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Ectopic Pregnancy: How Upcoming US Abortion Restrictions May Affect It

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An ectopic pregnancy is any pregnancy in which the embryo has implanted outside of the uterine cavity, meaning not in the endometrium, the layer of tissue that covers the inside of the uterus. Usually, ectopic pregnancies occur in a fallopian tube, particularly a part of the tube called the ampulla, the region of the tube that curves over the ovary. In these cases, the particular type of ectopic pregnancy is a tubal pregnancy. Other places where ectopic pregnancy can occur include the ovary, the cervix, the myometrium (muscular layer of the uterus), the abdominal cavity away from the uterus, and in a surgical scar, such as the uterine wall or abdominal wall resulting from a cesarean section. Approximately 20 out of every 1,000 pregnancies are ectopic. The condition threatens the mother’s life, because the pregnancy expands in places where it is not supposed to be. In tubal pregnancies, for instance, which constitute 95 percent of ectopic pregnancies, the embryo has implanted and can develop through some early stages, but if it continues to grow it will rupture the tube, causing hemorrhage, infection, and often sepsis (infection through the body), making it likely that the mother will die without intervention. Ectopic pregnancy thus accounts for 4 to 10 percent of pregnancy deaths.

There is no proven way to transfer such an embryo to the endometrium. Even if that could be done, such an embryo would likely have serious problems, making it unlikely to survive. Thus, an ectopic pregnancy is considered to be completely non-viable; there it is no way that it will ever result in a baby. An ectopic pregnancy must therefore be terminated to save the mother’s life, and yet, the Supreme Court of the United States (SCOTUS) is on the verge of a decision that will allow various extreme anti-abortion laws to come into effect in many US states. And the way that some of those laws are written suggests that treatment of ectopic pregnancy would become a crime in those states.

The reason is that, for ectopic pregnancy to kill the mother, some complication has to develop, such as peritonitis, sepsis, or severe hemorrhage, following the rupture of a tube or other structure where the pregnancy has developed. In such cases, the woman would be in critical condition, rather than being stable. She would likely be in shock. In normal, ethical practice, doctors terminate an ectopic pregnancy, either surgically, or, if early enough, with medication before it causes a rupture that puts the patient into shock. They don’t wait for the patient to suffer a tubal rupture and hemorrhage and become septic, putting her on the brink of death. But some of the laws that will go into effect when SCOTUS overturns the 1973 Roe versus Wade decision can be interpreted to mean that the mother must be on the brink of death in order for the termination of a pregnancy, even an ectopic pregnancy, to be legal.

The following factors increase your chances of suffering an ectopic pregnancy:

  • A previous ectopic pregnancy
    • This includes those with a previous linear salpingostomy, an opening made surgically into the fallopian tube to treat ectopic pregnancy. This elevates your chance of having an ectopic pregnancy the next time ranges from 15 to 20 percent. The risk increases further with as the number of past ectopic pregnancies rises, although if you achieve a normal pregnancy, after a series of ectopic pregnancies than your risk starts to go down.
  • Pelvic inflammatory disease
  • Infertility and fertility treatment
  • Smoking
  • Surgery on the fallopian tubes
  • Endometriosis
  • Anatomical abnormalities, such as a double uterus
  • Exposure to diethylstilbestrol (DES) when your mother was pregnant with you. DES is a synthetic hormone that was administered to some pregnant women in the period from 1940 to 1971. Consequently, this can be a factor today, only for women getting pregnant in their fifties, or older, so it is now very uncommon.

After symptoms, such as severe abdominal pain and vaginal bleeding, alert you and your doctor that something is wrong, you will be given a pregnancy test to detect the hormone beta human chorionic gonadotropin (beta HCG) in your urine and then to measure the concentration of beta HCG in your blood. You will also be tested with ultrasonography to look for a gestational sac in your uterus and a mass in your fallopian tubes. If no gestational sac is visible in your uterus, or of you beta HCG level is below 1,500 mIU/mL, you will be tested with a series of beta-HCG blood tests to see if the beta-HCG level is roughly doubling every 48 as it should in a normal pregnancy. If the beta HCG level is not increasing very much, this means that it is not a healthy pregnancy and that it could be ectopic. More ultrasonography will be conducted to see if a mass appears in a fallopian tube. If this doesn’t happen, your obstetrician will look for evidence of ectopic pregnancy in less common locations. Along the way, particularly if there is little or no vaginal bleeding, you will also be checked for other abdominal emergencies, such as acute appendicitis and acute cholecystitis. You also will be evaluated for other conditions that potentially could confuse the situation, such as familial Mediterranean fever. More than 85 percent of cases are diagnosed before the tube ruptures. Early diagnosis often allows for tubes to be preserved so that the woman can attempt pregnancy again. Thus, along with endangering the lives of women, laws prohibiting the termination of pregnancy until the mother is on the brink of death ironically would prevent a certain number of healthy babies from ever being born.

When ectopic pregnancy is discovered early, it can be handled through what’s called expectant management, sometimes called “watchful waiting”. This does not mean that doctors are waiting to see if the pregnancy will normalize, because it will not. As noted earlier, the embryo is completely non-viable. It will never develop to term. Rather, watchful waiting means that the woman is admitted to the hospital, where doctors monitor the condition to see if the ectopic pregnancy aborts spontaneously. If it does and if everything comes out without damage to the fallopian tube, ovary, or other structure, the patient will be fine and may even have a successful pregnancy in the future. Studies suggest that more than two thirds of ectopic pregnancies actually resolve without treatment. During the monitoring period, however, doctors also look for signs that the condition is worsening to the point of requiring medical or surgical treatment. Surgical treatment can be either salpingectomy (removal of the fallopian tube) or salpingostomy (clearing out the tube without removing the tube). Either of these operations can be performed as an open procedure (through an abdominal incision) or laparoscopically (through tubes inserted through very small incisions).

David Warmflash
Dr. David Warmflash is a science communicator and physician with a research background in astrobiology and space medicine. He has completed research fellowships at NASA Johnson Space Center, the University of Pennsylvania, and Brandeis University. Since 2002, he has been collaborating with The Planetary Society on experiments helping us to understand the effects of deep space radiation on life forms, and since 2011 has worked nearly full time in medical writing and science journalism. His focus area includes the emergence of new biotechnologies and their impact on biomedicine, public health, and society.

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