Chemotherapy drugs (National Cancer Institute | Unsplash)
For Wisconsin women who are pregnant and face a life-threatening illness — and for the doctors who treat them — the overnight change in abortion access has upended medical care.
Some cancer patients will no longer be able to get lifesaving chemotherapy or radiation treatment. Some people with chronic heart or kidney disease could face the risk of dying if they get pregnant without intending to. And some with an intended pregnancy could wind up dead when illness strikes unexpectedly and they cannot be treated because they are pregnant.
The U.S. Supreme Court’s 6-3 ruling issued on Friday that overturned the federal right to abortion also opened the door to reinstating Wisconsin’s 1849 ban on abortions — a law that only allows the procedure if it is necessary to save the life of the mother. The law has no exceptions for preserving the mother’s health or other circumstances, such as rape or incest.
On Tuesday, Attorney Gen. Josh Kaul and Gov. Tony Evers sued to block the 1849 law from being reinstated, arguing that it conflicts with numerous more recent laws regulating the procedure. For now, however, doctors are getting legal advice that assumes the nearly total ban is in effect.
That advice also suggests a cautious reading of how far the old law’s single exception will reach.
Choosing between treatment or pregnancy
Medical protocols forbid lifesaving cancer treatment such as chemotherapy or radiation during pregnancy because of the risk to the embryo or fetus, says Dr. Noelle LoConte, a chemotherapy cancer specialist at UW Health. (LoConte says she is speaking for herself, not as a representative of the UW Health system.)
Chemotherapy is prohibited in the first trimester of a pregnancy, and considered risky, although not entirely forbidden in later stages, LoConte says. Radiation treatment is prohibited throughout pregnancy. So are certain uses of X-rays, such as CAT scans.
Sometimes newly diagnosed cancer patients only learn they are pregnant at the time of their diagnosis. But whether a patient learns she is pregnant then or knows she is pregnant already and is subsequently diagnosed with cancer, what has followed until the court’s ruling has been the same.
The cancer is diagnosed by stage so doctors can determine how urgent treatment is, LoConte says. Doctors then discuss with the patient the options, “which would include trying to preserve the pregnancy and delay treatment for the cancer, or have an abortion and then proceed with more [immediate] treatment of her cancer.”
With some cancers — leukemia, for example — “we have hours to days to make that decision,” she says. “We don’t have weeks or months.”
Before the new court ruling, a patient who chose to have an abortion would be connected with appropriate medical care in the Ob/Gyn department or with a clinic such as Planned Parenthood. “Right now we are being told that that situation does not qualify” under the 1849 abortion ban’s exception, LoConte says.
Chemotherapy pregnancy tests
Sometimes patients get pregnant after they’ve started treatment.
“Before we start chemo we counsel all our patients on not getting pregnant and using two forms of birth control,” LoConte says. Patients of childbearing age get a pregnancy test with every visit for treatment.
Even then, “it does happen,” she says — a patient’s pregnancy test comes up positive. “And that’s very serious, because chemo is very, very bad for a new embryo or fetus.”
Until this week, those patients would also have been counseled about pausing treatment to continue the pregnancy or terminating the pregnancy and continuing treatment. Now, the options for doctors and patients are unclear.
Sometimes additional chemotherapy is prescribed for a patient to reduce a later risk of the cancer returning. “If she doesn’t get this chemo, she has 10% higher likelihood of the cancer coming back and then being terminal,” LoConte explains. At this point, “all the lawyers are saying we don’t know for sure, but what we’re being told is that would not qualify” under the exception, either.
“There is a tremendous amount of uncertainty for doctors that care for patients with cancer,” LoConte says. When the 1849 law was passed, “none of these [cancer] treatments existed,” she observes. “So the law doesn’t speak to that.”
With abortion off the table, “we’re doubling down on the message that they really cannot get pregnant on chemo,” LoConte says. But the lack of clarity now frustrates her.
“Abortion is part of health care,” she says. “And we don’t limit any other aspects of health care.”
Stress test on the body
The conflict between pregnancy and a patient’s health isn’t limited to cancer patients.
“I often tell my pregnant patients pregnancy is a stress test on the body,” says Dr. Eliza Bennett, an OB/GYN specialist. “And some people just don’t have enough bandwidth to sustain that stress test.”
Being pregnant demands a higher volume of blood, which makes the heart work harder to pump it through the body. For a person with a chronic heart condition, the heart muscle or valves might be too weak to function under the added load.
The ability to treat congenital heart defects that some people are born with is a modern medical success story. But while more of those patients live into adulthood, Bennett says, they still might not be able to safely make it through pregnancy.
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Other circumstances might be temporary, but while they’re present, pregnancy would pose serious risk. Autoimmune disorders that attack the joints, for example, are sometimes treated with methotrexate, a powerful drug that “can have really, really negative effects on fetal development,” Bennett says. For a patient who needs that drug and unintentionally gets pregnant, “there’s risks, that then they could have inadvertently caused that fetal anomaly just by taking medication to sustain their own health.”
Pregnancy also puts increased demand on kidneys. If a patient has severe kidney disease, “pregnancy can actually cause that disease to progress and turn into end-stage renal disease,” she adds.
Until this week, doctors were able to counsel patients with kidney disease who were pregnant about the risk for their illness getting worse. “And many people would choose not to continue a pregnancy if they knew that it would end up putting them at high risk for needing dialysis or a renal transplant,” Bennett says.
Referrals out of state
With the new legal landscape leaving abortion unavailable in Wisconsin, Bennett and her colleagues have made plans to refer patients who decide to terminate a pregnancy to providers in Illinois or Minnesota, where laws securing abortion rights are strong. She says it’s too soon to assess how that is working out for patients, “especially as we see more and more states coming online with abortion restrictions and bans that will result in more and more patients needing to travel to these states to be able to access care.”
An abortion ban “also puts patients that never think that they’re going to want or need an abortion in peril,” says Bennett.
In countries with restrictive abortion laws, she says, there have been “really striking cases of maternal death” among women with intended pregnancies who were hospitalized with an illness but not considered sick enough to qualify for an abortion that could have been lifesaving.
“Because every now and then something goes terribly wrong in a pregnancy,” Bennett says, “and people are confined to an institution where they are subjected to laws [preventing abortion], where intervention is delayed to a point where they become so ill that their lives cannot be saved.”
Bennett says that she and her colleagues will continue to try to do all they can for the patients in their care.
“We are going to try to protect our patients and take the very, very best care of them now that we possibly can, she says. “It is going to be hard, but we will continue on with that.”
A pregnancy and a cancer
In 1995 Racine resident Sara Bublitz learned she was pregnant by the man to whom she was engaged.
About two weeks later, she got a report back from her latest pelvic exam: she had cervical cancer.
It was overwhelming, says Bublitz.
“I was only 18 years old,” she says. “I was no way financially capable or mentally capable of taking care of a child.”
And the cancer diagnosis compounded her fear and anxiety. “I thought, ‘I don’t want to have this child and have the possibility of them being sick permanently, or whatever could happen,” she says. “It’s not fair to start life that way.”
Bublitz, supported by her sister, traveled to Milwaukee for an abortion at a Planned Parenthood clinic near downtown.
Inside, she was given an ultrasound exam. She was counseled about her options, including adoption, and her reasons for seeking an abortion.
Because she was just five weeks pregnant, Bublitz was told that if the abortion took place that day, she would be at risk for the procedure being incomplete. To ensure that it was thorough, she opted to return two weeks later instead.
On her return she walked past anti-abortion protesters across the street. One followed her across the street to the clinic entrance.
“She snidely whispered I was a baby-killer,” Bublitz says. She tuned out the rest of the woman’s comments. “My sister rushed me inside.”
Inside, after another ultrasound exam, she went through the procedure. She was awake. When it was over, she was taken to a room with recliners, to be monitored to ensure there had been no complications.
Not long after, she went for treatment of her cervical cancer. It was an outpatient process that involved freezing the suspect cells to remove them. When it was over, she says, she was pronounced cured.
The next few years were not easy. She ended the engagement and went through what she describes as “a very dark time.”
In the years that followed, she also became the mother of three, a son and two daughters. Her oldest is now 23; her youngest turns 18 this year.
Having her abortion was absolutely necessary for her future health, Bublitz says. It, and all the events of her life that surrounded it, were also emotionally draining. But she doesn’t regret the decision.
“There are some things in my life that I would have changed,” she says. “That is not one of them.”
She considered not using her full name for this story, but then decided it was important to stand up for what she felt was right.
“Women, girls, need to have all the options available to them,” Bublitz says. “Information is power, and the power to make your own choices about your own body is essential to my being.”
She also ponders the world in which her children are growing up.
“I’m thinking of my daughters in the future,” Bublitz says. “And I hope that if something were to ever happen to them, that they would have the ability to have access to abortion safely.”
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