In the United States, neither the state legislators nor the voters who elect them could likely imagine the clinical scenarios hematologists now face as a result of the Dobbs decision, state trigger laws, and recent legislation restricting access to abortion. For those unfamiliar with the complexities of modern medicine, U.S. laws that allow for pregnancy termination to save the life of the mother seem “sufficient” for these situations. If only it were that simple. But since it is not, the risk now is that patients are left to wait until their lives are at “real” risk before physicians — terrorized by fear of criminal prosecution, loss of license, or threats to their own lives and those of their families — are willing to intervene in an obstetric emergency.
Those of us who care for women of childbearing age with hematologic disorders are all too familiar with the gut-wrenching situations and ethical dilemmas that challenged us even before the Supreme Court overturned Roe v. Wade. During my rotation on the leukemia service, a 33-year-old woman who had been struggling with infertility finally became pregnant, only to find herself with poor-risk acute myeloid leukemia very early in her second trimester. In those pre-Dobbs days, we weighed the risks of proceeding with treatment jointly with the patient, her husband, and parents. We proceeded with treatment knowing that we had the option of terminating the pregnancy if things went badly, albeit with significant risk. We worried that choices we made in hopes of reducing risk to the fetus would compromise the mother’s chances for a complete remission and cure, leaving the baby motherless should she fail to respond to treatment or relapse. We worried about infection and bleeding. What would we have done had she been 10 weeks pregnant rather than 20? Pre-Dobbs, we also would have weighed the risks of proceeding with treatment versus pregnancy termination (with the woman as the final arbiter), but more likely proceeded with abortion because of the high risk of fetal toxicity from chemotherapy in the first trimester. Today, given current restrictions in many U.S. states, we may have no choice but to proceed with treatment, and in the event of complications, lose both the fetus and the mom, potentially leaving other children motherless.
Other scenarios abound: Consider my 22-year-old patient with relapsed Hodgkin lymphoma who became pregnant during total lymphoid irradiation prior to autologous hematopoietic stem cell transplantation, or my patient who was 11 weeks pregnant with a desperately wanted pregnancy but needed an urgent allogeneic transplant. Consider the patient with sickle cell disease, already with severe pulmonary hypertension and renal disease, who finds herself unexpectedly pregnant, or the patient on weekly methotrexate for her skin lymphoma whose physicians are loathe to refill her prescription and are advising a change in therapy to avoid the appearance of interfering with a potential pregnancy. Medical decision making is complicated, and there is no easy way to account for all situations in the face of a hematologic disorder other than to allow for these decisions to be made jointly between physicians and their patients. To wait for the life of the mother to be “in peril” is to wait too long.
Education and advocacy are our best allies in the fight for maternal health rights for our patients. ASH has begun an aggressive campaign to inform our lawmakers and the voting public of the consequences of Dobbs, trigger laws, and recent legislation, beginning with our June 2022 statement on “The Right to Maternal Health Care.” Whereas limits on pregnancy termination exist in nearly half of the states affecting our members and their patients, this must be a national campaign directed toward Congress as well as state legislators. Already, ASH along with other medical societies including the Council of Medical Specialty Societies, the American Medical Association, and the American College of Obstetrics and Gynecology, has signed onto letters to Congress voicing our stance, and this is in addition to the hundreds of letters and tweets from ASH members to both federal and state legislators. Our lawmakers need to hear not just that their constituents support the right to maternal health, but specific examples of how our patients are impacted. They must hear about the ramifications of their legislation. Specific clinical scenarios speak volumes. So first, please join the Grassroots Network. You will receive policy updates and links to resources such as talking points and letter templates to share with your federal and state representatives. Personalize your letter with a story about one of your patients. Seize every opportunity to educate others about the effect of restricting pregnancy termination on our patients. Write letters or op-eds to local papers. ASH staff can help arrange local in-person or virtual district visits to personally advocate for the repeal of restrictive abortion laws. Get the word out. Tell your patients’ stories to anyone who will listen.