June 21, 2022
8 min read
The news that the Supreme Court may overturn Roe v. Wade sent a shockwave through all corners of the United States.
After reproductive health care providers and pregnant people, that shock may arguably be felt most acutely by patients with rheumatic and autoimmune diseases, and the providers who treat them.
On May 2, the political media website Politico obtained a leaked preliminary draft majority opinion written by Justice Samuel Alito suggesting that the Supreme Court will overturn Roe in the case of Dobbs v. Jackson Women’s Health Organization. The final decision is expected to be officially released in June. It would end federal abortion protections and leave the question of whether abortion should be legal at all up to the states.
In the wake of that leak, several state legislatures have advanced legislation restricting or limiting abortions.
For example, Florida has passed legislation banning most abortions after 15 weeks of pregnancy. The law would go into effect July 1, under the presumption that the Supreme Court will no longer protect abortion until fetal viability as a constitutional right once Dobbs is decided. In addition, Oklahoma now restricts abortion access from the moment of fertilization, and Texas restricts access at 6 weeks. State legislators in Louisiana briefly considered a bill that would have charged anyone who has or performs an abortion with homicide, although that bill has been withdrawn.
“It is sad to see this type of legislation happening in the United States,” Nancy Lane, MD, of the University of California Davis Health System, told Healio. “The U.S. has been a leader for the world in human rights, and it seems right now we are moving backwards. Let’s all hope our patients do not suffer or their future children do not suffer due to these political winds.”
Elizabeth Kirchner, DNP, of the department of rheumatologic and immunologic disease at the Cleveland Clinic, offered a general comment on the impact of an overturned Roe on rheumatology.
“Those of us practicing in rheumatology could be forgiven for believing the impact on our practice will be minimal,” she said. “Unfortunately, we can expect that if Roe v. Wade is overturned, as is expected, our practice and our patients will be directly impacted.”
The nature of that impact is comprehensive. Some patients may have diseases or conditions where pregnancy could put their life at risk. In those cases, termination of the pregnancy is a potentially lifesaving intervention.
Other patients are being treated with medications that could cause fetal or maternal complications, or both. Balancing pregnancy and those medications would become considerably more difficult in a post-Roe world.
“Many of our patients are on disease-modifying agents like methotrexate that can negatively impact the fetus,” Lane said. “In those patients, I would recommend abortion.”
There is also a geographical component to the discussion.
“Although I cannot predict the future, places in the country to pass stricter anti-abortion laws are likely to see fewer rheumatologists than other areas,” Lane said. “I believe there tend to be fewer rheumatologists in those states with stricter anti-abortion laws now.”
Data from the American College of Rheumatology 2015 Workforce Study appear to generally support Lane’s belief. According to the study, the southeastern, south central and north central regions — which all contain multiple states with laws that would automatically ban abortion in the first and second trimesters if Roe were overturned — have 60,087, 52,689 and 47,165 adults per rheumatologist, respectively. Meanwhile, the northeast and mid-Atlantic regions have 26,719 and 34,587 adults per rheumatologist.
If Roe is overturned, rheumatology patients in these states specifically may find themselves at risk without available abortion services, in addition to being unable to see a rheumatologist. This risk may be particularly troubling for patients with systemic lupus erythematosus, who may be uniquely susceptible to the impacts of new anti-abortion laws.
‘Caught in a perfect storm’
“The disease that most of us in rheumatology get very nervous about when it comes to pregnancy is SLE, a disease which disproportionately affects young, minority women,” Kirchner said.
A 2013 study by Candace H. Feldman, MD, MPH, and colleagues, published in Arthritis & Rheumatology, demonstrated that African American women have the highest prevalence of SLE, 286.4 per 100,000 — nearly twice as high as white women.
Meanwhile, unintended pregnancies occur most commonly in teens, non-Hispanic Black individuals, people from lower socioeconomic backgrounds and those who are unmarried, according to a 2016 New England Journal of Medicine report, written by Lawrence B. Finer, PhD, and Mia R. Zolna, MPH.
In addition, data from 2011 showed that approximately 45% of pregnancies in the United States were unintended, which Kirchner defined as being either unwanted — occurring when no children are desired — or occurring at a different time than desired.
The implications of an overturned Roe, then, are clear.
“If abortion is severely restricted or outlawed, our SLE patients will be caught in a perfect storm,” Kirchner said.
“Putting additional roadblocks to care in front of those already suffering from lack of access, lack of equitable care, and lack of follow-up care will only exacerbate the issues these patients face,” she said.
Black women in particular frequently experience higher maternal mortality rates than their white counterparts.
“When these women have lupus — which, in itself, comes with higher complication and mortality rates — and face the loss of the right to terminate a pregnancy, it could jeopardize their long-term health, if not their lives,” Kirchner said.
With so-called “heartbeat laws” like those in Texas in place, even if abortion is permitted under certain circumstances, it is often unlikely that the patient will recognize an unintended pregnancy in time to do something about it, according to Kirchner.
“This will compound the hurdles they will face to get the care they need,” she said.
Lane added that, in addition to SLE, those with scleroderma are also most likely to be impacted. However, pregnancy-related complications can arise in patients with almost any rheumatic and autoimmune disease, including Sjögren’s syndrome, a condition associated with a high prevalence of anti-Ro and La antibodies, which can be problematic in pregnancy. In addition, fetal survival can decrease in patients who develop polymyositis or dermatomyositis during pregnancy. These outcomes can be mitigated when the disease is well under control, but that is not always the case, particularly in situations where the patient cannot access medication.
Indeed, medication access and adherence are critical to controlling disease, and some experts fear that access to medication will be restricted as the push toward limiting abortion continues.
Methotrexate restrictions next?
When it comes to medication, methotrexate is the primary focus for rheumatologists and advocates concerned about abortion restrictions. The drug is used for a wide variety of diseases, including rheumatoid arthritis, severe psoriasis, lupus, multiple sclerosis and polyarticular juvenile idiopathic arthritis. It may also be used to terminate ectopic pregnancies to save the life of the parent.
For Lane, it is important for rheumatologists to understand the practical implications of the association between methotrexate and poor pregnancy outcomes.
“We will have to counsel our patients on methotrexate to use effective contraception during their childbearing years, and to work with their rheumatologist when planning a pregnancy to be sure to discontinue medications that might harm the fetus before trying for a pregnancy,” Lane said.
Kirchner raised some serious questions about the ability of rheumatologists to prescribe methotrexate in a post-Roe United States.
“Will we need to somehow prove that every methotrexate prescription we write isn’t going to be used to induce abortion?” she said. “Will our ability to write prescriptions be hampered? Maybe just for certain populations, like perhaps women of childbearing age?”
When asked whether methotrexate restrictions could become a reality, Lane was cautiously optimistic.
“I am hopeful this does not happen,” she said. “However, if it does occur, our patients with rheumatic diseases should still be able to obtain it.”
Experts like Kirchner are not so certain.
“To some of you, this may seem like overzealous fear-mongering, but I urge you then to note Texas Senate bill SB4, which went into effect in December 2021,” she said. “This law specifically names methotrexate as an abortion-inducing drug. Pharmacists in Texas must jump through several hoops, including verifying that the patient is not pregnant, before they can dispense methotrexate.”
Although this law accounts for cases where methotrexate is dispensed for reasons other than inducing an abortion, the penalties involved may still have a cooling effect on its use, according to Karen Morrison, an attorney and associate member of the Virginia State Bar.
“The penalties are so steep — felony charges on top of the lawsuits brought by private citizens authorized by [Texas Senate Bill] 8 — that any pharmacist would be forgiven for being hesitant to fill a methotrexate prescription,” Morrison said.
These impacts — on patients, physicians and pharmacists — serve to highlight the potential that an overturned Roe could have a far-reaching ripple effect throughout multiple health care specialties.
‘Jockeying for space’ in the examination room
“The specter of a pending loss of federal protection of abortion rights has spurred many public discussions with and among health care providers, and to date that discussion has, understandably, focused primarily on the impact to abortion providers and OB/GYNs,” Morrison said.
However, it is easy to see how providers could face hurdles they might not even have considered while Roe was upheld, according to Morrison.
“In Texas and Oklahoma, providers must now add private citizens to the growing list of people with a potential vested interest in interfering with their practice, thanks to recently enacted laws that allow private citizens to bring civil suits and win monetary damages against providers, among others, for aiding and abetting abortion once a fetal heartbeat can be detected, which is at around 6 weeks gestation,” she said.
According to Kirchner, this will directly, negatively impact rheumatology practices.
“Our exam rooms will grow even more crowded,” she said. “It is bad enough when insurance companies tell us they won’t pay for tests that we, as health care providers, have deemed medically necessary, or pharmacy benefit managers notify us that they won’t pay for medications that we have determined are the best options for our patients.
“Now, as we look to a future without the federal legal protections afforded by Roe, it looks like we will have to worry about state governments potentially outlawing medical procedures that we, as providers, through shared and informed decision making with our patients, feel are in their best interests,” she added.
In short, rheumatologists may be presented with a sobering reality.
“With all of these entities jockeying for space within our exam room, it’s a wonder there’s enough left for the patient and provider,” Kirchner said.
“As health care professionals, we are all tired of the voices from the outside that impact how we practice medicine, those voices who like to think they know better than we do about how to deliver optimal care to our patients,” she added. “Frankly, it is exhausting some days.”
Morrison added that legislators who insert themselves in the provider-patient relationship could easily be emboldened to pass further laws restricting health care practices.
“This could happen because they have been successful with an initial mandate on abortion care,” she said.
In the face of these potential developments, advocacy is critical, according to Kirchner. She urged colleagues in rheumatology and beyond to involve themselves more heavily in lobby efforts on behalf of their patients.
“If you are unhappy with what our legislative and judicial branches are doing to patients and health care, consider getting involved,” she said. “Vote, certainly. Lobby, both in Washington, D.C., and in your state capital.”
Some providers may consider becoming active in a campaign or even running for office. “In the meantime, what do we need to do to adapt to the shifting political winds?” Kirchner said. “Regardless of your personal beliefs, the expected overturning of Roe v. Wade is going to require a proactive response so that our patients are not blindsided when they walk into our offices.”
Understanding the landscape of the state in which you practice is also critical, Kirchner added.
“Accordingly, we have a pretty good idea what sorts of issues and questions our patients are going to be wondering about,” she said. “Some of them are clearly scared already. It is up to us to be a conduit of information to help our most fragile patients overcome the additional barriers to their overall health. It won’t be easy. But it is what we do.”