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Hematology Post-Roe

September 21, 2022

October 2022

The strong link between hematology and maternal health care makes the recent SCOTUS decision particularly poignant for hematologists and their patients.

Tess Stafford

Tess Stafford is the editorial assistant of ASH Clinical News.

On June 24, 2022, the Supreme Court of the United States (SCOTUS) overturned Roe v. Wade through its decision on Dobbs v. Jackson, leaving the legality of abortion up to individual states. With trigger bans in place in numerous states and others considering legislation, the repercussions of the decision on clinical care have been swift and challenging for patients and providers alike.

Though some abortion bans have been blocked by the courts and the situation is rapidly developing, those who work in hematology and their patients are facing immense challenges.

Health care providers around the country are concerned about the lack of abortion access for their patients. Specifically, many worry they will be unable to provide the best care for their patients without the option of abortion. Without access to the procedure, patients may be left to carry a high-risk pregnancy or delay life-saving treatment for themselves.1,2

For hematologists and patients with hematologic conditions, lack of abortion access can complicate a multitude of circumstances.

According to a statement from American Society of Hematology (ASH) President Jane N. Winter, MD, “Blood disorders ... can pose a profound risk to maternal health. In some cases, denying women their right to terminate a pregnancy puts them at risk of serious illness or death.”3

ASH Clinical News spoke with experts about the link between hematology and maternal health care, the impact of the SCOTUS decision on clinicians and patients, and the post-Roe future of hematologic care.

Hematology and Maternal Health Care

Stepping back from abortion access specifically, the relationship between hematology and maternal health is a complex one.

For any individual, pregnancy alone can pose a variety of health risks, many of which are hematologic. Jason Vaught, MD, a maternal fetal medicine specialist and surgical critical care physician at Johns Hopkins Hospital in Maryland, said common hematologic pregnancy complications include obstetric hemorrhage, sepsis, stroke, preeclampsia, and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome.

Without safe and legal access to abortion, more people will become pregnant and will develop these complications, Dr. Vaught said. This not only puts patients’ lives at risk but threatens already stressed hematologic resources.

For example, with a potential increase in obstetric hemorrhages, there will likely be a higher need for transfusions, Dr. Vaught explained. U.S. blood banks may not be able to keep up with such an increase, which would not only affect pregnant patients but any patient who needs a blood transfusion.

The link between hematology and maternal health goes both ways. While pregnancy itself can cause hematologic complications, it can also complicate the care and treatment of hematologic diseases. Jennifer Holter-Chakrabarty, MD, a bone marrow transplant and cellular therapist at OU Health’s Stephenson Cancer Center in Oklahoma, noted certain hematologic conditions can be complicated by pregnancy.

Bleeding and clotting disorders, as well as conditions like sickle cell disease (SCD), can make pregnancy particularly dangerous, explained Dr. Holter-Chakrabarty, who is also the chair of ASH’s Government Affairs Committee and a member of its Task Force on Immunotherapies. More precisely, individuals living with SCD have a 10-fold risk of death during pregnancy,4 she said.

Pregnancy complications are incredibly common in SCD, and individuals who become pregnant are at high risk for blood clots, strokes, and vaso-occlusive crises.4,5 SCD is also associated with miscarriage, stillbirth, and maternal death, making abortion care vital for people with the condition.6

In a retrospective U.S. study observing 2,330 pregnancies in patients with SCD, 15.5% were incomplete, and 59.3% of these were miscarried. Of 936 first deliveries, 2.4% resulted in stillbirth, and of 862 live births observed in the study, five patients died, exceeding overall U.S. maternal mortality rates.6

Pregnancy can also threaten the lives of patients with leukemia, lymphoma, or other hematologic malignancies. Because chemotherapy is not considered safe during the first trimester of pregnancy, it is often recommended that patients who are diagnosed with cancer terminate their pregnancy to continue treatment, though some patients choose instead to delay treatment and carry the pregnancy to term.4

With the overturning of Roe v. Wade, many physicians worry patients will no longer have the option of abortion and will be forced to delay their own life-saving treatment.2 Dr. Holter-Chakrabarty said it is unlikely a patient would be able to carry the pregnancy to term in a situation like this, adding it is much more probable the mother and baby would both die because of inadequate care.

Recognizing these risks and the dangers they pose to patients, physicians, and the practice of hematology, ASH released a statement the day of the SCOTUS decision detailing the importance of maternal health care access in hematology.4

“Termination of a pregnancy is an important clinical consideration when the mother is at risk for serious health complications and death,” the statement said.

Legal Persuasions

With the legality of abortion changing rapidly and differing based on location, physicians and patients alike are struggling to understand what is legal and what may have criminal implications.2 As a result, individuals in the hematology field are left with questions that may not have a clear answer.

In some states, this confusion has already affected patients and doctors. National media have reported that physicians in Texas are unsure whether they can provide care for patients experiencing miscarriages.7 This caught the eye of Gerald Hsu, MD, PhD, the hematology/oncology fellowship program director at the University of California, San Francisco.

“Women are suffering complications, delays in miscarriage care,” Dr. Hsu said. “They’re having to deal with the pain associated with miscarriages; they’re having to deal with excess bleeding as a result of miscarriage on their own.”

For Dr. Vaught, a big question lies in what clinicians will be expected to report and what can remain confidential.

“Do you as a physician have to report positive pregnancy tests to the state?” Dr. Vaught speculated. “We already kind of do that for [sexually transmitted infections], things like that, so that concept is not impossible, right? That concept of reporting medical information because the state needs it is not this impossible thing. So, what happens when you don’t comply?”

With these types of uncertainties, Dr. Vaught said it’s important for hospital administrators and lawyers in states with restricted abortion access to be prepared. When patients do need access to abortion or life-saving care because of pregnancy complications, there needs to be a plan put in place, he said, and physicians need to know what is within their legal bounds. Dr. Vaught wondered whether physicians could refer their patients to other providers or transfer them across state lines.

While transferring patients across state lines may have legal implications, it could also be physically unsafe. For patients with blood cancers like acute leukemia, their health could take a turn for the worse in mere days, Dr. Holter-Chakrabarty said, noting that traveling to another state could be incredibly risky or even fatal.

Safety issues are just one obstacle in transferring patients to another state, however. Lydia Pecker, MD, assistant professor in hematology and director of the Young Adult Clinic at the Johns Hopkins Sickle Cell Center for Adults, explained that the lives of people who cannot afford to travel for their care will be disproportionately endangered.

Aside from the lack of legal clarity in these types of situations, many physicians are also concerned about how the potential legal ramifications could influence clinical practice. Though she doesn’t doubt that most physicians will always act in the best interest of their patients, Dr. Holter-Chakrabarty said the SCOTUS decision is something doctors will have to consider when making clinical choices.

“When you are being accused of a felony and [facing the risk of] going to jail for lifetime, that has to be something you at least contemplate — and that’s not right,” Dr. Holter-Chakrabarty said.

By the same token, Dr. Hsu worries uncertainty among physicians may lead them to develop a bias. Consequently, pregnant patients could experience delays in care or inadequate care, he explained.

However, some physicians think these side effects are the intended purpose of the SCOTUS ruling. Dr. Pecker said the ruling is frightening for everyone in the hematology space.

“I think that [one] point of these laws is to make people afraid and to make behavior erratic, and it’s working,” Dr. Pecker said.

Dr. Holter-Chakrabarty noted the decision to terminate a pregnancy is never an easy one and should be a private choice that is not influenced by the intrusion of potential criminal charges. A law that is not sound should not persuade physicians to provide inadequate care, she added.

Federal Intervention

While state laws alone are ever evolving and continue to cause confusion, President Biden signed an executive order to protect abortion access federally weeks after the SCOTUS decision was released. According to a fact sheet from the White House, President Biden directed the Secretary of Health and Human Services to ensure the protection of emergency medical care for pregnant patients.8

Still, physicians remain unsure whether this will protect patients with hematologic conditions. Even though terminating a pregnancy might prevent a medical emergency and be the right thing to do clinically, Dr. Holter-Chakrabarty said there will always be people willing to argue on either side.

“I think you’re going to see a lot of court cases where that is exactly what happens – a physician doing the right thing continues to do the right thing and then is pulled into litigation,” Dr. Holter-Chakrabarty said.

As a physician located in Oklahoma, she said she will likely face a situation in which a patient will need an abortion but state laws prohibit it. Knowing the likelihood of this occurring, her plan is to consult her attorney and explain the risk to the mother’s life.

“I will do what is right for the patient no matter what and I need to have a game plan because I do not want to go to jail,” Dr. Holter-Chakrabarty said.

Dr. Vaught sees the classification of a medical emergency from a different perspective. In his eyes, physicians should not have to deem their patient’s situation a medical emergency to give them the care they need.

In fact, he said, the concept of waiting for a medical emergency to happen before providing adequate care is a distinct barrier to caring for pregnant patients.

“This whole idea that we have to wait until there’s an emergency is something that we’re only doing to women,” Dr. Vaught said. “I think that it’s ludicrous that we have to wait for a medical emergency because that is not how we’ve been practicing medicine within the last 15 years. We try to get it before the emergency.”

Moreover, he explained, those unfamiliar with obstetrics often don’t know that by the time there is an emergency, it’s too late. A pregnant patient’s situation can escalate very quickly and once it’s truly an emergency, the patient may already have become septic and, in some cases, could lose her uterus entirely.

Dr. Vaught went on to say that the need to classify every medical situation as an emergency to gain access to necessary care could also be dangerous.

“If we say everything is an emergency, then all of a sudden nothing becomes an emergency,” he said.

Patient-Physician Relationship

On top of the physical and legal risks that a post-Roe world poses for those in the hematology space, one widespread concern is the ruling’s impact on the patient-physician relationship.

In 2019, ASH released a statement about federal policy and its influence on the patient-physician relationship.

“Treatment decisions should be made between a physician and the patient; yet many times, policies, put in place by the federal government or insurance companies, can impact these decisions,” the statement said.9

The relationship between physicians and their patients can be very intimate because of the trust required to put in one another, Dr. Vaught explained. In fact, he finds this to be one of the most rewarding aspects of being a physician.

However, with the overturning of Roe v. Wade, the trust between physician and patient may be lost. Dr. Vaught worries this will create obstacles in the relationship that would not otherwise exist.

For Dr. Holter-Chakrabarty, the concern is similar. She explained that she became a doctor with the intention of protecting people and helping them when they are most vulnerable. This interruption of the patient-physician relationship is a complete violation of privacy, she said.

“To have someone walk into that relationship and start exerting forces without understanding the medical implications impedes optimal care, is the antithesis of providing good care, and it is the antithesis of the Hippocratic oath that I took,” Dr. Holter-Chakrabarty said.

This intrusion may also affect fellows and trainees who are interested in entering the field of hematology, Dr. Hsu explained. He worries that the diversity of hematology providers may decrease as a result of Roe v. Wade being overturned.

When it comes to trainees who are already pregnant or have the ability to become pregnant, Dr. Hsu said these barriers may narrow the potential pool of hematologists. Without access to legal abortion, trainees may experience forced pregnancy before or during their training. This could deter individuals from attending medical school or pursuing specific residencies or subspecialties, he explained.

“If you are imposing restrictions on the autonomy and health of people who are providing care, they’re not in the best position to provide care to others,” he said.

Similarly, Dr. Pecker noted that it is always possible for hematologists to end up in the same position as their patients. In other words, they could also need life-saving abortion access.

“The idea that we’re drawing this distinction between clinicians and patients in this setting is dangerous because it only serves to divide people who all may have an indication for an abortion,” Dr. Pecker said.

Looking Forward

Through all the uncertainty surrounding abortion access and hematologic care, physicians are trying to predict how the ruling may affect other areas of care and how they can continue to support their patients as well as each other.

A major concern among physicians is the ways in which infertility treatments may be affected by the ruling. As some states define the beginning of life as the point of fertilization, many doctors worry in vitro fertilization (IVF) may become harder to access.

Because treatment for blood cancers can affect fertility, some patients may wish to pursue IVF after treatment. However, patients are not alone in this. IVF accessibility could also affect health care providers, Dr. Holter-Chakrabarty explained, as 20-24% of doctors experience infertility.4

Looking forward, Dr. Pecker said it is vital for all medical fields in the U.S. to recognize the maternal health care crisis, as abortion restrictions will exacerbate the already existing disparities in this field of care. Additionally, it is important for physicians to support not only their patients but also their colleagues and trainees by checking in with them.

“I think that we’re going to see incredibly sad things happen in this country in the next decade,” Dr. Pecker said. “It’s a very grim time and all of our professional societies need to be acting with a sense of urgency and emergency.”

Dr. Pecker suggested that all medical societies stand in solidarity at this time and look toward the American College of Obstetricians and Gynecologists and the American Society of Reproductive Medicine for guidance.

“No woman should face legal ramifications for childbearing decisions,” noted the statement from ASH. “The right to maternal life and well-being for our members and the patients they serve, must not be denied.”4

References

  1. ABC News. For pregnant women with cancer, doctors fear abortion bans ‘could be a death sentence.’ July 19, 2022. Accessed August 31, 2022. https://abcnews.go.com/Health/pregnant-women-cancer-doctors-fear-abortion-bans-death/story?id=85948248.
  2. NPR. For doctors, abortion restrictions create an ‘impossible choice’ when providing care. June 24, 2022. Accessed August 31, 2022. https://www.npr.org/sections/health-shots/2022/06/24/1107316711/doctors-ethical-bind-abortion.
  3. American Society of Hematology. ASH advocates for the right to maternal health care. June 24, 2022. Accessed August 31, 2022. https://www.hematology.org/newsroom/press-releases/2022/ash-advocates-for-the-right-to-maternal-health-care.
  4. American Society of Hematology. The right to maternal health care. June 24, 2022. Accessed August 31, 2022. https://www.hematology.org/advocacy/policy-news-statements-testimony-and-correspondence/policy-statements/2021/the-right-to-maternal-health-care-in-hematology.
  5. Singh A, Olsen C, Zhang, X, et al. Complications in pregnancy of sickle cell disease. Blood. 2020;136(Suppl 1):32-33.
  6. Fisch S, Brunson A, Mahajan A, et al. Pregnancy outcomes in women with sickle cell disease in California: a retrospective cohort study. Blood. 2021;138(Suppl 1):489.
  7. Belluck P. They had miscarriages, and new abortion laws obstructed treatment. The New York Times. July 17, 2022. Accessed September 13, 2022. https://www.nytimes.com/2022/07/17/health/abortion-miscarriage-treatment.html.
  8. The White House. FACT SHEET: President Biden to sign executive order protecting access to reproductive health care services. July 8, 2022. Accessed August 31, 2022. https://www.whitehouse.gov/briefing-room/statements-releases/2022/07/08/fact-sheet-president-biden-to-sign-executive-order-protecting-access-to-reproductive-health-care-services.
  9. American Society of Hematology. Access to Hematology Care in an Age of Innovation. November 22, 2019. Accessed September 8, 2022. https://www.hematology.org/advocacy/policy-news-statements-testimony-and-correspondence/policy-statements/2019/access-to-hematology-care-in-an-age-of-innovation.

Advocating for Change

With the legality of abortion contingent upon legislation and local government, physicians and patients may wonder what they can do to prevent further restrictions. ASH encourages its members to advocate through voting and other political outlets.

Individuals can make an impact by contacting congressional and state legislators, urging them to protect access to essential health care and oppose restrictions on abortion access. To streamline this effort, ASH has created a one-step process that allows readers to enter their information and send an email to elected officials expressing their concerns: hematology.org/advocacy/reach-out-to-congress/contact-your-elected-officials-to-protect-the-right-to-maternal-health-care.

In addition to contacting local officials, individuals can get involved in local efforts to make a difference. Joining the ASH Grassroots Network is one of many ways to do this and is a convenient way to stay up to date with advocacy efforts: hematology.org/advocacy/reach-out-to-congress/join-the-ash-grassroots-network. Individuals may also find the ASH Advocacy Toolkit to be helpful in guiding their endeavors: hematology.org/advocacy/advocacy-toolkit.

Most importantly, it is vital to get involved in local and federal elections to ensure that elected officials represent the values of their constituents. By staying informed, being involved, and voting for candidates who accurately represent their communities, it may be possible to prevent further restrictions on abortion access.

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