In the Wake of Dobbs v. Jackson Women’s Health Organization

Intent Matters

Drugs used to treat inflammatory conditions, including methotrexate, mycophenolate and cyclophosphamide, have effects that can call into question whether they are problematic for use in rheumatologic care under laws that prohibit abortion. Harm to the fetus is one potential effect, and the ability to induce abortion another.

Agents that can harm the fetus are referred to as fetotoxic or teratogenic, with the former referring to a substance that can cause degenerative effects in the developing fetus or embryo, and the latter referring to any agent that causes an abnormality after fetal exposure during pregnancy. Agents that can induce an abortion are referred to as abortifacient.

The standard of care for the most common rheumatic conditions includes medications that can harm the fetus and lead to miscarriage, or if the fetus is carried to term, can result in congenital anomalies.⁴ For patients receiving these medications while pregnant, elective termination of the fetus is sometimes chosen when signs of fetal malformation are found.

In the wake of Dobbs v. Jackson Women’s Health Organization, the choice to terminate a fetus in this situation may be limited and counseling patients on the risks they face should they want to terminate a pregnancy due to fetal abnormalities becomes all the more important.

“The patient has to be aware what could occur,” says Rosalind Ramsey-Goldman, MD, professor of medicine, the Feinberg School of Medicine at Northwestern University, Chicago. “If there is an abortion ban [in their state], they will have to grapple with the possibility of having a child with a congenital anomaly or seek an abortion out of state or [by another] avenue.”

Dr. Ramsey-Goldman

Numerous patients have reported difficulty obtaining methotrexate and other drugs used to treat rheumatic conditions since the Supreme Court ruling. An analysis by Starzyk et al. in Arthritis & Rheumatology, and discussed in an article in Bloomberg Law, describes the broad impact of the new ruling on the high percentage of patients with autoimmune conditions who require treatment with methotrexate.^5,6 In high doses, methotrexate can induce abortion, and it can harm the fetus. But in lower doses, as used in rheumatologic practice, it does not induce abortion.

“Rheumatologists do not prescribe methotrexate to patients to induce abortions; we use methotrexate at much lower doses to treat inflammatory conditions,” says Mehret Birru Talabi, MD, PhD, assistant professor of medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine.