Last year, a 35-year-old woman named Amanda, who lives in the Dallas-Fort Worth area, suffered a miscarriage in the first trimester of her pregnancy. At a major hospital, a doctor performed a surgical procedure often used as a safe and quick method of removing tissue after a failed pregnancy.
She awoke from the anesthesia to find a postcard signed by the nurses and a small pink and blue bracelet with a butterfly pendant, a gift from the hospital in sympathy for her loss. “It was so sweet because it’s so hard to go through,” said Amanda.
Eight months later, in January, Amanda, who asked to be named to protect her privacy, suffered another first-trimester miscarriage. She said she went to the same hospital, Baylor Scott and White Medical Center, doubled over in pain and screaming as she had a large blood clot.
But when she requested the same surgical evacuation procedure, called dilatation and curettage, or D&C, she said the hospital turned her down.
D&C is the same procedure used for some abortions. In September 2021, between Amanda’s two miscarriages, Texas passed a law banning almost all abortions after six weeks of pregnancy.
After the cancellation of Roe v. Wade, many states have bans or severe restrictions on abortion. Although the laws are technically meant to apply only to abortions, some patients report barriers to getting standard surgical procedures or medications to lose their desired pregnancy.
Amanda said the hospital didn’t mention the abortion law, but sent her home with instructions to only return if she bleeds so heavily that her diaper fills with blood more than once an hour. Hospital records Amanda shared with The New York Times note that her embryo had no heart activity during that visit and on an ultrasound a week earlier. “She reports being in a lot of pain” and “she looks distressed,” the notes said.
“It appears to be a miscarriage in progress,” the records noted, but suggested waiting to be confirmed, and a follow-up examination seven days later was recommended.
Upon returning home, Amanda said she was sitting on the toilet, digging in pain for “nail marks on my wall.” She then went to the bathroom, where her husband held her hand while they both cried. “The bath water is just dark red,” Amanda recalls. “For 48 hours it was like constant heavy bleeding and big clots.”
She added, “It was so different from my first experience, when they were so cute and so comfortable, to the point where now I just felt alone and scared.”
More on the end of Roe v. Wade
The hospital declined to discuss whether Texas abortion laws affected its medical care. The hospital said in a statement: “While we cannot speak on a specific case due to privacy laws, our multidisciplinary team of clinicians are working together to determine the appropriate treatment plan for each individual case. The health and safety of our patients is our top priority.”
John Seago, president of Texas Right to Life, said he considers any obstacles that miscarriage patients face “very serious situations.” He blamed such problems on “disconnection from the law, not the law itself,” adding, “I’ve seen reports of doctors being confused, but it’s the failure of our medical associations” to provide clear guidance.
The uncertain environment has left some doctors and hospitals fearful of being accused of facilitating an abortion, a fear that has also led some pharmacists to refuse or delay prescriptions for drugs to end miscarriages, medical professionals and patients say. Last week the Biden administration warned that if a pharmacy refuses to write prescriptions for pills “including medicines needed to treat miscarriage or complications from miscarriage because these medicines can also be used to terminate a pregnancy, the pharmacy can discriminate on the basis of sex.”
Delays in expelling tissues from pregnant women that are no longer viable can lead to bleeding, infections, and sometimes life-threatening sepsis, obstetricians say.
“In this post-royal world, women with miscarriages can die,” the doctor said. Monica Saxena, emergency physician at Stanford Hospital.
Medical experts determine miscarriage like a pregnancy that ends naturally before 20 weeks of gestation. Most miscarriages occur in the first 13 weeks; pregnancy loss after 20 weeks is considered a stillbirth. Miscarriage occurs in about one in 10 known pregnancies and can occur in one in four if miscarriages that occur before patients realize they are pregnant are included.
Medical terminology often refers to a miscarriage as a “spontaneous abortion,” which can heighten patients’ or healthcare providers’ concerns about the ban on abortion. The medical records also labeled Amanda’s second miscarriage as “threatened abortion: established and worsening.”
In typical early miscarriages when cardiac activity has stopped, patients should be offered three options for tissue expulsion. Sarah Prager is professor of obstetrics and gynecology at the University of Washington School of Medicine.
D&C is recommended when patients have severe bleeding, anemia, bleeding problems, or certain conditions that make them medically vulnerable. Prager said. Some other patients also opt for D&C, finding it emotionally easier than a protracted process at home.
Another option is medication—usually mifepristone, which weakens the membrane that lines the uterus and softens the cervix, followed by misoprostol, which causes contractions. The same pills are used for medical abortion.
The third option is “wait and see”: waiting for the tissue to fall off on its own, which can take weeks. This is unsuccessful for 20 percent of patients who then need surgery or treatment. Prager, co-inventor of miscarriage treatment guidelines for the American College of Obstetricians and Gynecologists.
When possible, patients should be allowed to choose a method because lack of choice exacerbates the trauma of losing a desired pregnancy, doctors and patients say.
In Wisconsin, where a 173-year-old abortion ban may soon be in effect again, Dr. Carly Zeal, an OB/GYN, treated a woman who said that immediately after her abortion rights were revoked, she was bleeding in a hospital that determined she had a miscarriage but told her “they can’t do a D&C because of the laws.” The hospital also did not offer her a cure for the miscarriage, advising her to see an OB/GYN. By the time she found Dr. Zeal, who gave her mifepristone and misoprostol, the woman had intermittent bleeding for several days, putting her at “increased risk of bleeding or infection.”
“Even in these simple cases of basic OB/GYN practice, the laws create doubt and fear among health care providers,” says Dr. Zeal said. “These laws are already hurting my patients.”
Doctors say even greater risk may arise in cases of “imminent miscarriage,” when the fetus’s heart is still going on, but the patient’s water breaks too early for the pregnancy to be viable, says Greer Donley, assistant professor at New York University. Pittsburgh Law School.
Study from two Dallas hospitals reported 28 patients who had water breaks or other serious complications prior to 22 weeks of gestation and who, due to Texas law, did not receive medical intervention until their lives were “imminently threatened” or until their heart stopped fetal activity. On average, patients waited nine days, and 57 percent had serious infections, bleeding or other health problems, the report said. Other articlein the New England Journal of Medicine, says similar patients returned with signs of sepsis after doctors or hospitals decided Texas abortion law didn’t allow them to intervene earlier.
In such cases, Dr. Seago of Texas Right to Life stated that the abortion ban may require a delay in intervention. According to him, what he described as the words of a doctor: “I want to cause the death of a child today, because I believe that in the end they will die” – is prohibited. He acknowledged that such delays could cause medical complications for women, but said that “severe” complications could legally be treated immediately.
One of the miscarriage medicines, mifepristone, must be prescribed by certified providers and cannot be sold in conventional pharmacies. Although the certification process is simple, Dr. Lauren Thaxton, assistant professor of women’s health at the University of Texas at the Dell School of Medicine in Austin, said some hospitals have expressed “concern that this drug is also being used for abortions and whether it might create some kind of bad look.” . ”
For example, in some states doctors prescribe misoprostol only for miscarriage, which may work on its own but is less effective. It is also used to treat other conditions and should be readily available from pharmacies, but some refuse to write prescriptions for misoprostol for women who have miscarriages or demand additional paperwork from doctors. Thaxton and others said.
Cassie, a Houston resident who asked to be named, said she learned she had a miscarriage on the day Rowe v. USA. Wade flipped over when her doctor found blood in her uterus and no heart activity.
She was prescribed misoprostol, but she said Walgreens made her wait all day for “additional approval” from the corporate office.
“When I went to pick it up, I had to talk to the pharmacist and claim again, even though they knew my doctor had prescribed it, that it was not for an abortion,” Cassie said.
A Walgreens spokesperson said some abortion laws “require additional steps to issue certain prescriptions and apply to all pharmacies, including Walgreens. In these states, our pharmacists work closely with prescribers as needed to write legitimate, clinically acceptable prescriptions.”
Dr. Thaxton said that when pharmacies delay dispensing misoprostol, some patients are financially or logistically unable to return for the medicine another day. Instead, some see doctors a few days later, still with pregnancy tissue or “having significant bleeding that needs to be stopped urgently,” she said.
In March, in Missouri, which now has a ban on abortion after Row, Gabriela, who asked for her name, said she had a damaged egg, in which a fertilized egg implants in the uterus but does not develop. “My body wouldn’t let it out,” she said.
Her doctor prescribed misoprostol, but it didn’t work well enough. When she asked for mifepristone, the doctor said it was hard to get there, according to a doctor’s note Gabriela shared with The Times.
The doctor prescribed a second course of misoprostol, but Gabriela said, “The pharmacist at Walgreens told me she couldn’t give it to me if I was pregnant. I was able to stutter that I was having a miscarriage and she gave it to me. I couldn’t help crying in front of all the people at Walgreens because I felt like I was being treated like a bad person for taking medicine to prevent an infection.”
Dr. Prager said she was told that some patients with miscarriages in Texas were rejected by doctors who worried the patients might actually have taken abortion pills that didn’t terminate the pregnancy, two situations that appear medically identical.
“A system is being created where there is no trust between doctors and patients, and patients would potentially choose not to go to the hospital even with something like a miscarriage because they are scared,” says the doctor. Prager said.
Some women who have had miscarriages and are at risk of future loss say they are considering moving out of states where abortion is illegal or are rethinking their life plans.
“We’re not going to try to get pregnant anymore,” Amanda said. “We don’t feel it’s safe in Texas to keep trying after what we’ve been through.”