to be miscarriage in process,” the records noted, but suggested waiting to verify and advised a follow-up in seven days.
Once home, Amanda said, she sat on the bathroom digging “fingernail marks in my wall” from the pain. She then moved to the tub, where her husband held her hand as they each cried. “The tub water is just dark red,” Amanda recalled. “For 48 hours, it was like a relentless heavy bleed and massive 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.”
Read More on the End of Roe v. Wade
The hospital declined to debate whether Texas’s abortion laws have had any impact on its medical care. In a press release, the hospital said, “While we aren’t able to talk about a person’s case as a consequence of privacy laws, our multidisciplinary team of clinicians works together to find out the suitable treatment plan on a person case-by-case basis. The health and safety of our patients is our top priority.”
John Seago, the 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 even have seen reports of doctors being confused, but that could be a failure of our medical associations” to supply clear guidance.
The uncertain climate has led some doctors and hospitals to fret about being accused of facilitating an abortion, a fear that has also caused some pharmacists to disclaim or delay filling prescriptions for medication to finish miscarriages, providers and patients say. Last week, the Biden administration warned that if a pharmacy refuses to fill prescriptions for pills “including medications needed to administer a miscarriage or complications from pregnancy loss, because these medications will also be used to terminate a pregnancy — the pharmacy could also be discriminating on the premise of sex.”
Delays in expelling tissue from a pregnancy that isn’t any longer viable can result in hemorrhaging, infections, and sometimes life-threatening sepsis, obstetricians say.
“On this post-Roe world, women with miscarriages may die,” said Dr. Monica Saxena, an emergency medicine physician at Stanford Hospital.
Medical examiners define miscarriage as a pregnancy that ends naturally before 20 weeks’ gestation. Most miscarriages occur in the primary 13 weeks; pregnancy losses after 20 weeks are considered stillbirths. Miscarriage befalls about one in 10 known pregnancies, and should occur in as many as one in 4 when including miscarriages that occur before patients realize they’re pregnant.
Medical terminology often calls miscarriage “spontaneous abortion,” a designation that may increase patients’ or providers’ concerns about being targeted under abortion 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 needs to be offered three options to expel tissue, said Dr. Sarah Prager, an obstetrics and gynecology professor on the University of Washington’s School of Medicine.
D&C is beneficial when patients are bleeding heavily, are anemic, have blood-clotting issues or certain conditions that make them medically fragile, Dr. Prager said. Another patients also select D&C’s, considering them emotionally easier than a lingering process at home.
Another choice is medication — normally 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 by itself, which might take weeks. It’s unsuccessful for 20 percent of patients, who then need surgery or medication, said Dr. Prager, who co-authored miscarriage management guidelines for the American College of Obstetricians and Gynecologists.
When possible, patients needs to be allowed to decide on the tactic because lack of alternative compounds the trauma of losing a wanted pregnancy, doctors and patients said.
In Wisconsin, where a 173-year-old abortion ban may soon turn into enforceable again, Dr. Carley Zeal, an obstetrician-gynecologist, treated a girl who said that just after abortion rights were nullified, she showed up bleeding at a hospital, which determined she had miscarried but told her “they couldn’t do a D&C due to laws.” The hospital didn’t offer her miscarriage medication either, advising her to seek out an obstetrician-gynecologist to assist. By the point she found Dr. Zeal, who gave her mifepristone and misoprostol, the girl had been bleeding intermittently for days, putting her at “increased risk of hemorrhage or infection.”
“Even in these straightforward cases of basic OB/GYN practice, the laws leave providers questioning and afraid,” Dr. Zeal said. “These laws are already hurting my patients.”
Doctors say even greater risks may occur with cases of “inevitable miscarriage,” where there continues to be fetal cardiac activity, however the patient’s water has broken much too early for the pregnancy to be viable, said Greer Donley, an assistant professor on the University of Pittsburgh Law School.
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, due to 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 percent ended up with serious infections, bleeding or other medical problems, the report said. One other article, within the Recent England Journal of Medicine, said similar patients returned with signs of sepsis after doctors or hospitals decided Texas’s abortion law prevented them from intervening earlier.
In such cases, Dr. Seago of Texas Right to Life said abortion bans might require delaying intervention. What he characterised as a health care provider saying “‘I would like to cause the death of the kid today because I think that they’re going to pass away eventually,’” is prohibited, he said. He acknowledged that such delays could cause medical complications for ladies but said “severe” complications could legally be treated immediately.
Certainly one of the miscarriage medications, mifepristone, should be prescribed by certified providers and can’t be allotted by typical pharmacies. Although the certification process is straightforward, Dr. Lauren Thaxton, an assistant professor within the department of girls’s health on the University of Texas at Austin’s Dell Medical School, said some hospitals have expressed “concern about this medication also getting used for abortion and whether or not that might create some kind of bad look.”
So, in some states, doctors only prescribe misoprostol for miscarriages, which might work by itself, but less well. Additionally it is used for other medical conditions and needs to be easily obtainable at pharmacies, but some have declined to fill miscarriage patients’ misoprostol prescriptions or required additional documentation from doctors, Dr. Thaxton and others said.
Cassie, a Houston woman who asked to be identified by her first name, said she learned she had miscarried the day Roe v. Wade was overturned, when her doctor detected blood in her uterus and no cardiac activity.
She was prescribed misoprostol, but said a Walgreens made her wait a day for “extra approval” from its corporate office.
“After I went to select it up, I then had to speak with the pharmacist and needed to state again, regardless that they were aware my doctor prescribed it, that it wasn’t for an abortion,” Cassie said.
A Walgreens spokesman said some abortion laws “require additional steps for allotting certain prescriptions and apply to all pharmacies, including Walgreens. In these states, our pharmacists work closely with prescribers as needed, to fill lawful, clinically appropriate prescriptions.”
Dr. Thaxton said that when pharmacies delay allotting misoprostol, some patients are financially or logistically unable to return for the medication one other day. As a substitute, some visit doctors days later, still retaining pregnancy tissue or “having significant bleeding that should be managed urgently,” she said.
In March in Missouri, which now has a post-Roe abortion ban, Gabriela, who asked to be identified by her first name, said she had a blighted ovum, during which a fertilized egg implants within the uterus but doesn’t develop. “My body wouldn’t release it,” she said.
Her doctor prescribed misoprostol, nevertheless it didn’t work well enough. When she asked for mifepristone, the doctor said it was difficult to acquire there, based on a health care provider’s note Gabriela shared with The Times.
The doctor ordered a second round of misoprostol, but Gabriela said, “The pharmacist at Walgreens told me she couldn’t give it to me if I used to be pregnant. I used to be in a position to stutter out that I used to be having a miscarriage, and he or she gave it to me. I couldn’t help but cry in front of all of the people at Walgreens because I felt like I used to be being treated like a nasty person for selecting up a drugs to stop an infection.”
Dr. Prager said she’s been told that some Texas miscarriage patients had been turned away by doctors who anxious the patientsmight have actually taken abortion pills that hadn’t expelled the pregnancy, two situations that appear medically similar.
“There’s a system being created where there isn’t any trust between physicians and patients, and patients are potentially going to decide on to not go to a hospital even with something like a miscarriage, because they’re fearful,” Dr. Prager said.
Some women who’ve miscarried and are vulnerable to future losses say they’re considering moving from states that ban abortion or are rethinking life plans.
“We aren’t going to attempt to conceive anymore,” Amanda said. “We don’t feel prefer it’s secure in Texas to proceed to try after what we went through.”