Maternal Morbidity and Fetal Outcomes Among Pregnant Women at 22 Weeks’ Gestation or Less With Complications in 2 Texas Hospitals After Legislation on Abortion
Authors: Nambiar Anjali , Patel Shivani , Santiago-Munoz Patricia , Spong Catherine Y. , Nelson David B. 
Published: April 2023

Abortion-related legislation on the state level has encroached on reproductive care access, disproportionately affecting underserved communities. This was first brought to the forefront following legislative actions such as Senate Bill 8 (SB8) in Texas, which bans abortions following detection of cardiac activity. Enforcement of this bill uses private plaintiffs through civil lawsuits based on the estimated gestational age. Senate Bill 4 not only expands abortion complication reporting, but it also renders all physician-administered medicine for the purpose of ending a pregnancy as felonies, punishable by jail time ranging from 180 days to 2 years and $10,000 fine (even in the case of maternal medical emergency). This publication reports an inner-city health care system experience in Texas following these legislative actions.

The safety net hospital for Dallas County, Parkland Hospital and William P. Clements Jr University Hospital, are both level IV designated maternal care facilities, with annual delivery rates of approximately 14,000. The inclusion criteria included patients presenting with a fetus with cardiac motion at <22 weeks without preterm labor and with a medical indication for delivery, such as vaginal bleeding, preterm premature membrane rupture, and/or preeclampsia with severe features. Potential candidates were identified from direct patient care and electronic health records. Before the passage of SB4 and SB8, these conditions led to patients receiving counseling and being offered expectant management or labor induction. Following the effective date, expectant management occurred alongside medical intervention when faced with immediate threat to maternal life. All cases were managed by and discussed with maternal fetal medicine leadership due to the potential of a felony. Fetal or neonatal demise was the primary perinatal outcome of the review, whereas primary maternal outcomes included time from presentation to delivery, indications for delivery, and maternal morbidities.

Study results determined that 28 pregnant patients met the inclusion criteria between September 2021 and May 2022. Preterm premature rupture of membranes affected 26 of 28 patients, 7 of which had fetal parts or umbilical cord prolapsed into the vagina. A mean of 9.2 days was recorded between presentation and delivery. A total of 27 patients experienced loss of the fetus or infant (96%). Of the 8 infants with cardiac motion at birth, 7 died within 24 hours, and 1 remains hospitalized. Some 12 of the 28 patients experienced clinical chorioamnionitis and hemorrhage, with 9 of these patients requiring intensive care unit admission, readmission, or dilatation and curettage. A single patient at 20 weeks' gestation required hysterectomy due to hemoperitoneum from uterine rupture with placenta accreta spectrum.

This analysis concludes that in these 2 Texas hospitals, significant maternal morbidity was associated with state-mandated expectant management for periviable obstetric complications. It is clear that a high risk of serious morbidity exists for pregnant patients at <22 weeks presenting with medical indications for delivery, with simultaneous poor fetal outcomes. In fact, serious maternal morbidity due to expectant management occurred for 57% of patients, versus 33% for those with similar medical conditions electing immediate pregnancy interruption in other states. Questions raised by this analysis include “How imminent must death be?” and “What does the threat of death need to be?” Although the study is limited by its small sample size, it is clearly indicative of the possible imminent future for maternal health care as mandated by this legislation.