Sarah woke up on a Tuesday morning in late August feeling bloated.
There could be a dozen reasons for it, she thought. Maybe it was a change she made in her diet recently, adding more greens. Maybe it was the asparagus she ate for dinner or the cruciferous vegetables — broccoli, cauliflower — she’d been trying to add to her plate. The high sulfur content in Brussels sprouts can cause pressure from gas, she surmised. But a day later the feeling persisted, so she texted a close friend who is a nurse practitioner.
If it’s the appendix, her friend responded, you need to get that checked. The pain was specific to the right lower quadrant in Sarah’s abdomen, which meant it couldn’t be ruled out.
Thursday morning, she went back to work, but the discomfort was constant. Sarah is a teacher, and her general attitude was that she could just power through the day and take care of a personal issue after school — not an uncommon approach for a lot of public school employees. By 3 p.m., the pain was bad enough that she decided to drive herself to Vanderbilt University Medical Center. She walked into the emergency room and checked in, not knowing what the next few hours would reveal: Sarah was pregnant, bleeding internally and about to run right into the teeth of Tennessee’s abortion ban.
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Months later, recounting the experience, Sarah still is astounded at the turn of events. (Editor’s note: Sarah is a pseudonym. She agreed to talk with the Banner and share her medical records under the condition that we not use her real name.)
An emergency room can seem like “controlled chaos” at times, she said, especially at Vanderbilt, home of the region’s only Level I trauma center. After checking in, Sarah was triaged, but it was an hour-and-a-half before her first blood was drawn for a complete blood count panel to give the doctors a baseline of her health. The results were inconclusive. Nothing immediately indicated to the medical staff that she was anemic or had an infection, but an inflamed appendix was ruled out.
By 6:45 p.m., an OB/GYN examined Sarah and wondered about her ovaries. The doctor ordered a urine test, which came back with a surprise: Despite having an IUD implanted earlier that year, Sarah was pregnant. A second blood test confirmed it.
“When I got to the hospital, that was on my radar – like, what if something happened with the IUD?” she said. “Still, again, not thinking that I’m pregnant? Like, why would I?” IUDs are one of the most effective forms of birth control, stopping more than 99 percent of pregnancies. “I wasn’t expecting that pregnancy result at all, because of the [IUD].”
But the presence of the device gave doctors and Sarah a clue as to why she was in such distress.
“I immediately knew that something wasn’t right, just from the sort of pain I was in, and I didn’t have any symptoms of pregnancy,” Sarah said. As a mother of two, she was very familiar with the early months of pregnancy and its side effects — nausea, tiredness, subtle changes in her body. But there were none. “So I just knew that something wasn’t right. I even asked [the OB/GYN], I said, ‘You know, I’m worried it’s ectopic.’ He said, ‘We’re going to send you to get an ultrasound done to confirm the location of the pregnancy.’”
Ectopic pregnancies are where the tissue — a fertilized egg — implants outside the uterus. According to Dr. Nancy Lipsitz, a longtime Nashville OB/GYN and former professor at Vanderbilt University, this occurs in roughly 2 percent of all pregnancies. Most commonly, the tissue implants in a woman’s fallopian tube. When an IUD fails, this is a common location for the pregnancy.
“Because it is pregnancy tissue, it grows in a space and expands,” Lipsitz said. “And if it’s not treated, it can cause internal bleeding, it can rupture. It can cause damage to fallopian tubes or other structures, and if it’s not treated, can cause hemorrhaging. It can cause hypovolemic shock, and rarely, it can cause death.”
By 8:15 p.m., pictures from an ultrasound gave doctors two sets of information. First, the pregnancy indeed was ectopic. And second, Sarah was experiencing enough bleeding for it to show up as floating around in her cavity. She needed surgery and an abortion in order to repair the damage.
A little after 9 p.m., as her blood levels raised the concern of Sarah’s doctors even more, one of her doctors told her something odd and a little disconcerting: She shouldn’t worry, because legal was getting involved.
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Tennessee’s ban on abortions became law after the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision in June, when a new majority on the court overturned abortion protections enshrined by Roe v. Wade nearly a half century earlier. The state’s so-called “trigger law,” enacted in 2019, banned all versions of the procedure. And unfortunately for Sarah, the law kicked in just days before she arrived in the emergency room.
Vanderbilt’s lawyers were grappling with language that made providing an abortion a Class C felony and subject to both a $10,000 fine and significant prison time. There was a provision for doctors to act, but they were required to make an affirmative defense to prosecution — i.e., they had to admit that they were in violation of the law, but that the mother’s life would be in jeopardy if they did not perform the abortion.
Indeed, inserted into Sarah’s charts are roughly 20 paragraphs of language detailing measures that Vanderbilt doctors took in order to provide a legal rationale for an abortion. According to Lipsitz, the area’s hospitals had begun preparing for just this kind of eventuality in June because ectopic pregnancies are not uncommon. An estimated 1 to 2 percent of all pregnancies are ectopic, meaning that in a state like Tennessee — which had 78,689 births in 2020 — somewhere between 780 and 1,570 women per year deal with a situation similar to Sarah’s.
Some lawmakers are beginning to express regret at passing a law that includes no exceptions for rape or incest and places the burden on doctors to defend their actions. Some voted for the law never expecting that it would be put in place, including state Sen. Richard Briggs (R-Knoxville).
“Here, the defendant is guilty until he can prove that he’s not guilty,” said Briggs, a Republican and retired heart surgeon, in an interview with ProPublica in November. “In my opinion, that is a very bad position to put the doctors in — why should this doctor have to pay his own legal bills for saving a woman’s life?”
For Lipsitz, the question of why this procedure requires such legal maneuvers is a perplexing one, since ectopic pregnancies will not lead to a birth.
“The only time I’ve seen a viable pregnancy from an ectopic pregnancy was on ‘Grey’s Anatomy,’” she said. “There was a segment where they found an ectopic pregnancy attached to the liver at 26 weeks. I don’t know who their medical consultants were. No, never you’re never going to get a viable pregnancy.”
Although some lawmakers have begun exploring making changes to the law, Gov. Bill Lee has said he’s “satisfied” with the current version. A Vanderbilt poll released last week showed that 75 percent of Tennesseans support making some exceptions to the law, including for rape, incest and the life of the mother.
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By 10:40 p.m., after hours of consultation, doctors assured Sarah there was no problem with the legality of treating her and began preparations to get her to surgery. In the interim, Sarah and her husband, as well as other family members, had begun exploring other options in case Vanderbilt balked, including transferring to Centennial Medical Center, which would do the procedure. She stayed, and at 12:48 a.m., she was wheeled into surgery. Doctors removed the pregnancy and part of a fallopian tube and cleaned up some of the damage from the bleeding.
Sarah said she feels lucky to have both family and legal support. As a resident of a city with multiple hospital options, she didn’t have to travel far for care. Even today, she’s flabbergasted that a doctor had to essentially break the law in order to treat her.
“It’s a felony, what they did, and that is crazy to me,” she said. “So while I’m recovering from surgery, and trying to emotionally process all of it, another layer of it was, what if my case wasn’t severe enough, right? And what if a prosecutor decides, ‘Well, we want to make an example.’ Like, what if I wasn’t bleeding internally enough? Or what if, because I was stable the whole time — I was very lucky that I was stable the whole time — but what if that’s used against me one day, or used against my doctor? Those are all things that were on my mind, after the fact. And they shouldn’t have been.”
The downstream effects of the law are only just beginning to be felt, said Lipsitz.
“Are our young OB/GYNs going to move to Tennessee and take jobs here?” Lipsitz said. “Are people going to want to come to residency in Tennessee? Even people who say, ‘This doesn’t really affect me’ — it could affect family members, it could affect your friends, it could affect your children. You’re going to have fewer people come to train here, possibly. You’re going to have fewer people move here and work.”
She pauses for a second and then recounts the conversations she’s had with patients.
“If you have healthy people who are worried about getting pregnant, we’ve created a culture of fear.”