Planned Parenthood provides explanations for four failed abortions cited by Missouri

Planned Parenthood made public for the first time Friday the reasons behind why four patients had failed abortions at its St. Louis clinic over a five-month period in 2018.

In a document filed with the Administrative Hearing Commission Friday, Planned Parenthood’s incoming chief medical officer Dr. Colleen McNicholas sought to rebut concerns raised in inspection records made public by the state health department through court filings.

As the last abortion provider in Missouri, Planned Parenthood is working to keep its license through litigation after the Missouri Department of Health and Senior Services rejected its renewal application. Its case was remanded to the administrative hearing commission, which handles disputes between state agencies and individuals or businesses. A commissioner ruled Friday that the clinic would be allowed to offer abortions throughout the appeal process.

The inspection records noted the cases of four patients, identified as Patient 1, Patient 2, Patient 3 and Patient 12. While DHSS noted other deficiencies, it said these cases were the ones that “resulted in serious patient harm.”

In the filing, McNicholas, who was the attending physician on almost all the cases, described what went wrong with each patient. She pushed back against what she called incorrect assumptions made by DHSS, who has accused the clinic of lax supervision of its trainees.

McNicholas stated the clinic had five failed abortions out of about 2,500 performed last year, a complication rate of about .2%.

“At the outset, it is important to note that DHSS has focused on a rare but known complication of abortion in which the pregnancy remains ongoing despite a reasonable belief that the intervention would terminate the pregnancy — also known as a failed abortion,” McNicholas wrote. “Complications in medicine, though unfortunate, are not entirely preventable despite our best efforts.”

Patient 1

In Patient 1’s case, DHSS noted that one woman had three abortions: surgical and medication abortions that failed to end the pregnancy and then another surgical abortion that succeeded.

McNicholas said a third-year resident and fourth-year fellow attempted the first surgical abortion but, noting the patient’s discomfort, switched to a noninvasive medication abortion, after consulting with McNicholas and the patient. The medication abortion — which has .7 percent failure rate — was not successful.

“Given there is no dispute as to the gestational age, it is difficult to conceive what user error or variation in skill could possibly occur,” McNicholas said. “Thus, to the degree DHSS is attempting to suggest the medication abortion would have been more likely to be successful had a resident or fellow not been involved in the patient’s care, this suggestion is misplaced.”

DHSS said the resident failed to take note of the position of the patient’s uterus.

McNicholas, who performed the final surgical abortion that succeeded, wrote the the position of a woman’s uterus changes and what the resident wrote in the patient’s chart did not conflict with her findings.

Patient 2 and Patient 3

Both Patient 2 and Patient 3 had surgical abortions, in which Planned Parenthood doctors and lab pathologists identified fetal parts in the remains. However, the women remained pregnant and had to return for a second abortion.

After Patient 2 had a surgical abortion, she contacted Planned Parenthood three weeks later, thinking she was still pregnant. DHSS criticized Planned Parenthood for allowing the procedure to take place in the second trimester, blaming it on the schedule of the physician, who had to travel from out of town.

What was not listed in DHSS’ complaint, McNicholas wrote, was that Planned Parenthood had contacted the patient 20 minutes after she called the clinic, urging her to schedule a second abortion immediately. She did not follow their advice.

“Our patients’ lives are complex and unfortunately it is not unusual for a patient not to come for a scheduled appointment or to be unable to arrange for an appointment when we suggest one; this can happen for any of a number of reasons including difficulty making work or childcare arrangements or travel arrangements — all of which are outside of our control,” McNicholas wrote.

McNicholas wrote Planned Parenthood believed that Patient 2 had an undiagnosed twin pregnancy.

The likelihood of that was low, DHSS countered, citing a study that showed out of 46 failed pregnancies, none of them involved twins pregnancies. The patient’s ultrasound did not show twins.

McNicholas noted the study DHSS cited was from 1978.

“It is unclear how the article’s authors could have known if there was an undiagnosed twin pregnancy,” McNicholas wrote. “In any event, as should be obvious, whether any of the 46 patients in that study had a twin pregnancy or not does not tell us whether Patient #2 had a twin pregnancy.”

Patient 12

The most egregious case involved a patient whose case, according to DHSS, resulted in “massive uncontrolled bleeding and an emergency transfer” to the hospital, where it was determined she had lost two liters of blood. Doctors eventually performed a uterine artery embolization — a procedure for removing fibrous growths from the uterus or stopping bleeding.

McNicholas wrote that DHSS has made “many factual misrepresentations” about this case.

“To be clear, the patient did not have an abortion or an attempted evacuation at Planned Parenthood,” McNicholas wrote. “Nor is it true the patient experienced ‘massive,’ ‘uncontrolled’ bleeding.”

The patient, who had a medical condition and came from out of state because of a lack of access to abortion services, was evaluated at Washington University School of Medicine, according to McNicholas, an associate professor at the school.

The abortion, which occurred at 21 weeks, had to be performed over two days, like most abortions done later in pregnancy. The first day includes getting dilators inserted in her cervix, which allows it to expand for surgical instruments.

That part of the process began at Planned Parenthood, but was stopped when the woman began to bleed “a small amount,” according to McNicholas. They controlled the bleeding and the patient was taken to nearby Barnes-Jewish Hospital by ambulance.

“Again, her bleeding was stopped and she was stable and alert upon arrival,” McNicholas wrote.

There, physicians performed the abortion and the subsequent uterine artery embolization.

Complication rate

Abortions are statistically safer than many surgeries, but complications do occur. In 2017, the Missouri health department said it received 74 reports outlining 86 separate complications in about 3,900 abortions, a rate of 1.9%.

That’s roughly in line with the rates found in studies of other states, including California. Major complications, resulting in trips to the emergency room, are more rare, occurring in about 0.11% of all abortions nationally, according to a study published last year.

Noting the failed abortions, DHSS has said it can’t renew the facility’s license until it talks to all of the physicians who were involved in the incidents cited in the inspection records.

DHSS Randall Williams likened the situation to the investigation following a plane crash by the Federal Aviation Authority. DHSS wants to interview to the “pilots,” or the physicians.

“We believe we have a duty to prevent future harm, to prevent future accidents or bad outcomes — to make sure there is not something systematic going on,” Williams told reporters in a press conference last week.

DHSS interviewed McNicholas and another physician employed by the clinic at the end of May. Planned Parenthood has said it cannot compel five other physicians to submit to interview because they are not employees and are contracted through Washington University School of Medicine and Barnes-Jewish Hospital.

This story was originally published June 28, 2019 at 7:26 PM.