a b s t r a c t

Background: Most obstetric emergencies are initially managed in the emergency department (ED). The supreme court decision of Dobbs v. Jackson Women’s Health Organization, overturning Roe v. Wade, in June 2022, eliminated constitutional protection of abortion rights, allowing states to swiftly enact laws that can greatly change repro- ductive medicine. In this post-Roe landscape, the ambiguity and uncertainty being imposed on clinicians regard- ing the legality of certain interventions may have catastrophic effects. To understand and plan for the changes that will come and attempt to mitigate adverse outcomes, the authors first assessed the current state of pregnancy-related complication care in the ED setting. This study utilized data obtained from the National Hos- pital Ambulatory Medical Care Survey (NHAMCS) to evaluate trends in pregnancy-related ED visits from 2016 to 2020 that could be impacted by restricted abortion access and trigger laws. The authors subsequently analyzed the legislative changes and translated the pertinent ones to dispel misunderstandings and provide a framework for appropriate medical practice.

Methods: The retrospective study utilized data from the NHAMCS database from 2016 to 2020, encompassing an estimated total of 4,556,778 pregnancy-related ED visits. NHAMCS is a multi-stage probabilistic sample collected by the National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention (CDC) using an annual survey of EDs in the United States. All data were summarized using descriptive statistics such as pro- portions and 95% confidence intervals Furthermore, the supreme court decision was analyzed in addition to mul- tiple state laws and legal texts. The findings were summarized and discussed.

Results: The majority (79.4%) of all studied visits were for patients between the ages of 18-34 years, capturing those in peak reproductive years. This age group also comprised of the bulk (76.4%) of visits for pathologic preg- nancies, including ectopic and molar pregnancies, and 79.8% of visits for a Spontaneous miscarriage or threatened miscarriage in early pregnancy. black patients accounted for 25.7%, white patients 70.1%. Regarding ethnicity, pa- tients were separated into Hispanic and non-Hispanic, with Hispanic patients comprising 27% of all ED visits for included diagnoses between 2016 and 2020. Most visits for complications following an induced abortion oc- curred in the south (70.8%) and were nearly twice as likely to occur in non-metropolitan areas. Approximately 18% patients presenting with a pathologic pregnancy required admission to the hospital and approximately 50% of those visits for pathologic pregnancies and visits for bleeding in pregnancy had a procedure in the ED (49.8% and 49.5%). There were 111,264 estimated visits in which methotrexate was administered, amounting to approximately 1 in 7 visits for ectopic or molar pregnancy. In this data set, approximately 14,000 miscarriage and early bleeding patients received misoprostol.

Conclusion: Pregnancy-related ED visits comprise of a significant proportion of emergency care. As it relates to many of the trends previously elucidated on, the true extent of the burden cannot be predicted. It must be em- phasized that contrary to popular belief, Dobbs v. Jackson does not prohibit termination of pregnancy in the set- ting of life-threatening conditions to the mother, including Ectopic pregnancy, preeclampsia, and others, but the resultant uncertainty and ambiguity surrounding the constitutional change is leading to an over-compliance of the law, necessarily obstructing reproductive health care. The authors recommend that physicians be mindful

* Corresponding author at: 8911 NW 19 St., Coral Springs, FL 33071, United States of America.

E-mail address: [email protected] (G. Goodwin).

https://doi.org/10.1016/j.ajem.2023.05.011

0735-6757/(C) 2023

of the rapidly-evolving laws in their particular state, and to also practice in accordance with Emergency medical treatment and Active Labor Act (EMTALA). Patient safety must be prioritized.

(C) 2023

1. Introduction

The emergency department (ED) serves as the initial portal for many medical conditions, with pregnancy-related visits constituting a signifi- cant number of visits. Studies have reported that up to 58% of pregnant women utilize the ED at some point during their pregnancy [1,2]. The acuity of these visits is high when one considers that up to 15% of pregnant patients suffer from a potentially life-threatening condi- tion during their first trimester [3]. Women may seek care for a threatened or actual miscarriage, ectopic pregnancy, or for other pregnancy complications, as well as complications related to medi- cal, surgical, or self-managed abortion. Prior to the recent supreme court decision in Dobbs v. Jackson Women’s Health Organization, overturning Roe v. Wade, many states and municipalities had already passed laws restricting abortion access [4]. Since the Supreme Court decision in June 2022, eliminating constitutional protection of abortion rights, some states enacted additional laws further limiting Access to abortion including the use of medications such as mifepris- tone, methotrexate, and misoprostol. In addition, women or physi- cians may be subject to criminal penalties under these laws [5]. In the post Roe landscape, the ambiguity and uncertainty being im- posed on clinicians regarding the legality of certain interventions, most famously, the misconceptions surrounding ectopic pregnancy management, may have catastrophic effects [6]. Regardless of the evolving legal environment across the U.S, there should be a prioriti- zation of stabilizing life-threatening medical conditions, which is sometimes misconstrued in mainstream media and hospital policies. To understand and plan for the changes that will come and attempt to mitigate adverse outcomes, we first assessed the current state of early pregnancy-related complication care in the ED setting. This retrospec- tive study utilized survey data obtained from the National Hospital Am- bulatory Medical Care Survey (NHAMCS) to evaluate trends in pregnancy-related ED visits in the United States from 2016 to 2020 that could be impacted by restricted abortion access and trigger laws. By initially assessing and establishing the recent landscape of pregnancy-related ED visits, we attempt to provide context which will help inform protocols as emergency physicians begin to navigate

healthcare in the post-Roe era.

1. Methods
   1. Study design

This retrospective study utilized data from the NHAMCS database from 2016 to 2020, encompassing an estimated total of 4,556,778 ED visits. NHAMCS is a multi-stage probabilistic sample collected by the National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention (CDC) using an annual survey of EDs. It is feder- ally funded using trained data abstractors [7].

Utilizing NHAMCS allows one to generate national-level esti- mates of types of ED visits, including patient demographics, reasons for visit, diagnoses, services provided, interventions performed, and patient disposition [7]. Particularly relevant factors such as insur- ance and payor status were also analyzed as well as hospital-level in- formation, such as geographic region and teaching/community status. NHAMCS is a de-identified, publicly available data source,

precluding the need institutional board review, as it is not consid- ered human subjects research.

• 1. Study objective

Our primary objective was to describe pregnancy-related ED visit in the United States that may be impacted by abortion restrictions and trigger laws.

• 1. Data abstraction

We identified possible ICD-10 diagnoses codes related to pregnancy complications and pertinent ED visits that may be impacted by abortion restrictions and trigger laws (O00-O20). We then grouped them into the following categories: pathologic pregnancies, comprising of abnor- mal pregnancies, including ectopic and molar pregnancies; pregnancies complicated by bleeding, comprising of threatened miscarriage, sponta- neous miscarriage, and maternal hemorrhage; and abortion complica- tions, comprising of complications following an induced or failed abortion. See Appendix 1 for respective breakdowns of group ICD-10 codes. We used the above specified Diagnosis codes from each group to select included visits for each year using the NHAMCS “DIAG” vari- able. To describe the characteristics of these eligible visits, we also ab- stracted demographic data (such as race, age, ethnicity, insurance status, region of hospital location, and hospital teaching status) and data that described the patient visits (e.g. patient admission status and location, whether a consult was obtained, imaging, procedures, and if the visit was an initial episode of care or a follow up) for all visits. Utili- zation of methotrexate and misoprostol were also captured. There were not enough encounters where mifepristone was administered in the ED to make any reliable estimates. The patient weight variable for all eligi- ble visits to estimate the number of visits for each group between 2016 and 2020 was abstracted. Our population of interest and eligibility criteria included females under 50 years of age, as this age bracket cap- tures most patients of reproductive age. Ages were stratified in

<18 years-old, 18-34, and 35-50, to address certain conditions being more prevalent in “high risk” age groups and legal abortion restrictions being more common in minors under the age of 18.

• 1. Outcomes

The primary outcome of our study was the incidence of visits per group between 2016 and 2020. Secondarily, we described the outcomes and characteristics of these visits including patient demographics, geo- graphical data, patient payment and insurance status, hospital and resource- utilization, and pharmacological interventions utilized in those visits.

• 1. Data compilation and analysis

To obtain our primary outcome, we tabulated all eligible visits (using patient weights for each visit) per group for all years in our defined timeframe. We used the visit weights to determine the prevalence of each secondary outcome for each group. All data were summarized using descriptive statistics such as proportions and 95% confidence in- tervals. All analyses were performed using IBM SPSS version 28.

1. Results

0, [0,0.01]

1, [0.99,1]

0, [0,0.01]

7.7, [7.4,8]

70.8, [70.3,71.3]

21.5, [21.1,22]

0, [0,0.01]

84.2, [83.8,84.6]

15.8, [15.4,16.2]

0, [0,0.01]

0, [0,0.01]

1, [0.99,1]

37.3, [36.8,37.9]

62.7, [62.2,63.2]

29.2, [28.7,29.7]

70.8, [70.3,71.3]

21.5, [21.1,22]

0, [0,0.01]

8.1, [7.8,8.4]

62.7, [62.2,63.2]

0, [0,0.01]

• 1. Total number of patients

Our study included an estimated total of 4,556,778 pregnancy- related ED visits during 2016-2020.

%, CI

• 1. Patient demographics data

Abortion complications (n = 33,114)

0

33,114

0

2548

23,439

7127

0

27,882

5233

0

0

33,114

The majority (79.4%) of all studied visits were for patients between the ages of 18-34 years, capturing those in peak reproductive years. This age group also comprised of the bulk (76.4%) of visits for pathologic pregnancies, including ectopic and molar pregnancies, and 79.8% of visits for a spontaneous miscarriage or threatened miscarriage in early pregnancy. Similarly, all (100%) visits for complications following an in- duced abortion or a failed abortion were also in this age group. It is worth noting that the other age groups may have had patients in the abortion complication group but the occurrence was too small to be captured, resulting in the 100% occurrence in the 18-34 age bracket. Black patients accounted for 25.7%, white patients 70.1%. Regarding eth- nicity, patients were separated into Hispanic and non-Hispanic, with Hispanic patients comprising 27% of all ED visits for included diagnoses between 2016 and 2020. (Table 1).

%, CI

3.53, [3.51,3.56]

79.8, [79.7,79.81]

16.7, [16.66,16.74]

13.9, [13.82, 13.88]

19.9, [19.88,20.0]

43.3, [43.25,43.35]

3.71, [3.69,3.73]

69.5, [69.45,69.6]

26.5, [26.46,26.54]

4, [3.9,4.02]

27.1, [27.09,27.2]

73.4, [73.37,73.5]

88.67, [88.6, 88.7]

11.33, [11.3, 11.4]

24.5, [24.49,24.6]

64.74, [64.7,64.8]

26.9, [26.89,27.0]

1.32, [1.31,1.33]

50.06, [50.01,50.11]

9.59, [9.56,9.62]

2.84, [2.82, 2.86]

12,360

20,755

9675

23,439

7127

0

2685

20,755

0

• 1. Geographical data

Miscarriage and early bleeding (n = 3,949,129)

139,537

3,150,040

659,553

546,855

786,550

1,709,830

905,894

2,744,689

1,046,371

158,070

1,071,363

2,899,015

Most visits for pathologic pregnancies and visits for bleeding in preg- nancy occurred in the west (37.6% and 43.3%), and in metropolitan areas (92.4% and 88.7%). However, the majority of visits for complica- tions following an induced abortion occurred in the south (70.8%) and were nearly twice as likely to occur in non-metropolitan areas.

3,501,547

447,583

968,578

2,556,734

1,063,491

52,256

1,977,127

378,593

112,244

• 1. Patient payment data

Table 1

Demographics of patients presenting to the ED with first trimester pregnancy complications (2016-2020, n = 4,556,778).

For visits involving pathologic pregnancies and visits for bleeding in pregnancy, the majority of patients had either Medicaid (46.9% and 50.1%) or private insurance (21.5% and 26.9%), but for those for compli- cations following an abortion, few patients had Medicaid (8.1%) and the majority were self-pay or had private insurance (62.3% and 21.5%). (Table 1)

%, CI

0, [0,0]

76.4, [76.2,76.5]

23.7, [23.6,23.8]

23.1, [23.0,23.3]

13.9, [13.8,14.0]

37.6, [37.4,37.7]

25.5, [25.4,25.6]

74.3, [74.2,74.4]

21.0, [20.9,21.1]

4.8, [4.77,4.9]

29.0, [28.8,29.1]

71.1, [70.9,71.2]

92.4, [92.3,92.5]

7.6, [7.55,7.7]

33.0, [32.9, 33.3]

57.6, [57.5578]

21.5, [21.4,21.6]

5.1, [5.06,5.2]

46.0, [45.8,46.1]

11.3, [11.26,11.4]

3, [2.98,3.1]

• 1. Hospital and resource-utilization data

Pathologic pregnancy (n = 574,534)

0

438,628

135,907

132,539

79,646

215,822

146,527

426,067

120,689

27,778

166,338

408,196

Approximately 18% patients presenting with a pathologic pregnancy required admission to the hospital, whereas almost all patients with spontaneous miscarriage or bleeding in pregnancy (97.4%) were discharged from the ED. Approximately 50% of visits for pathologic pregnancies and visits for bleeding in pregnancy had a procedure in the ED (49.8% and 49.5%), whereas visits for complications from in- duced abortions were 57% less likely to have a procedure in the ED (21.5%). However, visits for complications from induced abortions had a consultant called from the ED in 91.9% of visits. Imaging in the ED was utilized in the majority of visits for pathologic pregnancy, and for bleeding in pregnancy (56% and 71.8% respectively), and > 95% of the imaging modality consisted of Ultrasound imaging. Furthermore, 8-9% of visits for pathologic pregnancy, and visits for bleeding in pregnancy were repeat visits to the ED. Four to six% of those were repeat visits within the last 72 h (Table 2).

<18

18-34

35-50

Northeast South West Midwest White Black Other Hispanic

Non-Hispanic

hospital characteristics Metropolitan Status of Hospital

Metro. Non-Metro Teaching

Non-Teaching Private Insurance Medicare Medicaid/CHIP Self-Pay

Other

530,759

43,776

189,662

331,121

123,427

29,388

264,081

65,160

17,330

Teaching Status of Hospital

• 1. Pharmacological intervention data

Patient Insurance

From 2016 to 2020, there were 111,264 estimated visits in which methotrexate was administered. While this represents an overall small number in the data set, it amounts to methotrexate ad- ministration in approximately 1 in 7 visits for ectopic or molar preg- nancy. In this data set, approximately 14,000 patients received

Age

Region

Race

Ethnicity

misoprostol, all of which were given in the miscarriage and early bleeding group.

21.5, [21.1,22]

78.5, [78.0,78.9]

0, [0,0.01]

0, [0,0.01]

0, [0,0.01]

21.5, [21.1,22.0]

21.5, [21.1,22.0]

78.5, [78.0,78.9]

91.9, [91.6,92.2]

8.1, [7.8,8.4]

37.3, [36.8,37.9]

0, [0,0.01]

62.7, [62.2,63.2]

0, [0,0.01]

1, [0.99,1]

0, [0,0.01]

1, [0.99,1]

0, [0,0.01]

1, [0.99,1]

1, [0.99,1]

0, [0,0.01]

0, [0,0.01]

1. Discussion

CI

Dobbs V. Jackson overturned the previous law of the land that regarded abortion as a constitutional right, making it a state-by-state issue, specifically allowing each state to enact its own laws and practices surrounding abortion [8]. The pragmatic ramifications of this are the “opening of flood gates” in allowing states to swiftly begin limiting ac- cess to abortion. Our data demonstrate that the highest rates of ED visits for failed terminations and complications following induced termina- tion take place in southern states. Prior to Dobbs v Jackson, many south- ern states had already enacted laws severely limiting abortion access, leading women to find alternative and often unsafe termination methods [9,10]. Access to family planning clinics that provide abortion has already been found in prior studies to be limited in rural areas, pos- sibly accounting for the increased rates of complications from termina- tions or failed attempts at terminations in these areas [9,11]. The bulk of the new restrictions are taking place in southern states, which may lead to a further exacerbation of discrepancies in care across the country, likely increasing rates of complications from attempted or incomplete abortions, given the lack of medically supervised termination care.

Miscarriage and First trimester bleeding

104,608

3,844,522

4854

43,127

21,428

78,325

1,973,113

1,857,503

684,373

3,264,756

2,833,606

55,198

1,060,325

27,454

3,921,675

14,671

3,949,129

175,163

3,493,980

3,466,368

315,820

166,942

%, CI

Abortion complications

7127

25,987

0

0

0

7127

7127

25,987

30,430

2685

12,360

0

20,755

0

33,114

0

33,114

0

33,114

33,114

0

0

2.65, [2.63, 2.67]

97.35, [97.33, 97.37]

0.12, [0.12,0.12]

1.09, [1.08,1.1]

0.54, [0.53,0.55]

1.98, [1.97,1.99]

49.46, [49.91,50.01]

47.04, [46.99,47.09]

17.3, [17.29,17.37]

82.7, [82.6,82.71]

71.75, [71.71,71.79]

1.4, [1.39,1.41]

26.85, [26.81,26.89]

0.7, [0.69,0.71]

99.3, [99.29,99.31

0.3 [0.29,0.31]

99.7 [99.69,99.71]

4.44, [4.42,4.46]

88.47, [88.44,88.5]

87.78, [87.75,87.81]

8, [7.97,8.03]

4.23, [4.21,4.25]

Ectopic and molar pregnancies are life threatening pregnancy com- plications, which if left untreated, inevitably lead to complications such as pre-eclampsia, hemorrhage, sepsis, future fertility impairment, and death [12,13]. The American College of Gynecology (ACOG) sup- ports that the only treatment options for ectopic pregnancy and gesta- tional trophoblastic disease is surgical or medical termination of pregnancy [14,15]. Almost half of the patients with a pathologic preg- nancy in this study were treated with a procedure. Despite the abortion ban or severe limitations in several states, states have continued to allow for the termination of a pregnancy in the setting of life- threatening conditions to the mother, explicitly including ectopic pregnancy, molar pregnancy, premature rupture of membranes, pre- eclampsia, and other conditions [3]. However, there remains ambiguity surrounding pregnancy terminations after the recent legislative change. While state legislature assures that abortion care will be provided in life threatening conditions, it inevitably creates confusion among physicians as to what constitutes a “life threatening condition.” What do clinicians do in a pathological pregnancy in which the fetus has car- diac activity but still has no chance of survival (inevitable abortion, some ectopic pregnancies, etc.)? Further complicating matters, the actual definition of pregnancy is also highly variable among states. Does pregnancy start at the moment of conception or after a certain amount of gestational weeks? Any failure to address ectopic pregnan- cies or other pregnancy-related life-threatening conditions in the ED is a breach of the Emergency Medical Treatment and Active Labor Act (EMTALA) [3]. The Centers for Medicare and Medicaid Services issued a memorandum in July 2022 specifically stating that if a pregnant patient were to present to an ED with an emergency medical condition and that abortion is the stabilizing treatment necessary, and if the state law does not include an exception for life threatening conditions, then EMTALA supersedes state law [3].

Table 2

Resource utilization of patients presenting to the ED with first trimester complications.

Pathologic Pregnancy

104,599

469,934

9770

18,746

76,264

18,565

286,304

287,327

134,402

440,132

321,436

15,914

237,185

83,810

490,724

0

574,534

36,755

540,797

515,941

53,476

5117

%, CI

Yes No

Critical Care Floor/Obs OR

Other bed/units Yes

No Yes No Yes

-

-

-

-

-

-

-

-

-

-

US

Other

-

-

-

18.2, [18.1,18.3]

81.8, [81.7, 81.9]

1.7, [1.67,1.73]

0.84, [0.82,0.86]

13.3, [13.2,13.4]

3.2, [3.18,3.28]

49.8, [49.7,50.0]

50.0, [49.9,50.1]

23.4, [23.3,23.5]

76.6, [76.5,76.7]

56.0, [55.8,56.1]

2.8, [2.7,2.81]

41.3, [41.2,41.4]

14.6, [14.5,14.7]

85.4, [85.3,85.5]

0 [0,0]

1 [1,1]

6.4, [6.3,6.5]

94.1, [94.07,94.2]

89.8, [89.7, 90.0]

9.3, [9.2,9.4]

0.89, [0.87,0.91]

No Yes No Yes No Yes No Yes No

Unknown

Misoprostol given in the ED and/or Prescribed at DC

Due to the highly litigious nature of emergency medicine and obstetrics-gynecology (OBGYN), medical establishments are enacting policies, protocols, and legal review boards to ensure compliance with the new laws when providing pregnancy terminations, which could lead to delays in care. An additional complication arises surrounding the reporting of these issues. Many states mandate reporting of all abor- tions but one must consider whether ectopic pregnancies and miscar- riages are considered as abortions in their respective state [16]. In response to these complications, some hospitals, such as Indiana University (IU), are establishing rapid response teams composed of an OBGYN, lawyer, and ethics committee member. While a large resource-rich institution such as IU can take these steps to address the

Patient Admitted

Location of Admission

Procedure

Consultant from the ED

Imaging in the ED

Methotrexate given in ED

Patient seen in ED in prior 72 h

Initial episode of care in the ED

confusion, this leaves the majority of smaller institutions and physicians to wade through the obscurity on their own.

We also found that there were racial and ethnic differences in rates of visits to the ED for pregnancy complications. Black women make up approximately 7% of the population but nearly 16% of failed termina- tions and termination-related complications in our study set [17]. Black women also disproportionately were seen in the ED for ectopic and molar pregnancies (21%) and hemorrhage or miscarriage (21%). Furthermore, 27% of the patients presenting for early pregnancy compli- cations to the ED self-identified as Hispanic, while only comprising

<10% of the US population [17]. Prior to Dobbs v Jackson, the laws in

certain states that already limited abortion access, forced the closure of numerous clinics [9,18]. Adding to the gravity of the closures is the fact that many of these clinics provide care that extends well-beyond that of abortions [19]. It has already been shown that when outpatient care sources are limited, ED-utilization rates increase [20]. Furthermore, when prenatal care is limited, rates of complications in early pregnancy increase [21]. Based on prior research, patients of low socioeconomic status have suffered inadequate access to early pregnancy care, leading to more complications in early pregnancy [22]. By further restricting abortions, complications will inevitably rise with patients seeking alter- native avenues. It is essentially exacerbating a pre-existing problem. It is well-established that limiting access to federally-funded family plan- ning clinics lead to increased rates of pregnancy complications, as well as complications from unsafe abortion methods [9,11]. These clinics often provide care well beyond abortions, making them a crucial part of primary care medicine [20]. In light of the new legislative changes, several concerns have arisen relating to discrepancy in OBGYN training in more restrictive states. Essentially, more restrictive states may be viewed as being less desirable training sites for OBGYN residents, lead- ing to discouragement and geographical discrepancies [20]. There are circumstances in which abortive interventions can be life-saving and the fear is that residents will not receive adequate training in that regard [10]. This concern is adding to the already-anticipated shortage of OBGYNs prior to the Dobbs decision [23,24]. Essentially, there will be an increase in reliance on OBGYN consultations from the ED and a si- multaneous decrease in those OBGYNs. This inevitably leads to even longer transfers, increased cost of care, and worse patient outcomes.

Methotrexate has long been established as the standard of care for

pharmacological treatment of ectopic pregnancies and its prompt ad- ministration has been shown to decrease complications [25]. The data demonstrate that 14% of ectopic pregnancies resulted in the administra- tion of methotrexate, amounting to nearly 84,000 patients a year. Meth- otrexate has definitively been shown to have much less complications and deleterious effects than ectopic surgical interventions such as sal- pingectomy and/or laparoscopy [25]. Similarly, misoprostol for the treatment of missed or incomplete miscarriage, has lower complication rates than surgical intervention and better outcomes than Expectant management [26,27]. The indications for misoprostol use in the ED from our data set include abnormal products of conception, spontane- ous abortions (including missed and incomplete), induced abortions, and failed attempted termination. It is worth noting that misoprostol’s wide-ranging indications and utility changes depending on trimester and stage of reproduction. The focus of its use from our data set was in the context of first trimester ED visits. The equivocation surrounding methotrexate and misoprostol could have devastating effects when one considers the number of patients receiving the medications. While Dobbs v. Jackson does not explicitly prohibit ectopic pregnancy abortive treatment, the drastic legal ramifications and uncertainty are compel- ling many hospitals to enact protocols that impose extra steps in obtaining methotrexate, possibly leading to delays in care. Several stud- ies have demonstrated how litigious environments can lead to increases in defensive medicine practices, which often have detrimental ramifica- tions on patient care and society [28-30]. The litigious battles are al- ready coming to fruition in the case of mifepristone, where in Texas, attempts are being made to suspend the FDA’s approval of the drug [31].

1. Limitations

Several notable limitations existed in this study. The data comprising the survey was self-reported, carrying implicit limitations such as sam- pling bias, response bias, and interpretation of questions [32]. One lim- itation of utilizing the NHAMCS dataset is that due to sampling error, it may not accurately capture values of rare characteristics. For example, in our study, we found that diagnoses of complications from abortions were uncommon and as a result the data may not be representative.

Furthermore, we only analyzed visits during years 2016-2020 since these were the only years where NHAMCS coded visits using ICD-10 codes, which enabled us to do an accurate analysis capturing specific di- agnosis codes. Additionally, it should be noted that since the numbers provided by the database are estimates and are sometimes missing, not coded, and/or not coded properly, they may not accurately add up or represent the population.

1. Conclusion

By examining and publishing the current trends in pregnancy- related ED visits, the authors hope to help initiate preemptive action to help mitigate the possible poor outcomes related to Dobbs v. Jackson. Dobbs V. Jackson allows states to rapidly and radically change their laws regarding abortion without considering the consequential burden placed on the medical field. The true extent of the burden cannot be pre- dicted, due to the deeply ingrained intersectionality that exists between so many aspects of society, our government, and medicine. It must be emphasized that contrary to popular belief, Dobbs v. Jackson does not prohibit termination of pregnancy in the setting of life-threatening con- ditions to the mother, including ectopic pregnancy, preeclampsia, and others, but the resultant uncertainty and ambiguity surrounding the constitutional change is leading to an over-compliance of the law, nec- essarily obstructing reproductive health care. The authors recommend that physicians be mindful of the rapidly-evolving laws in their particu- lar state, and to also practice in accordance with EMTALA, and a priori- tization of patient safety.

Funding

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

There were no sources of support for this paper. No grant was needed or obtained. The authors all also report no conflicts of interest.

CRediT authorship contribution statement Glenn Goodwin: Writing - review & editing, Writing - original draft,

Validation, Project administration, Methodology, Investigation, Formal

analysis, Data curation, Conceptualization. Erin Marra: Writing - review & editing, Formal analysis, Data curation, Conceptualization. Christine Ramdin: Validation, Methodology, Formal analysis, Data curation. Andreia B. Alexander: Writing - review & editing, Methodology, Formal analysis, Conceptualization. Peggy P. Ye: Writing - review & editing, Investigation, Formal analysis. Lewis S. Nelson: Writing - review & editing, Supervision. Maryann Mazer-Amirshahi: Writing - review & editing, Validation, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

Declaration of Competing Interest

None.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2023.05.011.

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