Abortion is a term that has been politically polarizing and culturally divisive since well before the Supreme Court overturned Roe v. Wade, the 1973 case that constitutionally protected the right to abortions, in June of 2022. But the reality is, abortion is neither of those things. It's a medical term, and there are situations that call for an induced abortion to save a pregnant person's life. (To be clear, also simply wanting to have an abortion, even if your life is not in danger, is still reason enough to be afforded the safe and legal access to one.)
However, proper access to the care required to treat pregnant people with life-threatening conditions is at risk as doctors and patients struggle to interpret newly activated trigger laws (state-led laws designed to go into effect when Roe v. Wade was overturned) and subsequent abortion bans and restrictions, according to experts.
On July 8, President Biden signed an executive order to safeguard access to reproductive health care services, including abortion. Since then, the U.S. Department of Health and Human Services (HHS) also clarified that federal law preempts state abortion bans when the mother’s life is at risk, citing the Emergency Medical Treatment and Active Labor Act, which protects the right to emergency medical care. This means that providers are protected “when offering legally-mandated, life- or health-saving abortion services in emergency situations,” according to the HHS statement.
But that doesn’t mean all pregnant people will be able to receive the care they need. “Any kind of abortion restriction — even so-called exemptions for the health of the pregnant person — result in delayed care,” says Jennifer Lincoln, M.D., a board-certified ob-gyn in Portland, Oregon, and author of Let’s Talk About Down There. In fact, there were already barriers to getting access to care for life-threatening medical conditions that call for abortions to save a mother’s life even when the right to an abortion was constitutionally protected.
Any kind of abortion restriction — even so-called exemptions for the health of the pregnant person — result in delayed care.
“In order to provide abortions [even when Roe v. Wade was in effect] for medical indications for maternal health, [providers] have to go through quite a process,” says Hanna Peterson, M.D., an ob-gyn in Louisville, Kentucky where a judge recently granted a temporary suspension of the state’s trigger law that aims to ban abortion. In fact, obtaining an abortion in these circumstances can take days to weeks in states such as Kentucky, where physicians must get two other physicians, such as a maternal-fetal specialist or a neurologist if the patient has a stroke history, to agree that pregnancy is a danger to a person’s life and that terminating it will save their life or preserve their health, says Dr. Peterson. Sometimes, specialists and physicians turn down these requests, and it can even be difficult to find staff to participate in the actual procedures.
Many of the patients who Dr. Peterson provides induced abortions for are those who live with serious heart conditions or have had strokes, and carrying on with their pregnancies puts their lives at risk, she explains. Additionally, the need for cancer treatment, being suicidal from pregnancy, and trauma are a "small handful of reasons why an abortion may be considered 'medically necessary,'" according to Dr. Lincoln.
While the list of reasons someone may get an abortion varies, below you'll read about some of the most common conditions that can act as a catalyst.
Life-Threatening Conditions That Require an Abortion
Learn more about life-threatening conditions where an abortion is necessary to save a mother's life to understand the importance of access to abortion care. "Make no mistake though, abortions do not need to be deemed medically necessary to be necessary," says Dr. Lincoln.
Ectopic Pregnancy
An ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, such as the fallopian tube (where eggs are carried from the ovaries to the uterus) or ovary, according to the Mayo Clinic. Ectopic pregnancies aren’t viable, and if the fertilized egg continues to grow, it can rupture and cause the pregnant person to bleed to death. Ectopic pregnancies are usually discovered during the first trimester, though occasionally later at 12 or 13 weeks, says Dr. Peterson. People with ectopic pregnancies will have excruciating abdominal or pelvic pain as well as vaginal bleeding, extreme lightheadedness, or fainting, reports the Mayo Clinic.
Although treatment for an ectopic pregnancy isn't technically an abortion, it is a termination of pregnancy, explains Dr. Peterson. That's because an abortion is the termination of an intrauterine pregnancy and it involves medication or surgical abortion, while an ectopic pregnancy occurs outside of the uterus and is managed differently.
If the pregnancy hasn’t ruptured, physicians can end an ectopic pregnancy through medication. “We give methotrexate, which is a chemotherapy drug, but the patient has to be a good candidate for it because it’s very toxic,” says Dr. Peterson. Methotrexate stops cells from growing, allowing the pregnancy to be absorbed by the body over four to six weeks, according to the American College of Obstetricians and Gynecologists. This method prevents the need to remove the fallopian tube, which comes with potential risks, including blood clots, infection, and damage to surrounding organs and tissues, notes the Cleveland Clinic. Additionally, if both fallopian tubes are removed, natural pregnancy is no longer possible.
Surgery is needed to treat an ectopic pregnancy if the pregnancy has ruptured, but sometimes surgery is required even if it hasn't ruptured. This method is common and safer for the patient in some cases, says Dr. Peterson.
While both of these methods aren't technically abortions — because the pregnancy occurs outside of the uterus — newly activated trigger laws are vague. Physicians might be worried about risks when treating an ectopic pregnancy out of fear of being charged with a felony for facilitating an abortion, adds Dr. Peterson.
Intrauterine Infection
Some of the most common causes of intrauterine infections happen from infections that start in the vagina and travel to the uterus. This is more common when a patient's bag of water (amniotic sac) has broken, but it can also happen without the bag breaking, says Dr. Peterson. Intrauterine infections can also happen because the fetus has died and the dead products inside the uterus cause an infection, she says. So, if an intrauterine infection is the result of the death of a fetus, removing the fetus is necessary.
In some cases, intrauterine infections are the result of pregnant people trying to manage abortions themselves at home with pills they purchased online without consulting a doctor, such as through telemedicine service, she adds. While people can safely self-manage abortions with medication, such as abortion pills, under the supervision of a physician, ordering medications off the internet without consulting a doctor or knowing how far along you are and what dosage you need puts you a great risk for complications.
"If an infection is in the uterus during pregnancy, there are no antibiotics to treat that," says Dr. Lincoln. "The only cure is delivery of the fetus [whether viable or not] because the infection is in the placenta (the organ in the uterus that provides oxygen and nutrients to the fetus) and/or amniotic sac (the sac filled with fluid that protects the fetus in the uterus), and those must be removed in order for the body to clear the infection," says Dr. Lincoln says.
Antibiotics are given after delivery, but they aren't enough alone to treat an infection in the uterus. "We do give antibiotics if someone comes in with their bag of water broken and they are preterm, not as a way of treating infection but in the hopes of preventing infection…However, if there's already an infection in the uterus (and maybe that is what caused the bag of water to break) antibiotics will not help," says Dr. Lincoln.
Placental Abruption/Previa
Placental abruption happens when the placenta completely or partially detaches from the uterus due to some sort of trauma. When the placenta detaches from the uterus, it decreases the amount of oxygen and nutrients being delivered to the fetus and can cause severe bleeding, reports the Cleveland Clinic.
"Placental abruption can be managed without delivery until the amount of bleeding causes the pregnant person to become unstable," says Dr. Lincoln. In the case of life-threatening bleeding, the fetus must be delivered, both for the health of the mother and the fetus if it's viable, she explains. "If [the fetus is] not [viable], then abortion is indicated because, without removal of the bleeding placenta, the patient will continue to bleed and hemorrhage to death," she adds
This is also true for pregnant people who have placenta previa, where the placenta is covering the cervix and may cause life-threatening bleeding. In cases where the bleeding is severe, a surgical abortion is necessary to save the patient, regardless of the viability of the fetus, as the mother could die from blood loss, says Dr. Peterson. Bleeding from placenta previa usually happens after 20 weeks of pregnancy, according to the Mayo Clinic.
Previable Pre-Labor Rupture of Membranes (PROM)
When there's a previable pre-labor rupture of the membranes (PROM), the membranes (amniotic sac) break open before labor, leaving no amniotic fluid for the fetus.This puts the mother at risk of infection because it allows bacteria from the vagina to travel to the uterus, says Dr. Peterson.
Risk factors for premature rupture of membranes include intrauterine infection (as described earlier), multifetal gestation (including twins, triplets, or other multiples), and cervical insufficiency, when the cervix may open (or dilate) early, which could cause premature birth,according to the Society for Maternal-Fetal Medicine. PROM usually occurs between 20 and 25 weeks of pregnancy, but it can happen earlier.
“It’s actually part of our guidelines for managing that condition to offer termination [whether with medication to induce labor or surgical abortion] because 50 percent of those patients will deliver within one week,” says Dr. Peterson. That’s significant considering the fetus might not yet be viable, and infants born before 24 weeks of gestation have less than a 50 percent chance of survival. “You can manage [the rupture of membrane] with close observation…But a lot of patients, I would say, choose to terminate those pregnancies, because imagine going 20 weeks with no fluid in the uterus.” ICYDK, amniotic fluid is what protects a fetus from injury and allows room for growth, movement, and development in the womb, according to the Mayo Clinic.
Severe Cases of Preeclampsia
Preeclampsia is a form of high blood pressure that develops usually after 20 weeks of pregnancy, according to the Mayo Clinic. Preeclampsia poses a danger to the mother and the fetus because it raises blood pressure, which restricts blood supply to the placenta that supports the fetus.
The exact cause of preeclampsia isn't known, but Dr. Peterson describes it to patients as "being allergic to your own placenta." Something abnormal happens during the formation of the placenta, and it causes the blood vessels in the placenta to constrict. This blocks the blood supply to the placenta, and if it's severe, the fetus will die.
“Occasionally we have patients who will come in and have HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, a very severe manifestation of preeclampsia,” says Dr. Peterson. HELLP syndrome can be difficult to diagnose, because patients don’t usually experience the typical symptoms of preeclampsia, according to the Preeclampsia Foundation. But some common symptoms of HELLP syndrome are abdominal and chest pain, shortness of breath, nausea, vomiting, and a headache that doesn’t get better with medications.
If the mother's life is at risk due to life-threatening amounts of blood loss, having low platelets, having high blood pressure that won't come down, or other situations, termination of surgical and medical abortion are offered, depending on the gestational age of the fetus and a patient's preference, according to Dr. Peterson.
“If [the fetus is] viable and [the patient is] desiring their pregnancy, then induction of labor or delivery via C-section is done,” says Dr. Lincoln. “If they are previable, then an abortion will be performed, with the method depending on gestational age, the wishes and health of the patient, and the availability of providers to perform certain procedures. Options can include induction of labor or a D&E (dilation and evacuation).”
Antepartum Sepsis
Antepartum sepsis (sepsis during pregnancy) is the result of an infection that happens anywhere in the body, such as the lungs, gastrointestinal tract, or urinary tract, according to the Centers for Disease Control and Prevention. Sepsis is life-threatening because it causes the body to damage its own tissues in response to the infection, reports the Mayo Clinic. Antepartum sepsis can cause organ and placental dysfunction and is one of the biggest contributors to maternal and fetal mortality, according to an article in published in StatPearls.
If a patient is septic and pregnant, and the uterus is the source of the infection, an abortion is necessary, says Dr. Lincoln. However, if the pregnant person is septic due to an infection elsewhere, such as the kidneys, they can likely be treated with antibiotics, she adds. "We know that sepsis in pregnancy can lead to fetal demise, which is why treating it as the emergency it is (if the source is not the uterus) is imperative both for the maternal and fetal health."
