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Maternal morbidity and fetal outcomes among pregnant women at 22 weeks’ gestation or less with complications in 2 Texas hospitals after legislation on abortion

      Objective

      Recent state-level legislation on abortion has encroached on access to reproductive care with disproportionate effects on underserved communities.
      • Perritt J.
      • Grossman D.
      The health consequences of restrictive abortion laws.
      In Texas, 2 legislative actions have been at the forefront of this public health issue. Senate Bill 8 bans abortions once cardiac activity is identified using standard medical practice on the basis of the estimated gestational age with enforcement by private plaintiffs through civil lawsuits. Senate Bill 4 states that a physician administering medicine to end a pregnancy even in the setting of a maternal medical emergency has committed a felony, with jail time ranging from 180 days to 2 years and a $10,000 fine; it also expands abortion complication reporting. The current national standard of care of women not in labor presenting with rupture of membranes before neonatal viability allows expectant management or immediate delivery following shared decision-making.
      Prelabor rupture of membranes: ACOG Practice Bulletin, Number 217.
      We report the experiences from 2 urban, inner-city healthcare systems in Texas after these legislative actions.

      Study Design

      William P. Clements Jr. University Hospital and Parkland Hospital—the safety net hospital for Dallas County—are both level IV designated maternal care facilities, with approximately 14,000 deliveries annually.
      Texas Health and Human Services
      Texas maternal facilities.
      The inclusion criteria were pregnant patients presenting at <22 weeks without preterm labor and with a medical indication for delivery (preterm premature rupture of membranes, preeclampsia with severe features, and/or vaginal bleeding) and a fetus with cardiac motion, identified from electronic health records and direct patient care. Given the potential of a felony, all cases were discussed with and managed by maternal fetal medicine leadership (C.Y.S., D.B.N., and S.P.). Before the passage of state Senate Bills 8 and 4 (effective 21 September 2021), women with these conditions were counseled and offered expectant management or induction of labor. After September 2021, all were expectantly managed with medical intervention when there was an immediate threat to maternal life. The primary perinatal outcome was fetal or neonatal demise. The primary maternal outcomes were maternal morbidities (Table), time from presentation to delivery, and indications for delivery. The University of Texas Southwestern Medical Center Institutional Review Board approved this study with exemption of patient consent.
      TableMaternal demographics, pregnancy outcomes, and morbidities for women presenting with cardiac activity at <22 weeks gestation and requiring obstetrical management
      DemographicsMedian (Q1–Q3) or N (%)
       Maternal age (y)30 (26–33)
       Nulliparity15/28 (54%)
       Gestational age at presentation19 wk 4 d (17 wk 6 d–20 wk 2 d)
       Gestational age at delivery20 wk 1 d (18 wk 4 d–21 wk 0 d)
      Clinical characteristics at presentation
       Preterm premature rupture of membranes26/28 (93%)
       Fever1/28 (4%)
       Antepartum hemorrhage2/28 (7%)
       Severe hypertension1/28 (4%)
       Fetal parts or cord in vagina7/28 (25%)
      Clinical course
       Mean duration (presentation to delivery, d)9.2±23.0 (0–121)
       Duration (presentation to delivery, d)3 (1–7)
       Antenatal corticosteroids4/28 (14%)
       Indications for delivery
      There may be >1 indication for delivery
       Fetal demise9/28 (32%)
       Fever/clinical chorioamnionitis
      Clinical chorioamnionitis defined as chorioamnionitis documented by a physician and prompting treatment with intravenous antibiotics;4
      10/28 (36%)
       Severe preeclampsia1/28 (4%)
       Spontaneous labor8/28 (29%)
      Delivery outcomes
      Vaginal delivery25/28 (89%)
       Induction of labor14/25 (56%); 14/28 (50%)
      Cesarean delivery2/28 (7%)
      Hysterectomy1/28 (4%)
      Fetal or neonatal outcomes
      Intrapartum demise10/28 (36%)
      Born with cardiac activity8/28 (29%)
       Admitted to neonatal intensive care unit3/8 (38%); 3/28 (11%)
       Neonatal demise <1 d7/8 (88%)
      Maternal complications
      Clinical chorioamnionitis
      Clinical chorioamnionitis defined as chorioamnionitis documented by a physician and prompting treatment with intravenous antibiotics;4
      10/28 (36%)
      Placental pathology with chorioamnionitis22/26 (85%)
      Placental abruption2/28 (7%)
      Intensive care unit admission1/28 (4%)
      Blood transfusion5/28 (18%)
      Dilatation and curettage7/28 (25%)
      Maternal death0
      Postpartum emergency room visit
      Postpartum emergency room visits and readmissions limited to those within 42 days after delivery. Placental pathology complete for 26 patients at time of submission.
      4/28 (14%)
      Postpartum readmission
      Postpartum emergency room visits and readmissions limited to those within 42 days after delivery. Placental pathology complete for 26 patients at time of submission.
      1/28 (4%)
      Composite maternal morbidity
      • Sklar A.
      • Sheeder J.
      • Davis A.R.
      • Wilson C.
      • Teal S.B.
      Maternal morbidity after preterm premature rupture of membranes at <24 weeks’ gestation.
      16/28 (57%)
      The data are reported as median (interquartile range) and number (percent) with mean±standard deviation (range) only where noted.
      Q1–Q3, first quartile to third quartile.
      Nambiar. Maternal morbidity and fetal outcomes at 22 weeks’ gestation or less with complications in 2 Texas hospitals after legislation on abortion. Am J Obstet Gynecol 2022.
      a There may be >1 indication for delivery
      b Clinical chorioamnionitis defined as chorioamnionitis documented by a physician and prompting treatment with intravenous antibiotics;
      • Sklar A.
      • Sheeder J.
      • Davis A.R.
      • Wilson C.
      • Teal S.B.
      Maternal morbidity after preterm premature rupture of membranes at <24 weeks’ gestation.
      c Postpartum emergency room visits and readmissions limited to those within 42 days after delivery. Placental pathology complete for 26 patients at time of submission.

      Results

      Between September 21, 2021 and May 20, 2022, 28 pregnant patients met the inclusion criteria. The most common reason for presentation was preterm premature rupture of membranes affecting 26 of 28 (93%) patients, with 7 of them (25%) having fetal parts or umbilical cord prolapsed into the vagina. The mean (standard deviation) days between presentation and delivery was 9.2 (23.0) (range: 0–121) (Table). Of the 28 cases, indications for delivery included infection in 10 (36%), spontaneous labor in 8 (29%), and fetal demise in 9 (32%) patients. Twenty-seven patients (96%) had loss of the fetus or infant. Of 8 infants with cardiac motion at birth, 7 died within 24 hours and 1 remains hospitalized (Supplemental Table). Maternal morbidity—including conditions such as clinical chorioamnionitis and hemorrhage—occurred in 12 of the 28 patients (43%), and 9 of them (32%) required intensive care admission, dilatation and curettage, or readmission. One patient required a hysterectomy after presenting at 20 weeks 6 days with hemoperitoneum from uterine rupture owing to a placenta accreta spectrum.

      Conclusion

      In 2 Texas hospitals, state-mandated expectant management of obstetrical complications in the periviable period was associated with significant maternal morbidity (Figure). Consistent with reports evaluating outcomes in women requesting expectant management,
      • Sklar A.
      • Sheeder J.
      • Davis A.R.
      • Wilson C.
      • Teal S.B.
      Maternal morbidity after preterm premature rupture of membranes at <24 weeks’ gestation.
      most of the pregnant patients at <22 weeks presenting with medical indications for delivery experienced serious morbidity, and fetal outcomes were poor. Expectant management resulted in 57% of patients having a serious maternal morbidity compared with 33% who elected immediate pregnancy interruption under similar clinical circumstances reported in states without such legislation.
      • Sklar A.
      • Sheeder J.
      • Davis A.R.
      • Wilson C.
      • Teal S.B.
      Maternal morbidity after preterm premature rupture of membranes at <24 weeks’ gestation.
      The patients were observed 9 days before developing complications that qualified as an immediate threat to maternal life. Because of the intense politicization of these issues nationally, some have questioned, “What does the threat of death have to be?” and “How imminent must it be?”
      • Harris L.H.
      Navigating loss of abortion services - a large academic medical center prepares for the overturn of Roe v. wade.
      As large academic medical centers prepare to navigate the potential for loss of access to services, more questions are raised than answers.
      • Harris L.H.
      Navigating loss of abortion services - a large academic medical center prepares for the overturn of Roe v. wade.
      Although limited by sample size, our findings offer a glimpse into the possible not-so-distant future.
      Figure thumbnail gr1
      FigureMaternal morbidity nearly double with expectant management
      • Sklar A.
      • Sheeder J.
      • Davis A.R.
      • Wilson C.
      • Teal S.B.
      Maternal morbidity after preterm premature rupture of membranes at <24 weeks’ gestation.
      Nambiar. Maternal morbidity and fetal outcomes at 22 weeks’ gestation or less with complications in 2 Texas hospitals after legislation on abortion. Am J Obstet Gynecol 2022.

      Appendix

      Supplemental TableOutcomes of infants with cardiac activity at birth
      Gestational age at presentationGestational age at deliveryNeonatal intensive care unitInfant length of stayInfant complicationsMaternal complications
      17 wk 5 d17 wk 5 dN<1 dNNDPPROM, antepartum hemorrhage
      18 wk 4 d19 wk 0 dN<1 dIUFD twin A, fetal parts in vagina, NND twin BPPROM, clinical chorioamnionitis
      19 wk 1 d20 wk 1 dN<1 dNNDPPROM and clinical chorioamnionitis
      19 wk 2 d32 wk 1dY<1 dPPHN, pulmonary hypoplasia, multiple pneumothoraces, chest tubes × 3, ventilator, pressor support, and NNDPPROM and cesarean delivery for nonreassuring fetal heart tracing
      20 wk 2 d24 wk 0 dYAdmittedIVH and NEC; respiratory failure, chronic lung disease; hypotension, PDA, TPN-induced cholestasis, NEC, and germinal matrix hemorrhagePPROM, NRFHT at 24 wk, repeat Cesarean delivery, postpartum hemorrhage, and ileus
      20 wk 3 d20 wk 4 dN<1 dNNDPPROM, clinical chorioamnionitis, and cerclage
      21 wk 0 d22 wk 0 dN<1 dTwin gestation NNDPPROM, clinical chorioamnionitis
      21 wk 5 d25 wk 5 dY<1 dNND unable to ventilatePPROM
      IUFD, intrauterine fetal demise; IVH, intraventricular hemorrhage; NEC, necrotizing enterocolitis; NND, neonatal demise; NRFHT, nonreassuring fetal heart tracing; PDA, patent ductus arteriosus; PPROM, preterm premature rupture of membranes; TPN, total parenteral nutrition.
      Nambiar. Maternal morbidity and fetal outcomes at 22 weeks’ gestation or less with complications in 2 Texas hospitals after legislation on abortion. Am J Obstet Gynecol 2022.

      Supplementary Data

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      References

        • Perritt J.
        • Grossman D.
        The health consequences of restrictive abortion laws.
        JAMA Intern Med. 2021; 181: 713-714
      1. Prelabor rupture of membranes: ACOG Practice Bulletin, Number 217.
        Obstet Gynecol. 2020; 135: e80-e97
        • Texas Health and Human Services
        Texas maternal facilities.
        (Available at:)
        • Sklar A.
        • Sheeder J.
        • Davis A.R.
        • Wilson C.
        • Teal S.B.
        Maternal morbidity after preterm premature rupture of membranes at <24 weeks’ gestation.
        Am J Obstet Gynecol. 2022; 226: 558.e1-558.e11
        • Harris L.H.
        Navigating loss of abortion services - a large academic medical center prepares for the overturn of Roe v. wade.
        N Engl J Med. 2022; 386: 2061-2064