Last year, Amanda, a 35-year-old woman living in the Dallas-Fort Worth area, had a first-trimester miscarriage. In a large hospital, a doctor performs a surgical procedure used as a safe and quick method to remove tissue from a failed pregnancy.
She awoke from anesthesia to find a card signed by nurses and a small pink and blue bracelet with a butterfly charm, a gift from the hospital to express condolences for her loss. “It was so sweet because it’s 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, suffered another first-trimester miscarriage. She said she went to the same hospital, Baylor Scott & White Medical Center, doubled over in pain and screaming when a large blood clot passed out.
But when he requested the same surgical evacuation procedure, called dilation and curettage, or D&C, he said the hospital told him no.
A D&C is the same procedure used for some abortions. In September 2021, between Amanda’s two abortions, Texas enacted a law banning nearly all abortions after six weeks of pregnancy.
After the overturning of Roe v. Wade, many states are banning or tightening restrictions on abortion. Although the laws technically only apply to abortions, some patients report barriers to receiving standard surgical procedures or medications for the loss of an intended pregnancy.
Amanda said the hospital didn’t mention the abortion law, but sent her home with instructions if she bled so much that her blood filled a diaper more than once an hour. Hospital records that Amanda shared with The New York Times noted that her fetus had no heartbeat during that visit and on an ultrasound a week earlier. “She reported a lot of pain” and “she appeared distressed,” the records said.
“It appears to be a miscarriage in process,” the records noted, but advised waiting to confirm and follow-up in seven days.
Once home, Amanda said, she sat on the toilet digging “nail marks in my wall” from the pain. She then walked into the bathtub, where her husband held her hand as they both cried. “The water in the bathtub was just dark red,” Amanda recalls. “For 48 hours, it was like constant heavy bleeding and big clots.”
She added, “It’s so different from my first experience where they were so nice and so relaxed, now just feeling alone and terrified.”
Read more at the end of Roe v. Wade
The hospital declined to discuss whether the Texas abortion law has had any impact on its medical care. In a statement, the hospital said, “While we cannot speak to an individual’s case due to privacy laws, our multidisciplinary team of physicians work together to determine the appropriate treatment plan on an individual case-by-case basis. The health and safety of our patients is our highest priority.”
John Seago, president of Texas Right to Life, said he considers any obstruction of abortion patients a “very serious situation.” He blamed such problems on “a breakdown in communication of the law, not the law itself,” adding “I’ve seen reports of doctors being confused, but it’s the failure of our medical association” to provide clear guidance.
The uncertain climate has led some doctors and hospitals to worry about being accused of facilitating abortions, a fear that has led some pharmacists to refuse or delay filling prescriptions for drugs to complete abortions, providers and patients say. Last week, the Biden administration warned that if a pharmacy refuses to fill prescriptions for pills “including those needed to manage abortion or complications of abortion, because these drugs can also be used to terminate a pregnancy — the pharmacy may be discriminating on the basis of sex.” “
Obstetricians say the delay in removing tissue from a pregnancy that is no longer viable can lead to bleeding, infection and sometimes fatal sepsis.
“In this post-Ro world, women who have abortions can die,” said Dr. Monica Saxena, an emergency medicine physician at Stanford Hospital.
Medical experts define miscarriage as a pregnancy that ends before 20 weeks of gestation. Most miscarriages occur in the first 13 weeks; Pregnancy loss after 20 weeks is considered stillbirth. Miscarriage occurs in about one in 10 known pregnancies and may occur in one in four, including miscarriages that occur before patients realize it.
Medical terminology often refers to abortion as “spontaneous abortion,” a designation that may raise concerns among patients or providers about being targeted under the abortion ban. In the medical records, Amanda’s second miscarriage was marked as “threatened miscarriage: established and bad”.
In typical early miscarriages, when the heart stops working, patients should be offered three options to get the tissue out, said Dr. Sarah Prager, a professor of obstetrics and gynecology at the University of Washington School of Medicine.
A D&C is recommended when patients have profuse bleeding, anemia, blood clotting problems or certain conditions that make them medically fragile, Dr. Prager said. Some other patients also opt for D&C, which they consider easier emotionally than the lengthy procedure at home.
Another option is medication – usually mifepristone, which weakens the lining of the uterus and softens the uterus, followed by misoprostol, which causes contractions. This same pill is used for drug abortion.
A third option is “expectant management”: waiting for the tissue to pass on its own, which can take several weeks. It fails for 20 percent of patients, who later require surgery or medication, said Dr. Prager, who co-authored the Abortion Management Guidelines for the American College of Obstetricians and Gynecologists.
When possible, patients should be allowed to choose the method because the lack of choice increases the trauma of losing a wanted pregnancy, doctors and patients say.
In Wisconsin, where a 173-year-old abortion ban could soon be reinstated, Dr. Carle Zill, an obstetrician-gynecologist, treated a woman who said she had bleeding shortly after abortion rights were repealed at a hospital, which determined she had miscarried. But told him “they couldn’t do D&C because of the law.” The hospital didn’t even give her abortion pills, suggesting she find an obstetrician-gynecologist to help. By the time she found Dr Zell, who had given her mifepristone and misoprostol, the woman had been bleeding intermittently for days, putting her at “increased risk of bleeding or infection”.
“Even in this straightforward area of basic OB/GYN practice, the laws question and intimidate providers,” says Dr. Zell. “These laws are already harming my patients.”
Doctors say the risk may be even greater in cases of “inevitable miscarriage,” in which the fetus still has cardiac activity, but the patient’s water has broken too early for the pregnancy to be viable, said Greer Donley, an assistant professor at the University of Pittsburgh Law School.
A study at two Dallas hospitals reported on 28 patients whose waters broke before 22 weeks’ gestation or who had other serious complications and who, by Texas law, did not receive medical intervention until there was an “immediate threat” to their lives. or fetal cardiac activity ceases. On average, patients waited nine days, and 57 percent 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 symptoms of sepsis after doctors or hospitals decided Texas abortion laws prevented them from intervening earlier.
In such cases, Texas Right to Life’s Dr. Sego says that abortion bans may require delayed intervention. What he says as a doctor “‘I want to kill the baby today because I believe they will die eventually,'” is taboo, he said. He acknowledged that such delays could lead to medical complications for women but said “serious” complications could legally be treated immediately.
One of the abortion medications, mifepristone, must be prescribed by certified providers and cannot be dispensed by general pharmacies. Although the certification process is simple, an assistant professor of women’s health at the University of Texas at Dell Medical School in Austin. Lorraine Thaxton said some hospitals have expressed concern “that the drug is being used for abortions and whether or not it could create something ugly.”
So, in some states, doctors prescribe only misoprostol for abortion, which can work on its own, but less well. It is also used for other medical conditions and is readily available at pharmacies, but some abortion patients refuse to fill misoprostol prescriptions or require additional documentation from doctors, Dr. As Thaxton et al.
Casey, a Houston woman who asked to be identified by her first name, learned she had miscarried the day Roe v. Wade was overturned, when her doctor detected blood in her uterus and no cardiac activity.
He was given misoprostol, but said a Walgreen made him wait a day for “additional approval” from its corporate office.
“When I went to pick it up, I had to chat with the pharmacist and say again, even though they were aware that my doctor had prescribed it not for abortion,” Casey said.
A Walgreens spokeswoman said some abortion laws “require additional steps to dispense certain prescriptions and apply to all pharmacies, including Walgreens. In these states, our pharmacists work closely with prescribers, as needed, to fill valid, clinically appropriate prescriptions.”
Dr. Thaxton said that when pharmacies delay dispensing misoprostol, some patients cannot financially or logistically return for the medication another day. Instead, go to the doctor a few days later, still retain pregnancy tissue or have “significant bleeding that needs to be managed urgently,” she said.
In March in Missouri, which now has a ban on post-Ro abortions, Gabriella, who asked to be identified by her first name, said she had a blighted ovary, in which a fertilized egg implants in the uterus but does not develop. “My body won’t let it go,” she said.
His doctor prescribed misoprostol, but it didn’t work well enough. When she asked for mifepristone, the doctor said it was hard to get, according to a doctor’s note Gabriela shared with the Times.
The doctor ordered a second round of misoprostol, but Gabriella said, “The pharmacist at Walgreens told me he couldn’t give it to me if I got pregnant. I stammered that I was having a miscarriage, and she gave it to me. I couldn’t cry in front of all the people at Walgreens because I felt like I was being treated like a bad person for taking medication to prevent an infection.”
Dr. Prager said he has been told that some abortion patients in Texas have been turned away by doctors who were concerned that the patients had actually taken abortion pills that did not expel the pregnancy, two situations that appear to be medically identical.
“A system is being created where there is no trust between doctors and patients, and patients will choose not to go to the hospital for something like a possible abortion, because they are afraid,” Dr. Prager said.
Some women who have had abortions and are at risk of future harm say they are considering moving from states that ban abortions or reconsidering life plans.
“We’re not going to try to conceive anymore,” Amanda said. “We don’t think it’s safe in Texas to keep trying after what we’ve been through.”