Katrina Heyrana, MD, discusses legal implications of mifepristone

This is part 3 of our 3 part series on abortion. Click here for part 1. Click here for part 2.

Transcript (edited for clarity):

Dr. Heyrana, thank you so much for joining us. Can you give us the full title of your position?

Yeah, so, I am the I'm a staff physician at Cedars Sinai and in the OB GYN department in the Division of Family Planning. I'm also the Ryan Residency Program Director, which is a national program that helps train residents in providing abortion care and contraception care.

Wonderful. So to start with, could you break down the ruling for us that has come from the Supreme Court? It looks like it's a temporary ruling, but then what happens after that or what is going on with the lower courts in trying to appeal that decision?

Yeah, I think it's probably helpful to step back to like a couple of months ago when this when this case was starting to be heard in Texas. So an alliance of anti-abortion doctors brought the suit against mifepristone to the US District Court in Texas. That challenges the FDA’s approval of mifepristone, which happened back in 2000. The judge in that case decided in favor of the alliance and imposed a nationwide ban on mifepristone. But at the same time, an opposing ruling was issued in Washington state by another judge in a different case that protected the use of mifepristone, at least in the 17 states and Washington, DC, which were the plaintiffs in the case. In order to resolve that, the Fifth Circuit Court, which is the court of appeals that the Texas Court goes to next, basically allowed mifepristone to remain on the market, but with significant restrictions, for example, it could only be used up until 7 weeks of abortion or for medical abortions. There were no generics that were allowed, which is troubling because GenBioPro, which makes generic mifepristone makes two thirds of this in the country. The court also said you couldn't get the medication by mail. The Supreme Court issued a stay on this ruling and essentially said you know, mifepristone needs to be widely available, while this case makes its way through the court system. And so they issued the initial ruling 2 weeks ago at this point. And then this past Friday it was decided it would remain broadly available, as the case makes its way through the court. And so for now, for doctors, what all that jargon means is that doctors can still prescribe mifepristone as they have been, and patients can still take the medication and this status quo will likely remain in place until the case is appealed all the way up to the Supreme Court.

Right, which could take weeks, months, sometimes even years. If this appeal moves forward, and they're successful in blocking the drug, how does that play out for ob-gyns across the country?

Right, it could really present a worrying set of circumstances. I think there are a few possibilities for what could potentially happen. We could see a ruling that restricts mifepristone availability, kind of like what the fifth court decided to do initially. And restrictions on mifepristone availability would mean you know, that potentially in places where abortions are banned, that mifepristone wouldn't be available, which is effectively the case right now. But the thing that we're worried about the most is what happens if there's no mifepristone. Medication abortions currently make up more than 50% of the abortions in the United States. It's an incredibly safe procedure. And so more patients would be forced to turn towards procedural or in-clinic abortions in order to obtain abortion care. The other thing that could happen is that mifepristone is the gold standard regimen for the safe evacuation of pregnancies that are early pregnancy loss. And so one of the other things that doctors are worried might happen is that this could increase the rate of incomplete abortions in the setting of early pregnancy loss. Yeah, I think one thing to put on people's radar is that there are many countries in the world where mifepristone isn't available. And because of you know, the necessity for patients to end pregnancies like early in their pregnancy, there is a safe and effective misoprostol-only protocol that has been refined over the years. It's 93 to 98% effective at or below 12 weeks, sort of depending on the literature that you read. And that regimen is 3 to 4 doses of 800 micrograms of misoprostol.

When you think of it, overall, anything else you'd like to add or comment as far as what ob-gyns should know going forward?

Yeah, I think one thing to put on people's radar is one of the big downsides of this misoprostol protocol is that there are a lot more side effects that causes you know, the nausea, the vomiting, causes patients to have bleeding and cramping and things of that nature. So going from one dose misoprostol to 3 to 4 doses definitely has implications for patients comfort during a medication abortion.

Yeah, adverse effects to look out for. Thank you so much. I know you have a very busy schedule. I'd really appreciate it. And we'll see what happens going forward. Thank you.