Ryan Hamilton wonders if doctors were too afraid of Texas’ extreme abortion ban to provide adequate care to his bleeding wife in a post-Roe world.
This story was originally published on Courier Newsroom.
When Ryan Hamilton’s wife began to miscarry at the end of her first trimester, neither he nor his wife ever expected that she would end up unconscious, bleeding and near death on her bathroom floor.
But that’s exactly what happened to the Texas mom after three trips to medical centers in their rural area outside of Dallas. After receiving the heartbreaking news that their much-wanted second child had died in her womb, Ryan believes his wife received inadequate care thanks to Texas’ extreme abortion ban.
Instead of being able to access a simple medical procedure, called a D&C, to remove the dead fetus and surrounding tissue from her uterus, Ryan’s wife was given three rounds of a medication called misoprostol over three days.
Misoprostol can be inserted vaginally and works to soften the cervix and expel all of the tissue in the uterus that is associated with the pregnancy. Once all the tissue is expelled, the miscarriage has been completed.
While misoprostol is generally safe, it can occasionally have complications that require medical care. In Hamilton’s wife’s case, she experienced severe pain, dehydration, and bled profusely through three days and nights.
Since two rounds of misoprostol had not worked to complete her pregnancy, Ryan’s wife was given a prescription from a hospital she visited for a third round of the medication, featuring two ‘stronger’ doses.
After using the third round of medication, she stayed awake all night, bleeding heavily. Finally, around 10 a.m. on a Sunday morning, exhausted from a lack of sleep, she collapsed unconscious on the floor of the couple’s bathroom floor due to severe blood loss.
Ryan raced her to a nearby hospital, where the doctor who treated his wife told him: “I’m so glad that you brought her in when you did.”
Ryan’s wife finally regained consciousness after two hours of receiving treatment, including IV fluids.The couple learned that her body had at last completed the miscarriage, but she had nearly died in the process.
Today, his wife, who is a medical doctor herself, is recovering. But the question that haunts the couple is what went so horribly wrong with her miscarriage in Texas, which has one of the most extreme abortion bans in the country.
Abortion was completely banned by the Republican-dominated legislature, except to save the life of the mother or prevent “substantial impairment of a major bodily function.” However, the law was written in such an ambiguous way that it has also caused widespread confusion about what if any medical exceptions to the abortion law are allowed.
The penalties for medical professionals who perform an abortion in Texas are very clear: Doctors can be sentenced to up to 99 years in prison, receive a $100,000 fine, and lose their medical licenses.
The vagueness of the law led to a lawsuit that made it all the way to the state Supreme Court to try to get more clarification on exceptions, however the Court declined to insist that the state provide more explicit guidelines. Instead, the court blamed Texas doctors for not going ahead with abortions they thought were necessary.
However, the penalties for medical professionals who perform an abortion in Texas are very clear: Doctors can be sentenced to up to 99 years in prison, receive a $100,000 fine, and lose their medical licenses.
So the question is: Did Ryan’s wife receive inadequate care from doctors, who were confused about how they could treat her, despite the fact that her fetus had no heartbeat? Miscarriage treatment is not an abortion, but the procedure and prescription pills to complete a miscarriage are the same as for an abortion.
With the risk of a lifelong sentence in jail hanging over their heads, were doctors too afraid to provide what should have been standard care?
To get answers, we spoke to two doctors: a Texas OB-GYN and a Texas family medical doctor specializing in abortion, miscarriage, and gender-affirming care.
1. Could Ryan’s Wife Have Died After Falling Unconscious?
Dr. Judy Levison, a retired professor of obstetrics and gynecology in Houston, believes that Ryan’s wife was in danger of losing her life.
“I suspect she was,” she told Courier DFW. “If you lose enough blood to lower your blood pressure, you start having less circulation to all your vital organs and your brain. And if the circulation to the brain becomes low enough, loss of consciousness is common.
“Loss of consciousness is certainly something we would prefer to avoid.”
2. Was Ryan’s Wife Prescribed an Inadequate Amount of Misoprostol?
Ryan’s wife was prescribed three separate doses of two misoprostol pills to insert vaginally, several hours apart—twice by a medical center and once by a hospital. The hospital physician told Ryan’s wife that she was given a ‘stronger’ dose of misoprostol for a third round of treatment after the first two rounds were unsuccessful in completing her miscarriage.
Doctors that Courier DFW spoke to were confused by this regimen, since misoprostol usually needs to be taken vaginally in four pill dosages adding up to 800 mg, said Dr. Bhavik Kumar, a family doctor who provides miscarriage and abortion care in Houston. If that dosage doesn’t complete the miscarriage, another four-pill 800mg dosage can be repeated.
“Hearing that somebody used (only) two pills twice doesn’t make sense to me,” he said. “And there aren’t ‘stronger’ dose pills.”
Using the correct four-pill, 800mg dose is “pretty successful with up to an 84 percent success rate with just the first dose and then the second dose gets them into the 90s,” Dr. Bhavik said.
Dr. Levison concurred that Ryan’s wife may have been “underdosed,” which is why it took so many doses to finally complete the miscarriage.
Dr. Kumar also said that when he treats miscarriage patients using misoprostol, he also provides them with medication for the pain and cramping that accompany the process.
Misoprostol can cause nausea and vomiting in some patients, he explained, so “we give folks nausea medication to premedicate before they start the process.”
Ryan’s wife received no prescriptions for pain or nausea medications.
3. Should Ryan’s Wife Have Been Able to Get a D&C to Complete Her Miscarriage?
Dr. Levison said yes, she should have been able to, stating: “This woman was already bleeding and should have been offered choices.”
Dr. Kumar agreed but added that in Texas, it was already hard for women and doctors to find a medical facility to do a D&C, even before abortion was banned in the state. “It’s a longstanding problem that has become worse.”
He pointed out that all the independent abortion clinics, which also provided miscarriage care, have closed in Texas since the abortion ban was implemented.
This woman was already bleeding and should have been offered choices.
Dr. Levison
“When (doctors) prior to Dobbs were seeing folks in this situation, they would refer them to one of these facilities that provided abortion care and have them manage” their miscarriages. “So now, doctors are seeing these (miscarriage) patients and they don’t have anywhere to refer them to, especially urgently. So we are seeing a lot more folks providing inadequate care or no care at all in the state of Texas.”
4. Did Ryan’s Wife Get Inadequate Miscarriage Care Due to Texas’ Extreme Abortion Ban and its Harsh Penalties for Doctors?
There is no legal reason for a doctor not to remove a dead fetus from a mother’s uterus in Texas, so why did one provider who treated Ryan’s wife refuse to prescribe her more misoprostol? Why did doctors likely underdose her and seem reluctant to offer her a D&C?
Dr. Kumar believes the Texas abortion ban “has colored the fear about stepping over the line.”
“The repercussions if you are charged (with providing an abortion) are huge: a $100,000 fine and 99 years in prison,” he said. “It’s also just created fear to even deal with miscarriage—like helping women complete miscarriages.”
“What’s happened in the post-Dobbs landscape in Texas, when we’ve got intrusive interference from the government and politicians into people’s lives, is there’s a huge amount of stigma and uncertainty on what we can and can’t do,” he added.
Dr. Levison agreed that the climate of fear almost certainly contributed to the poor care Hamilton’s wife received.
“I think some doctors fear that they’re going to be accused of having induced a miscarriage of a living baby, which doesn’t make sense because they had an ultrasound already documenting that there was no heartbeat. But I think the two have gotten somewhat mixed up in the interpretation,” she added.
“The change in the laws has really made for a lack of clarity.”
The risk of a 99-year prison sentence hanging over your head, if somebody’s going to disagree with you, you’re going to think twice.
Dr. Levison
Dr. Levison retired from practice after Roe v. Wade was overturned because she didn’t believe she could practice medicine any longer in a way that was consistent with her ethical obligations as a physician.
She points out that there are huge pressures on Texas doctors struggling to provide reproductive care in Texas.
“The risk of a 99-year prison sentence hanging over your head, if somebody’s going to disagree with you, you’re going to think twice,” she said.
“I mean, where else in medicine, when you make a decision, are you thinking about 99 years in prison? I can’t think about any. That’s a real exception to medical care.”
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