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Neurologists who see patients with neurologic conditions who are pregnant, or who are considering pregnancy, said the Supreme Court decision to reverse Roe v. Wade, the right to an abortion, interferes with their ability to provide informed decisions about health care for their patients.

Neurologists who care for patients who are pregnant, or who are planning pregnancies, are facing new discussions about clinical care in the wake of the Supreme Court's June 24 Dobbs v. Jackson Women's Health Organization decision to reverse the historic Roe V. Wade 50-year precedent to legalize abortion.

Neurologists have a critical window into how the reversal of Roe will impact patients with neurologic disease. Neurologic health is inextricably linked with reproductive health, said Sara LaHue, MD, a neurohospitalist and assistant professor of clinical neurology at the University of California, San Francisco.

...Bans on abortion will immediately affect the delivery of current standard neurologic care for many patients, specifically standards that depend on planning or preventing pregnancies using individual choice, Dr. LaHue and colleagues wrote in a viewpoint on the impact of the Dobbs decision on neurology in the July 13 issue of JAMA Neurology article.

I dare say that there are very few specialties within neurology that don't have some connection to how reproductive health influences the health of our patients, said Diana Cejas, MD, MPH, a child neurologist who specializes in autism spectrum disorders, intellectual disabilities, and neurodevelopmental disabilities.

As a pediatric neurologist, I talk about these issues with my patients all the time: the risks of certain medications to a developing fetus, the need to be on birth control, what it would mean for them if they got pregnant. There are all kinds of implications for reproductive health that we are involved with as neurologists. We have patients with significant illnesses and chronic disability within neurology, for whom pregnancy could be devastating if not life-threatening. This decision is absolutely going to affect our patients' health and the way we practice.

Many neurologic conditions that commonly affect women in their reproductive years, including epilepsy, migraine, multiple sclerosis, myasthenia gravis, and brain tumors, are often managed with medications that are known to be teratogenic, with many more lacking clear evidence about their teratogenicity.

As an epileptologist, I see many patients who are on antiseizure medications known to be teratogenic, such as valproic acid, said Ima Ebong, MD, an assistant professor of neurology at the University of Kentucky.

We have conversations about reproductive health and what the consequences of these medications can be, weighing the pros and cons of treating your epilepsy and the protections you need to put in place for yourself and potentially a pregnancy, including barrier contraception, hormonal contraception, and having the ability to abort a pregnancy if necessary. Not every patient wants to use contraception, even though we recommend it; none of the methods are 100 percent effective, and many antiseizure medications lower the efficacy of contraceptives, so it is unavoidable that some people will become pregnant while on these medications. With the reversal of Roe, in some states women no longer have the ability to make these decisions for themselves, and I think it's inevitable that we will see increases in serious birth defects as a result.

Similarly, both the National Multiple Sclerosis Society and the Food and Drug Administration recommend discontinuing the use of most disease-modifying therapies (DMTs) for multiple sclerosis while trying to conceive, during pregnancy, or breastfeeding.

Glatiramer acetate and interferon beta are thought to be the safest of the DMTs, so if a woman wants to get pregnant with active disease, in rare situations a neurologist might leave a woman on one of those therapies, but they are modestly effective compared to the highly effective newer agents, said Amy Hessler, DO, FAAN, who recently left her position as director of women's neurology at the University of Kentucky to establish a women's neurology clinic in Jacksonville, FL.

Teriflunomide is the worst oneif accidental pregnancy occurs while on this agent, the medication is immediately stopped and a rapid elimination procedure is required urgently, as well as counseling [for] the mother about the increased risk of teratogenicity. Dimethyl fumarate should be stopped at the same time the woman stops contraception, due to uncertain but potential risks. Fingolimod is also associated with increased risk of adverse fetal outcomes. There are pregnancy registries associated with all these medications to make the best treatment decisions. Also, there is risk to the woman of rebound relapse if she is rapidly taken off her MS medication, particularly with fingolimod and natalizumab. It can be hard to get it back under control and it can even be life-threatening.

If one of our patients were to become pregnant while on any of these medications that can cause severe teratogenic effects, there are currently no options for them in Texas, said Audrey Nath, MD, PhD, a pediatric epileptologist and clinical assistant professor of neurology at the University of Texas Medical Branch in Galveston.

Concerns about legal restrictions or even prosecution for the use of these medications in a patient's reproductive years could potentially lead neurologists to be restrictive in their prescribing of appropriate therapies, Dr. LaHue and coauthors suggested in the JAMA Neurology article.

In a climate of increased limitations on reproductive rights, whereby pregnancies cannot be reliably timed or prevented, neurologists might possibly restrict use of the effective medications that are standard care for other patient groups because of potential concerns about causing fetal harm, they wrote. This could increase risk of morbidity, mortality, and irreversible disability accumulation for women with neurologic diseases.

Attempts to restrict the use of such medications even when prescribed by a physician have already been reported in states that have banned abortion. Methotrexate, a folate antagonist that can cause miscarriage at high doses and is the preferred treatment for ectopic pregnancy, is also one of the most used drugs for the treatment of inflammatory conditions such as rheumatoid arthritis, lupus, psoriasis and psoriatic arthritis, and Crohn's disease. It is sometimes used off label for the treatment of multiple sclerosis and as a less expensive, steroid-sparing agent for the treatment of myasthenia gravis.

But the cases that keep Dr. Nath up at night are those pertaining to children and teenage girls she has cared for with intellectual disabilities caused by neurodevelopmental conditions. These conditions may be due to a genetic disorder that affects brain development, brain injury earlier in life, or childhood seizure disorders that can affect cognition, she said.

It's well known that young women with intellectual disabilities are at higher risk for unplanned and unwanted pregnancy, Dr. Nath said. They are more likely to be targeted for sexual assault, they may be easier to manipulate because of their intellectual disability and find themselves in situations that they can't handle, and they are at high risk for becoming pregnant because they may not take birth control reliably or even be aware of their menstrual cycles.

They may not even realize they are pregnant, she added. The entire pregnancy and delivery process can be very traumatic for someone with an intellectual disability who may be functioning at a level much below their actual age, and young girls like this are a very high-risk population for pregnancy and delivery.

Women with a family history of neurogenetic disorders, ranging from neurofibromatosis to Fabry disease, Canavan disease, and Tay-Sachs disease are likely to be denied the option to make decisions about their pregnancy depending on the state they live in, said Janet F. Waters, MD, FAAN, clinical associate professor of neurology and division chief for women's neurology at the University of Pittsburgh Medical Center. Previously, these women could undergo testing during pregnancy and make a choice as to whether to continue if the child would be born with these significant and sometimes fatal neurologic diseases, but now they will not have the option.

Sonika Agarwal, MBBS, MD, previously practiced maternal fetal medicine in India and now specializes in fetal and neonatal neurology at the Children's Hospital of Philadelphia of the University of Pennsylvania.

Our role as pediatric neurologists should extend to women's health care before, during, and between pregnancies to maximize both the woman's health and the neonatal outcome which impacts pediatric health, Dr. Agarwal said. This ruling takes away both the patient's autonomy and the primacy of the physician-patient relationship. The only way we can render safe, effective, and evidence-based care in what are often profoundly challenging situations is to come together as a team of medical experts, critically evaluate all testinggenetics, imaging scans for the fetal brain and other systemsand any complications in the pregnant woman's health and go through the complex process of counseling a pregnant woman/couple about the likely prognosis and outcomes.

For example, she continued, in cases of anencephaly, we know the baby is not going to survive. There are other neurologic conditions where the baby may survive but would face significant challenges around birth and need lifelong support due to a severe and complex brain malformation or extensive brain destruction by stroke or brain bleed; we can reasonably say they will have a profoundly impaired neurological function or quality of life, or a reduced lifespan where they will live only for a few years sustaining on life support with feeding and breathing tubes. In these challenging fetal neurologic consultations, the clinicians and the parents together weigh all the information about the quality of life and possible outcomes for the unborn baby and the medical team supports them in the decision-making process. This critical relationship between patient and medical professionals is not something that should be intruded on by legislators.

Abortion bans also limit clinicians' options for managing women who develop life-threatening problems during pregnancy, said Mary Angela O'Neal, MD, FAAN, division chief of general neurology at Brigham and Women's Hospital in Boston and an expert in the neurology of pregnancy.

I've had patients diagnosed with brain cancer in pregnancy, and the treatment for mom is not something that's going to be good for the babysurgery, radiation, chemotherapy or all three. This is a very difficult choice for families to make, but it should be theirs. Or when a woman develops pre-eclampsia, that can cause stroke, hemorrhage, and death, and the only treatment is delivery. Will induction of labor in circumstances like these, such as in the late second trimester when the baby is unlikely to survive, be allowed under some of these state laws?

No one seems to know for sure, as many of these laws are vague and choices about enforcement are left up to local and state officials. In Ohio, for example, state law says that abortion is permitted only in a medical emergency requiring the immediate performance or inducement of an abortion to prevent death or irreversible bodily harm that delay in the performance or inducement of the abortion would create.

With such vague, open-to-interpretation language, how do clinicians decide just how immediate the medical emergency is? If states write laws that are completely vague about what the requirements are, they can still have abortion on the books, but have an environment in which no physician is willing to provide it, Melissa Murray, a law professor at New York University, told opinion writer Michelle Goldberg in a July 14 article in the New York Times.

Dr. Waters is haunted by the case of a woman who was brought to Magee-Womens Hospital at about 21 weeks of pregnancy in flagrant eclampsia like no case I have seen before. She had hidden her pregnancy from a strict family and sought no prenatal care; her pregnancy was diagnosed only after she came to the hospital with seizures and was given a routine pregnancy test prior to undergoing a head CT.

By the time she reached us, this woman was blind, she had so much brain edema that she was essentially comatose. We had to save the mom and save her fast, said Dr. Waters. We had to go through basically a delivery at 21 weeks, which would be considered an abortion under many of these laws. The baby was already gone, but what if it had still been alive? In a state with an abortion ban, what choice do you make? In any decision about delivery, the woman has to come first.

Although abortion remains legal and likely to be protected in 19 states, women in large swaths of the country will have to travel long distances to access an abortion, which poses a significant problem of equity.

Here in Kentucky, our trigger ban was enjoined by a court, but if it goes into place, leaving the state is not realistic for the average person, said Dr. Ebong. Kentucky is a very poor state, and the nearest states are West Virginia, Tennessee, and Ohio, which are in the same boat as Kentucky when it comes to their laws. Women can't just get a plane ticket to go further for an abortion, that's not a realistic option and it shouldn't have to be. You should have access close to where you are.

Individuals who have more resources are going to have more choices, agreed Dr. O'Neal. This will affect lower-income people more devastatingly because they're not going to have the financial and other resources to be able to make those choices. We know that people from marginalized communities have less opportunity to have neurologic care to plan and optimize their medications, so they are at even more risk. Their choices are being taken away from them as we speak, and I can't see this as doing anything but magnifying the already existing inequities.

These laws are directly in conflict with our code of ethics as neurologists and as physicians, which is to put our patient's best interest first, said Dr. Cejas. We won't be able to provide appropriate care. Regardless of what a person thinks about abortion from an ideological perspective, abortion is health care, and it is a medical procedure, and we have to offer our patients multiple options with respect to their care. But as more of these restrictions come into place, we'll see more and more neurologists put into positions where taking the best care of our patients from a medical and ethical perspective is in conflict with what we are allowed to do from a legal perspective. When I talk to colleagues in states with these bans already in place, they don't know what to do and what to tell their patients. And what will our hospitals do to protect us and our right to provide optimal care?

The AAN, Association of American Medical Colleges, the American Medical Association, the American Academy of Pediatrics, the American Psychiatric Association, the American Epilepsy Society, as well as the Child Neurology Foundation and Child Neurology Society, have all published statements in response to the Supreme Court decision, focusing on the primacy of the relationship between physicians and their patients in making health care decisions.

Dr. Nath urges neurologists to make their voices heard by becoming more involved in advocacy. When we have our voices heard in the rooms where they are writing legislation, that can have a very big impact, particularly within state legislatures, she said. This is one among many issues that shows us that we need to have a seat at the table. It's a wakeup call for us. It matters who's in these legislatures, and your professional and life experience matters.

In this issue, we cover the impact of the recent Supreme Court decision overturning Roe vs. Wade on the field of neurology. The editors of Neurology Today believe that abortion is health care, and health care decisions should be made between patients and their physicians. We fear for the impact on the health of women with neurologic disorders, who may find themselves in life-threatening situations due to this decision. We will continue to cover the impact of the Supreme Court decision on our patients and our practice.

More here:
Neurologists Discuss the Impact of Roe v. Wade Reversal on... : Neurology Today - LWW Journals

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