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Elise Taft and her husband were giddy on their drive to the obstetrician’s office. They had been waiting all summer to hear a fetal heartbeat from Taft’s belly, and after two previous healthy pregnancies, she was excited for that “first connection with our baby.”
Taft put on a white cloth gown with little blue pansies, and the sonographer smeared gel across her not-yet-swollen abdomen, scanning for signs of life. The ultrasound tech suddenly went silent and excused herself to fetch the doctor. There was no cardiac activity to hear.
“That’s a devastating moment for anyone who wants a child,” Taft said.
For three brutal weeks, Taft and her husband mourned the child who would never be born and waited for Taft’s body to recognize that she was no longer pregnant. But nothing happened, she said. Her obstetrician, who had delivered her two older daughters, checked her periodically and asked if she had developed a fever – a sign of infection called septic abortion. One day in late August, Taft’s thermometer hit 102.
READ MORE: Majority of Americans think Supreme Court overturning Roe was more about politics than law
“‘That’s enough. You’re coming in,’” Taft recalled her doctor saying.
Taft underwent surgery for an emergency dilation and curettage, often called a D&C, within hours of talking to her doctor. Even under ideal conditions, these infections, whether as a result of miscarriage or an incomplete abortion, force pregnant people and their care team to race against time before bacteria enters the patient’s bloodstream.
Four years later, infections like Taft’s are likely to become far more common, complicated and costly to treat across the United States, reproductive health experts are warning. As more states ban or severely restrict abortion after the Supreme Court’s decision to overturn Roe v. Wade, doctors may be unable or more hesitant to initiate the life-saving procedure that’s conducted after both miscarriage and abortion, and patients may be “afraid to come in,” said Dr. Kim Puterbaugh, an obstetrician based in Cleveland, Ohio.
When faced with this kind of infection, “it’s all about getting care quickly,” said Puterbaugh, president of the Society of Ob-Gyn Hospitalists, whose members manage emergency reproductive health care in hospital settings.
Each year, Puterbaugh sees one or two cases of pregnancy-related sepsis. It’s been rare in the United States for decades, and deaths from these infections have been nearly unheard of. According to maternal mortality data from the Centers for Disease Control and Prevention covering the last three years, no more than 45 people died of complications linked in any way to this form of sepsis.
But after more than 17 years of practicing in Texas, where abortion essentially has been banned since last year, Dr. Rakhi Dimino said more patients come to her now with sepsis or hemorrhaging “than I’ve ever seen before.”
Before Roe enshrined the right to an abortion, these infections – and resulting deaths – were far more common, Puterbaugh said. An entire generation of obstetricians and gynecologists have been practicing medicine while sepsis during pregnancy was not a common concern, Puterbaugh said, and they may not all recognize the warning signs.
Providers are developing new materials tailored for emergency settings. The goal is to equip providers with warning signs and symptoms so they can do a better job of identifying sometimes rapidly escalating conditions that require urgent care and connect them with at times life-saving services.
In states where abortion is protected, obstetricians are preparing for an influx of patients requiring care for conditions like sepsis abortion out of fear that they might be prosecuted in their home state, Dimino and Puterbaugh said.
During a miscarriage, which experts say occur in as many as one out of three pregnancies, a patient may begin spontaneously bleeding, cramping or passing fluid or fetal tissues. Hormones typically help the body flush these products from the uterus (which must remain uncontaminated for the pregnant person’s safety) and out the vagina. But sometimes that doesn’t happen perfectly. After hormone levels subside, some tissue may stay behind. Remnants of that lost pregnancy could cause infection in the uterus. Signs that something has gone wrong include unpleasant odors in vaginal discharge, worsening fever and abdominal cramping. If detected early, these infections can be treated with antibiotics, and the patient’s chances of recovery are high. If untreated, the patient may require a blood transfusion, a hysterectomy or other surgeries. Any delays mount risks against that patient’s life.
WATCH: Texas clinics resume abortions past 6-week mark, but women fear access may be temporary
Typically, providers and patients have been able to discuss the risks of continuing a pregnancy and what options a pregnant person might consider for their own safety. But in Texas, which last year passed its so-called “heartbeat” law that banned abortion services six weeks after conception (before many people realize they are pregnant), providers cannot provide elective terminations and instead must wait to have those conversations “when the risks start,” Dimino said.
A health care provider who fails to comply with the law – including reporting people who are suspected to have sought out abortion services more than six weeks after conception – faces steep fines and the loss of their medical license. Sometimes, physicians avoid asking questions that could incriminate a patient – but looking the other way could also mean they miss critical details that could save a patient’s life.
Even in cases where a miscarriage naturally occurs, patients may fear potential legal ramifications if they disclose to their health care provider what brought them to the hospital. When patient trust in the health care system erodes, the dangers multiply, Dimino said.
“We could be losing valuable time, [and the patient could] lose her reproductive organs and her life,” Dimino said.
With new restrictions in place across much of the country, more pregnant people will need to travel further and rely on a deeper well of resources (if they have them) to prevent deadly infections.
Sixteen states and the District of Columbia each passed laws that protect the right to have an abortion, according to the Guttmacher Institute. But given how quickly a majority of states have clamped down on abortion access, even people in states withabortion guarantees may still run into access issues because of demand spilling over from more restrictive parts of the country.
Taft, who received a D&C after her miscarriage, said that if the same circumstances played out today, she would be forced to leave her home state of Wisconsin for treatment, find child care for her children, take time off of work, reserve and pay for a hotel room and drive four hours to Illinois to have the same procedure done. Not everyone can afford to do that. Puterbaugh said she expects sepsis infections to rise among women from low-income households and women of color, and that providers like herself simply want to respond to those in need.
Those patients are “just going to delay care,” she said. “The further you are from care, the worse it is.”
READ MORE: Inside a Memphis clinic during its final days of abortion care
An obstetrician in New York state, Dr. Brigid McCue is already seeing “a line being drawn” across the country “where the most marginalized, least able to care for themselves population is going to truly suffer.”
The health care system already has been stretched thin. In 2020, as the nation wrestled with the coronavirus pandemic, maternal mortality, morbidity and related health disparities went from bad to worse. During that year, 861 women died from pregnancy-related complications, the CDC reported, up from 754 women in 2019. Black women died at a rate of 55 deaths per 100,000 live births – nearly three times the rate of white women.
Now, in New York, McCue said she is seeing more pregnant people traveling into the state to receive abortion-related services.
“Providers in border states are completely overwhelmed with people seeking medical and surgical termination and consequences because these people are petrified with going to their emergency rooms,” she said.
Health care workers are exhausted but want to be in a position to help anyone who comes to them in need. Puterbaugh and her colleagues with the Society of Ob-Gyn Hospitalists are producing updated training materials and simulations “for things they don’t see every day” that is devoted to septic abortion before they meet this September. They created similar guidelines when the coronavirus compelled them to figure out how to save pregnant people in crisis and infected with COVID. At the start of the pandemic, Puterbaugh said, no one knew how to treat pregnant people in COVID wards or how to intervene if those patients entered a crisis. They developed guidelines as the pandemic dragged on, treating women who endured respiratory failure and sharing their lessons through remote simulations (another experience largely informed through what they learned along the way).
WATCH: Doctors worry abortion laws will hinder treatment of patients in life-or-death situations
Puterbaugh said the new training on septic abortions will include a lecture and simulations that attempt to replicate different scenarios that can develop into septic shock. It will also include hands-on coursework.
“The fact is medically, whether a septic abortion occurs after a miscarriage or an abortion, the way OB-GYNs manage the mother is the same,” Puterbaugh said.
Before the Roe decision came down in 1973, hospitals would set aside space where women with infections could die quietly. For years, retired obstetricians and reproductive health advocates have reminded the public of these haunting facilities. With restrictions on reproductive health care again descending on a growing number of states, the need for so-called “septic wards” may return. Puterbaugh’s goal is trying to do everything she can to stop that from happening.
Laura Santhanam is the Data Producer for the PBS NewsHour. Follow @LauraSanthanam
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