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Consequences of ‘medical exceptions’ in restrictive abortion legislation: caesarean scar ectopic pregnancy and beyond
  1. Natalie DiCenzo,
  2. Adam Elwood,
  3. Ruby Lin,
  4. Lily Bayat,
  5. Todd Rosen
    1. Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
    1. Correspondence to Dr Natalie DiCenzo, Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA; nataliedicenzo{at}

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    After the 2022 Supreme Court decision Dobbs v. Jackson Women’s Health Organization to revoke federal abortion rights, many restrictive state abortion laws took effect.1 2 Most legislation limits abortion under almost all circumstances, with exceptions for ‘life-threatening emergency’ –an ill-defined term. Pregnancy even without comorbidities can be life-threatening, particularly in the United States (US) where pregnancy-related morbidity and mortality are disproportionately high.3 Restrictive abortion legislation creates a system where physicians are expected to make clinical decisions based on legal interpretation rather than standard of care, subjecting patients to treatment delay or denial.

    To better comprehend the scope of this legislation from the perspective of those interpreting and acting on it, we – a group of obstetrician-gynaecologists – evaluated language used to define legislative ‘medical exceptions’. We focused on applying exceptions to treating the condition of caesarean scar ectopic pregnancy (CSEP). CSEPs occur when an embryo implants within a caesarean hysterotomy site, making progression to a viable gestational age high risk for placenta accreta, hysterectomy and haemorrhage.4 Due to this morbidity, the Society for Maternal–Fetal Medicine (SMFM) recommends CSEP termination, which could be criminalised depending on state law.5

    Legislation review

    We evaluated 22 state abortion bans (table 1) identified via the Guttmacher Institute in January 2023.1 Legislative texts were obtained from state government websites and read to examine requirements for medical exceptions. Legal terminology was clarified with an attorney.

    View this table:
    Table 1

    Proposed state abortion bans as of January 2023. *Updates as of June …

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    • LB and TR are joint senior authors.

    • Contributors Each of the authors participated in the drafting, editing, and approval of the final manuscript. None of the authors has a financial or other conflict of interest. NDC is the guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.