The Fall of Roe Makes Complex Pregnancies Even Riskier

Doctors who care because pregnant people often have to make time-sensitive decisions when lives are at stake. But following the US Supreme Court Dobbs decision, which overturned the national right to abortion, time is no longer on its side.

Many states have now implemented tough restrictions that do not necessarily prohibit doctors from acting none abortions, but make them wait until a “medical emergency” or “life-threatening” event occurs, and what these terms mean is not well defined. These delays can endanger patients who suffer from incomplete abortions (when a miscarriage begins, but some pregnancy tissue remains in the uterus) or ectopic pregnancies (in which the fetus implants in a different place than the uterus). In many cases, terminating the pregnancy is the safest option. But without the blanket protection once provided by Roedoctors in these states may not be able to provide appropriate care in a timely manner.

Katrina Green, an emergency physician who practices in Tennessee, has seen many of these pregnant patients who, she says, “are very critically ill. Time is of the essence to get them to an operating room, stat. We don’t have time of calling a lawyer and finding out: am I going to jail for doing my job?

For example, during an incomplete miscarriage, if the parent’s body cannot evacuate the rest of the tissue on its own, the standard of care may include a process called dilation and curettage (also known as a D&C). This is a uterine aspiration, a procedure in which the remaining tissue of the pregnancy is removed. Here, Green says, time is of the essence. “What we’re trained to do, what’s supposed to happen, scientific evidence-based medicine here, is to do the D&C up front,” he says. “The longer the products of conception are in the uterus, the more likely there is an infection.”

And if this infection becomes very severe, it can lead to sepsis, when the bacteria from the infection travel into the bloodstream. This can make the D&C or other procedures to remove the remaining pregnancy tissue riskier. “Surgeons like to have a stable patient on the operating table,” adds Green. “Outcomes are much worse when you’re septic.”

Or sometimes, in the process of providing emergency care, a doctor will discover information that makes abortion no longer an option in that state. The diagnosis of an incomplete miscarriage is based on a variety of factors, says Stacy De-Lin, a physician and associate director of Planned Parenthood in New York. While many patients experience heavy bleeding, some do not, and doctors may look at hormone levels or an ultrasound to determine whether an incomplete abortion has occurred or is inevitable. One of the problems, however, is when “by the time we diagnose it, there may still be a fetal heartbeat,” De-Lin says.

Several states (including Georgia, South Carolina, and Texas) explicitly prohibit abortions after a fetal heartbeat is detected, sometimes with exceptions in cases of rape or incest or if the life of the pregnant person is in danger. If a doctor detects a heartbeat in these states, they often have to wait until the heartbeat goes away or the pregnant person’s condition worsens enough to be considered life-threatening. “What I’m seeing and hearing from my colleagues across the country is that patients are being told to go home and wait until they bleed or have signs of infection, such as a fever, that it can be really dangerous for the pregnant person,” says Amy Addante, an OB/GYN in Illinois.

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