By Dorothy Brooks
Now that the Supreme Court has shifted abortion lawmaking decisions to the states, matters for frontline providers have become more complicated in multiple ways. In addition to tracking patchwork laws, providers must be prepared to manage pregnancy- or abortion-related complications that might have been better managed at clinics that provide appropriate services.
In a statement, the American College of Emergency Physicians (ACEP) said it was concerned about the medical and legal implications of judicial overreach into the practice of medicine. “Decisions by non-medical professionals that interfere with the physician-patient relationship are extremely worrisome,” said ACEP President Gillian Schmitz, MD, FACEP.1
Nursing organizations expressed similar dismay. National Nurses United issued a statement condemning the ruling, and the American Nurses Association said the ruling “paves the way for laws that will fundamentally come between patients and healthcare professionals.”2,3
The Emergency Nurses Association and the American Academy of Emergency Nurse Practitioners issued a joint statement noting the ruling changes the landscape of healthcare for women. The groups argued allowing abortion laws to be determined at the state level “will create a ripple effect across the healthcare continuum, including in the emergency department.”4
Emergency providers in states that have banned or severely limited access to abortion likely will experience the most problems. However, experts believe there will be spillover effects that extend to providers in states that plan to maintain access to legal abortion. Either way, there are concerns that patients suffering from abortion-related complications will delay seeking care because they fear legal consequences, a scenario that could lead to more deaths.
Caitlin Bernard, MD, MS, an assistant professor of clinical obstetrics and gynecology at Indiana University-Purdue University Indianapolis, is concerned about states passing even stricter anti-abortion laws. If that happens, Bernard anticipates many abortion-related complications typically managed at the Planned Parenthood healthcare center where she works may wind up in the ED.
“Because [patients] will be going out of state and out of our system to receive abortion care, they are not necessarily going to have the ability to travel back to the health center where they initially received abortion care if they are having complaints. They may turn more to their local EDs for management of those types of complications,” Bernard explains. “Thankfully, complications from safe, legal abortions are incredibly rare for both medication and surgical procedural abortions. But when you are talking about thousands of people getting an abortion every year, there are going to be some complications.”
For example, after an abortion, patients experience ongoing bleeding. “It is very common after a medication abortion or even a procedural abortion to have some ongoing bleeding even for several weeks,” Bernard says. “But many people may become concerned with those symptoms and may reach out [to EDs] for care.”
Another issue Bernard anticipates is what she terms incomplete abortion. “That means that the pregnancy was not fully [expelled] from the uterus,” she says. “That can either mean that patients are having an ongoing pregnancy — the pregnancy is still growing and there is cardiac activity — or it can mean that there is pregnancy-related tissue left ... and it just needs to be removed.”
In cases where a woman is experiencing active bleeding and her cervix is open but she cannot expel the pregnancy, that would be an emergency. “Very rarely, one of these conditions could end up causing an infection, but [such infections] could increase if people are afraid to seek care,” Bernard says. “We do anticipate that there may be an increase in people delaying care, and therefore an increase in complications like infections.”
Considering EDs could see more of these patients, Bernard is preparing a presentation for her own ED on what pregnancy- or abortion-related issues providers should be anticipating. She encourages other ED providers and their OB/GYN colleagues to collaborate on how they intend to manage such cases. For instance, Bernard notes ED providers need anticipatory guidance on what types of pregnancy-related cases they may see, as well as a game plan in terms of how they will communicate with their OB/GYN colleagues when a patient with a pregnancy- or abortion-related complication presents.
For cases not considered medical emergencies, it will make sense to create a fast pathway referral process so these women can be seen quickly by an OB/GYN in outpatient care. However, Bernard notes there also might be emergencies, so it is important to designate who to call and how that case should be managed.
Bernard admits such processes will look different depending on what resources are available. For example, EDs at tertiary care centers might be able to access all their many OB/GYN colleagues on a 24/7 basis, but that likely will not be the case at a smaller hospital in a rural area where an OB/GYN is not on staff. “Programs are going to need to figure that out,” Bernard says. “All abortion care is essentially the same thing as miscarriage care. Whichever pathways already exist for that, it would make sense to use them for this type of care as well.”
Lily Bayat, MD, MPH, an OB/GYN at Robert Wood Johnson University Hospital in New Brunswick, NJ, agrees emergency providers should prepare to work closer with their OB/GYN colleagues. “I am always a fan of simulation, especially in the world of ED training,” Bayat says. “If there is some sort of didactic component and then a simulation where you go through the most common complications of unsafe abortion, I think that would be most helpful.”
While logistical planning can be managed, both Bayat and Bernard are concerned about state laws that may be open to differing legal interpretations. “We have to rely on our legal interpreters to tell us what we can and cannot do, and that is very dangerous,” Bernard warns. “We are faced with literally life and death consequences of that legal interpretation.”
Another cohort to consider includes patients who have planned or desired pregnancies, but their water breaks before the fetus is viable outside the womb. “In the world of OB/GYN, we know that pregnancy has an incredibly poor prognosis, which means that the chance of the fetus having a good outcome is slim to none, but the chance of the mom getting an infection is very high. Infection can quickly progress to sepsis and worse,” Bayat says. “There are going to be situations like that where ... the standard of care would be interventions to terminate the pregnancy, but patients [in some states] may not have access to these interventions.”
There is going to be much confusion over not only when providers can intervene to help a woman who is experiencing pregnancy complications of this nature, but also about how sick the woman needs to be before providers can intervene.
“We all have to be prepared regarding how to anticipate and manage these complications,” Bayat says. “Even as OB/GYNs, this is not something we have had to do for a long time because all of us practicing now have practiced in an ED where abortion was legal.”
Bernard is encouraging providers to work their state legislators to include language to ensure there is a clear definition of abortion that does not include conditions where providers need to intervene to save lives, such as in the case of an ectopic pregnancy. “We are working closely with lawmakers to say ‘this is the clear definition of abortion that we need. This is not an exception. It is a completely separate condition,’” she says.
Other legal concerns pertain to patients who present to the ED for care following a self-managed abortion. “We are going to see an increase in people who are obtaining medication abortion through potentially non-legal means,” Bernard predicts. “They are not going to a clinic where abortion is available. That could involve [obtaining the medication] online, through telehealth, or [from] a friend.”
Bernard is worried about providers playing any sort of role in potential criminal charges against such patients. Bayat agrees providers must think about how they can take care of women with abortion- or pregnancy-related complications without legal harm. “That is something we all need to explore with our legal and ethics people,” she says. “I think it is going to be really hard in states with abortion bans or very restrictive laws.”
REFERENCES
1. American College of Emergency Physicians. Emergency physicians deeply concerned by laws that interfere with the physician-patient relationship. June 24, 2022.
2. National Nurses United. Nation’s largest union of nurses condemns Supreme Court overturn of constitutional right to abortion. June 24, 2022.
3. American Nurses Association. US Supreme Court’s decision to overturn Roe vs. Wade: Is a serious setback for reproductive health and human rights. June 24, 2022.
4. Emergency Nurses Association. ENA-AAENP statement on Supreme Court decision. June 24, 2022.
Now that the Supreme Court has shifted abortion lawmaking decisions to the states, matters for frontline providers have become more complicated in multiple ways. In addition to tracking patchwork laws, providers must be prepared to manage pregnancy- or abortion-related complications that might have been better managed at clinics that provide appropriate services.
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