When Desired Pregnancies Lead to Painful Choices

Only a small percentage of people who terminate pregnancies each year do so because of a maternal or fetal medical problem.1 Within that group, however, patients and caregivers encounter myriad complexities that can make risk-benefit assessments difficult and raise questions about what it means to comply with changing law.

“No patient ever expects to end a desired pregnancy,” says Maeve Hopkins, MD. “That’s the last thing they think they would do. So in our line of work, when this happens, we often face situations where there are no good options.”

Dr. Hopkins, a maternal-fetal medicine specialist, and Ashley Brant, DO, a specialist in complex family planning, are colleagues in the Ob/Gyn & Women’s Health Institute at Cleveland Clinic. They recently spoke to Raj Bhardwaj, MD, host of the medical podcast DDx, for a series of episodes devoted to abortion as medical care. Drs. Brant and Hopkins shared cases in which severe fetal abnormalities drove decisions to terminate.

Such cases make up a fraction of their practice, the doctors say, but when they occur, expert medical care is essential.

“The number of abortion cases we do each year is relatively small,” says Dr. Brant. “But these families are faced with making time-sensitive, unimaginable decisions, so it feels like the most important thing I do. We can help them get the care that they need quickly.”

To hear the cases Drs. Brant and Hopkins discussed with Bhardwaj, listen to DDx podcast Season 7. The doctors also spoke to Consult QD about other circumstances in which pregnancy termination was considered to address a difficult medical condition.

When a fetal anomaly is present

Fetal anomalies complicate 3% of pregnancies. Some are minor. Others are serious. Still others are incompatible with life.

For the podcast, Dr. Brant discussed a case in which a fetus was diagnosed around 16 weeks gestation with hypoplastic left heart syndrome, a congenital heart defect that is fatal without either a heart transplant or multiple surgeries after birth.

It is among a number of conditions that can be devastating to key systems of the body.

“We also can see developmental issues with the brain, spine, kidneys and lungs,” says Dr. Brant. “Patients often choose to end pregnancies when they know a condition is incompatible with life or where there is a substantial risk of a serious impact on the baby’s quality of life and life expectancy.”

In her interview for the DDx podcast, Dr. Hopkins described a case involving a desired pregnancy in which one fetus in a twin pair was discovered to have a lethal genetic abnormality. Left unaddressed, the condition likely would pose a risk to the healthy baby. The choices were to do nothing or to terminate the unhealthy fetus with the hope of saving the healthy twin.

“That is a perfect example of how no option is good,” says Dr. Hopkins.

Other cases have been similarly fraught.

“I had a patient who was excited about the pregnancy,” Dr. Hopkins says. “When she came in for her first trimester ultrasound, we saw a lot of abnormalities consistent with a condition called Trisomy 13. It’s a genetic condition characterized by many birth defects, which are incompatible with survival.”

The patient expressed discomfort with the option of terminating the pregnancy, but was concerned about waiting, whether to see the pregnancy end in stillbirth or to deliver a baby who would not live long after birth. She chose to terminate the pregnancy with the hope of becoming pregnant again and delivering a healthy baby.

When maternal health is the issue

Many of these fetal anomalies are rare. A more common medical reason for termination is the rupture of the amniotic sac before fetal viability, which carries a high risk of life-threatening maternal infection and poor neonatal outcomes.

Other situations involve the pregnant patient’s pre-existing health condition.

“I took care of someone who had serious heart issues before she became pregnant,” says Dr. Brant. “Pregnancy would be extremely stressful on her cardiovascular system, and her risk of having a life-threatening heart complication during pregnancy was high.”

Dr. Hopkins also had a patient who had become extremely sick because of a renal condition exacerbated during a previous pregnancy. When she became pregnant again, patient and caregiver both worried that a second such experience could be life-threatening; the patient ended the pregnancy.

In states with more restrictive abortion laws, Dr. Hopkins notes, a patient in such a situation might not meet the criteria for legally terminating the pregnancy because the risk to the mother’s life might not be considered sufficiently acute.

A changed reproductive landscape

In the past few decades, the doctors note, new factors affecting maternal health have added complexity to reproductive healthcare. These include rising rates of obesity and hypertension, as well as the crisis of opioid abuse among women of reproductive age. A number of medical conditions affect pregnant patients now were not common or did not exist decades ago.

There also have been advances in maternal care. Fetal abnormalities, for example, can be detected much more easily and sooner than before.

“I can diagnose a lethal birth defect as early as 10 or 11 weeks now,” Dr. Hopkins says. “That wasn’t the case in 1970. Patients just carried their pregnancy and hoped for the best. So the more information that we gather, the more access to safe reproductive services we need.”

It will become ever more important to understand these complexities so that all patients can receive optimal healthcare for themselves and their families.

REFERENCES
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5957082/