For pregnant patients, abortion restrictions threaten care - The Texas Tribune

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Teresa Kim Pecinovsky is terrified she will have a miscarriage.

The 38-year-old Houston mother of two children is in the second trimester of a high-risk pregnancy, but uncertainty about Texas abortion laws means that she — and her gynecologist — are worried about her access to proper medical care if that nightmare were to come true.

"She actually couldn't give me a solid answer, which was horrifying to me," said Pecinovsky, who is an ordained minister.

Late last year, the lesser-known abortion restriction known as Senate Bill 4 went into effect, making it a state jail felony in Texas for medical personnel to administer the ulcer drug misoprostol to induce an abortion after seven weeks of pregnancy.

Misoprostol is commonly used for miscarriages, and the law doesn't outlaw the drug's use for that.

But Pecinovsky's doctor worried that a pharmacist will misinterpret the drug's prescribed use and refuse to provide misoprostol for a miscarriage. Already, some Texas doctors are reporting prescription holdups due to the confusion about the law.

"It's awful and hard enough when you have a pregnancy and you miscarry. And then to have to think about all of this extra layer of legality, psychological and emotional distress placed on you now that these laws are in effect," Pecinovsky said.

The new state abortion restrictions, including Senate Bill 8, which passed last year and bans most abortions after about six weeks of pregnancy, have made care for pregnant people more challenging than ever, providers say.

Some say they are holding back when they need to outline medical options for their pregnant patients, particularly in the cases of those with high-risk pregnancies.

"​​It's a challenging situation where politicians are interfering with the patient-physician relationship," said Dr. John Thoppil, president of the Texas Association of Obstetricians and Gynecologists.

The impact of Texas abortion restrictions doesn't stop with current patients. For medical students considering obstetrics and gynecology as a career, it means they now have to leave Texas if they want to get hands-on training in abortion care — what doctors call a vital part of comprehensive women's health care and needed training in case a pregnant patient's life is at risk.

"Their training is diminished because they're very interested in comprehensive women's health care, which includes women having pregnancies that they might not want to continue either electively or because of the health issue or because it's a product of sexual violence," said Dr. Tony Ogburn, professor and chair of the University of Texas Rio Grande Valley's Department of Obstetrics and Gynecology. "And those things are not really available to them now."

Now, Texas lawmakers are set to ban most abortions altogether if the U.S. Supreme Court overturns the landmark abortion ruling Roe v. Wade in deciding a challenge to Mississippi's 15-week ban on abortion, expected next month.

That seems likely considering a recently leaked draft opinion from the court, and if that happens, caring for — and even counseling — patients with high-risk pregnancies will become even more complicated, medical providers say.

Post-Roe threats to health care

If Roe is overturned, a "trigger law" in Texas would go into effect 30 days later that would ban abortion from the moment of fertilization, and it offers no exceptions for rape, incest or conditions in utero that are likely to result in the death of the baby. Violators of that law — those who perform an illegal abortion, and those who aid someone who is seeking one — would face second-degree felony charges.

Under SB 8, anyone who performs an abortion or helps someone with obtaining an abortion after cardiac activity is detected in an embryo — usually about six weeks into a pregnancy — could face a lawsuit. Diagnosis and treatment of patients experiencing pregnancy complications often occur well beyond that point.

But OB-GYNs and others who care for pregnant people say that if Roe v. Wade is overturned, even early detection and treatment of potentially life-threatening problems will become more difficult, and sometimes impossible.

"The changes in the laws and the regulations that may potentially come into play [with new laws triggered by the overturning of Roe v. Wade] will make it more challenging to provide optimal women's health care," Ogburn said. "That does worry patients, and it worries providers, too."

For health care providers, navigating last year's new restrictions has meant constantly evaluating what they need to do as caretakers and considering what they can tell patients without risking costly lawsuits or worse.

"The whole atmosphere [brought by the restrictions] … has created a real cloud of suspicion and fear among a lot of people," Ogburn said. "There's concern that if you even talk to someone about what their options are, that you're at risk of someone filing suit against you. … There's just been a lot of anxiety around that."

Threat to life

While supporters of Texas' abortion restrictions say the laws only target those wanting to terminate their pregnancies, those restrictions could mean higher maternal mortality rates among those who want to carry a pregnancy safely to term, said Dr. Stephanie Mischell, ​​a provider at a medical facility in Dallas and a fellow with Physicians for Reproductive Health.

"Even things like miscarriages can be impacted by abortion bans because so many of the treatments are regulated the same way," Mischell said. "This is something that I think really impacts everybody, not only the people who are seeking abortions."

In Houston, Pecinovsky is at a high risk of miscarriage and complications not only because of her age but also because she has rheumatoid arthritis, which increases the likelihood of premature delivery.What worried Pecinovsky's gynecologist is the lesser-known SB 4 that went into effect in December and singled out two popular OB-GYN drugs, mifepristone and misoprostol.

Thoppil said pharmacists across the state have expressed apprehension to the Texas Association of Obstetricians and Gynecologists about providing OB-GYN medication. One Austin pharmacy refused to fill a prescription for the treatment of an ectopic pregnancy — when a fertilized egg grows outside the uterus — due to misunderstanding around Texas' new anti-abortion laws.

"They're also afraid. We've had some pharmacists reach out to us as an organization, asking for clarity because they're concerned about their scenario," Thoppil said. "There's a lot of unknown here."

Abortion-inducing medication is the most common method used by Texans to terminate pregnancies, according to Texas Health and Human Services.

But it also has a broad range of other uses in obstetrics and gynecology, according to the U.S. National Institutes of Health, including medical management of miscarriage, induction of labor, cervical dilation before surgical procedures, and treatment of postpartum hemorrhage.

The medication, developed in 1973 to treat peptic ulcers, is on the World Health Organization Model Lists of Essential Medicines because of its wide range of uses in the area of reproductive health.

"Given its low cost and ease of use, misoprostol has the potential to improve women's health worldwide," a 2009 NIH report says.

Without medical assistance during a miscarriage, especially later in the pregnancy, the patient faces risks such as deadly hemorrhaging and sepsis.

Texas abortion laws make exceptions for the procedure if the mother's life is in danger, but even that is fraught with uncertainty, doctors say.

"Physicians can now be second-guessed about, 'Well, was her life really in danger?' and it's always somebody looking in hindsight," Ogburn said. "If your kidneys are failing because of your severe preeclampsia at 18 weeks, is that life-threatening? Some people will say, 'Oh, no, you could have dialysis,' whereas others would say, 'No, that is life-threatening.' … It's not spelled out in the law."

Dr. CeCe Cheng, a maternal fetal medicine specialist in San Antonio, performs abortions as only a small part of her practice, but sometimes she has to help expectant parents make difficult, life-saving decisions about terminating a pregnancy for medical reasons.

Today, her hospital requires her to involve leadership and staff across departments when deciding whether a complication threatens a pregnant patient's life.

Most of her patients are well into their pregnancies, referred to her when they have concerns about complications like fetal abnormalities or other medical conditions, and sometimes a mother's health risk may not be immediate or obvious.

A pregnant patient may need chemotherapy for cancer but in the rare case that the fetus can't tolerate the prescribed dosage, termination of the pregnancy may be the only way to allow her to get life-saving treatment.

For those and other potentially life-threatening complications, Cheng said, "my only options now are to refer out of state or wait."

"I have to wait until my patient comes in with an emergency," Cheng told The Texas Tribune after the new restrictions went into effect last year. "Wait until the patient is bleeding profusely. Wait until there are signs of infection. Wait until the patient goes into labor, which for some may not ever happen."

The lack of an exception in the current restrictions and in the trigger law for what are known as "lethal fetal anomalies" — conditions that are typically diagnosed well past the first six weeks of pregnancy and make it impossible for an embryo to develop or a fetus to survive — can have some devastating outcomes for both the patient and the fetus, doctors say.

A striking example is anencephaly, a fetal congenital condition in which the baby develops without most of its brain and skull. The problem typically develops early in the pregnancy, and if the fetus survives through birth, the baby dies within hours or days. Anencephaly is considered one of the most lethal congenital defects, with a death rate of 100% in the first year of life.

And as long as the fetus has a heartbeat — even if there is no brain activity and never will be — terminating a pregnancy for anencephaly is illegal. If Roe v. Wade is overturned, it won't be allowed from the moment the egg is fertilized.

"If [a fetus] is diagnosed with something that's truly incompatible with life, such as anencephaly, that woman then has to carry that pregnancy to term" if it can't be terminated, Ogburn said. "That increases her risk, because carrying a pregnancy to term physically is more dangerous than terminating when that's diagnosed — but it's also the emotional toil of that."

Overhauling the script

When one of Thoppil's patients became pregnant unintentionally while using an intrauterine device — one of the most effective forms of birth control — the Austin OB-GYN said he felt like his hands were tied.

His patient was at high risk of complications for other reasons, he said, but because fetal cardiac activity had been detected, she fell under the current Texas abortion ban.

Thoppil did not believe he was free to explicitly mention abortion as a medical option without risking a lawsuit because of the way the law is written.

"I can't really talk about what options are available to you due to the current legal climate," he said he tells patients now. He pointed out the state's new laws and hoped she would be able to think through her situation on her own.

Cheng, in San Antonio, doesn't use the word abortion anymore in her conversations with patients about their medical options — her hospital has asked her to try to be nonspecific.

But she gives them as much information as she can because she sees counseling patients about their options as part of her responsibility.

"I don't say anything specific, but I do still talk about the options and let them know that there are other options out of state if that's what they need," Cheng said.

Since Texas' new abortion restrictions went into effect, three lawsuits have been filed against Dr. Alan Braid, a San Antonio doctor who intentionally violated SB 8 to bring a challenge to the law. There have been no public reports of additional lawsuits.

Limiting training 

It's too early to tell if Texas' restrictions, both the current ones and any new restrictions that may come this summer, will have any effect on overall interest in the field of obstetrics and gynecology here, Ogburn said. But the state's abortion laws have hindered the ability of Texas medical schools to offer the range of training most OB-GYN students want.

National standards for medical schools require them to offer abortion care training and residency rotations to OB-GYN students. The training is not required to complete a medical degree, said Ogburn, a member of the Accreditation Council for Graduate Medical Education that reviews OB-GYN programs' course requirements.

Even so, most students ask for the training, he said — but the number of abortions in Texas has drastically fallen both in clinics and at the UTRGV medical school, where they were mostly done for medical reasons. That has made the on-site training opportunities practically disappear for medical students in residency in Texas, he said.

Instead, UTRGV is sending its OB-GYN students out of state to get that training, and Ogburn said he knows other Texas schools are doing the same. It's unclear how long that would be sustainable, he said, and many students may not be able to leave their lives, jobs or families for weeks on end to do residential training somewhere else.

Current students could decide to leave Texas once they graduate so they can practice in a state that allows them to give women the full spectrum of pregnancy and abortion care.

Also, prospective students could choose to attend medical school in another state to get the skill set they want.

"I can tell you that the residents are frustrated and angry, and disappointed," Ogburn said. "Name an emotion, and I've experienced that with my residents over the last six months. Because the patients haven't gone away."

Meanwhile, in Houston, Pecinovsky is entering the most critical period for her pregnancy.

As a patient who was once excited about bringing her third baby into the world, the uncertainty around whether she'd be able to get necessary treatment should tragedy strike — compounded by her own doctor's trepidation about it — has "clouded the joy I initially felt."

She said she's felt a dramatic difference navigating pregnancy care this time around.

"It's just really unbelievable," she said. "And yet it is believable because of the day and age we live in."

Disclosure: The University of Texas Rio Grande Valley and Planned Parenthood have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.

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