[Voiceover:] Pregnant individuals might have various, diverse reasons for seeking to terminate their pregnancies; for some, abortion is medically indicated. This may be due to a serious pregnancy complication, or when a chronic medical condition makes pregnancy dangerous or limits treatment options.
The range of situations where abortion is evidence-based care is really broad, and extends across medical specialties; many of these situations are not obvious. Let’s take a closer look.
The most common situation where a pregnant patient would need a procedure to terminate their pregnancy is a miscarriage. In medical terms, a miscarriage is called a spontaneous abortion, which can be confusing to patients. An estimated 10% to 20% of confirmed pregnancies in the US will end in miscarriage. The majority of these will complete without intervention; but some patients might require medication or surgical intervention, using the same procedure performed during an abortion.
[Gyamfi-Bannerman:] And so when we are treating miscarriages, we actually are essentially performing abortion services to treat miscarriages and to prevent women from bleeding and hemorrhaging or to prevent sepsis.
[Voiceover:] Dr Cynthia Gyamfi-Bannerman is chair of the Department of Obstetrics, Gynecology & Reproductive Sciences at UCSD. She explained that pregnancy termination is also standard care for conditions such as ectopic pregnancies and complete molar pregnancies, which are both nonviable pregnancies that could not result in a live birth, but could result in significant maternal harm or even death if not terminated.
The medical decision-making becomes much more complex when a pregnancy complication carries serious risks to the pregnant patient, but the fetus is at the cusp of being viable and is otherwise developing normally.
One example of this is preterm premature rupture of membranes, or PPROM, that occurs at a periviable gestational age. Rupture of membranes is when the water breaks, and periviable gestational age is broadly defined as 20 through 25 weeks of gestation. PPROM during this period carries a high risk of neonatal morbidity and mortality. The possibility of the neonate surviving to be discharged from the hospital has to be weighed against very real and very serious risks to the pregnant patient, particularly when PPROM occurs before 23 weeks gestation.
[Gyamfi-Bannerman:] And so in those scenarios, it becomes very important, in terms of the counseling, one of the options that we give a patient is pregnancy termination. It becomes less of an option, more of a recommendation if we see signs of infection, because that can quickly ascend to a very bad infection for the mother and that can be life threatening.
[Voiceover:] The other large category of pregnancies where a physician might suggest or recommend an abortion is when the pregnant patient has a pre-existing disease that's associated with high maternal morbidity and mortality.
This category includes a number of conditions, including cystic fibrosis, sickle cell disease, Marfan syndrome, lupus nephritis, cardiomyopathy, and pulmonary hypertension. For the majority of patients with these and other chronic medical conditions, a successful pregnancy is possible. But the risks for any individual patient will depend on a number of factors. For some patients, the risks of a continued pregnancy might include death, or severe morbidity that has life altering consequences, such as organ damage.
Pregnancy is a stress test for the entire body; by the end of pregnancy, light physical activity might make even the healthiest individual short of breath.
[Gyamfi-Bannerman:] So just in that context, think of someone who has severe cardiac disease. By the time they make it to the third trimester and then at the time of delivery, they might not be able to to survive delivery. And what we know about a lot of these cases is that that postpartum period is very dangerous for them. So the first 24 to 48 hours postpartum, for some of these women with cardiac disease is spent in an ICU sometimes.
[Voiceover:] According to Dr Gyamfi-Bannerman, the right approach when counseling some pregnant patients might be to suggest or even recommend an abortion, followed by a discussion of reproductive options including optimization of their current state of health in planning for a possible future pregnancy.
Another key consideration when it comes to pregnancy and pre-existing disease is the use of teratogenic medications. These are medications that can cause birth defects or abnormalities in the embryo or fetus, and they include some of the most effective treatments across medicine.
One of the medical specialties in which physicians and patients rely on the use of teratogenic medications is rheumatology.
[Birru Talabi:] I use rheumatoid arthritis as the prototypic example. Rheumatoid arthritis is a fairly common autoimmune disease. Many people have heard of it, and one of our gold standard therapies in rheumatoid arthritis management is methotrexate. Methotrexate is cost effective. It is highly clinically effective and probably between 80 to 90% of all patients with rheumatoid arthritis will use methotrexate at some point. But it's a teratogen.
[Voiceover:] That's Dr Mehret Birru Talabi, a rheumatologist with a specialty practice that focuses on women's reproductive health.
[Birru Talabi:] I really have been struck by the number of patients that I've cared for who have had a prior pregnancy in which they were exposed or used a teratogen. And usually the context of this is the patient is taking the teratogen for the purposes of disease control and then they find out that they're pregnant.
[Voiceover:] Unintended pregnancies occur even when someone is using highly effective birth control. And when physicians prescribe teratogenic medications to patients with reproductive potential, it is usually with the understanding that in case the patient became pregnant, abortion would be available to them as an option.
For some conditions, non-teratogenic alternative therapies are available. For rheumatoid arthritis, for instance, TNF inhibitors are a pregnancy-compatible, effective alternative to methotrexate. But they come with a much higher price tag, so defensively prescribing TNF inhibitors to every rheumatoid arthritis patient with reproductive potential is not feasible.
And for some conditions, like lupus nephritis, there may not be any alternative, non-teratogenic therapies available.
[Birru Talabi:] A disproportionate number of lupus patients are female, and lupus tends to manifest during childbearing years. And if they develop renal complications of lupus, which about 40% will. The best evidence-based medications we have for that entity are both teratogenic.
[Voiceover:] Another example of a situation where a continued pregnancy might limit effective treatment options is cancer treatment.
Cancer is not a common diagnosis in pregnancy, but it still affects about 1 in 1000 pregnancies in the US. An estimated 9% to 28% of pregnant patients with a cancer diagnosis choose to terminate their pregnancies. So while the majority of pregnant individuals with a cancer diagnosis choose to continue the pregnancy, this adds a layer of complications to the cancer treatment. Take breast cancer, which is the most common pregnancy-associated cancer.
[Christian:] Historically abortion was actually recommended for all women with breast cancer. We now have the evidence that we can support women through pregnancy while getting treatment for their breast cancer. But that may come with limitations about the types of treatments we can offer.
[Voiceover:] Dr Nicole Christian is a breast surgical oncologist at the University of Colorado. She explained that treating breast cancer with surgery, while it comes with some risks, is comparatively safe to the embryo or fetus. Chemotherapy is also possible later in the pregnancy. But treating breast cancer with radiation is contraindicated in pregnancy. And many of the newer targeted therapies, while they have less severe toxic effects and offer excellent outcomes for patients, carry significant risks for the fetus. For some patients, delaying the use of these treatments until after delivery can increase the likelihood of adverse oncological outcomes, like cancer recurrence, or death.
[Christian:] That's the situation in which we talk to women about termination of their pregnancy in order to give us and them an opportunity to treat their breast cancer in the most appropriate and aggressive way.
[Voiceover:] This complex and shared decision-making, in which physicians work with a patient to design a treatment plan that is right for them—and which might include an abortion—is replicated across medicine--in oncology as much as rheumatology, cardiology, neurology, pulmonology or critical care.
There is clear evidence that abortion is a safe procedure; and importantly, it can also be lifesaving.