Your treatment options for an ectopic pregnancy, and why the overturn of Roe hasn’t affected them

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With the recent overturn of Roe v Wade, headlines abound with the claim that access to lifesaving treatment for women in the event of an ectopic pregnancy is now in jeopardy. Nothing could be further from the truth, as abortion (whether chemical or surgical), has never been the standard treatment for an ectopic pregnancy (which is a pregnancy that takes place outside the uterus, most often in the fallopian tube, which may eventually cause tubal rupture and the death of the mother). Nor is treatment for ectopic pregnancy coded as an abortion in ICD-10 medical codes. In fact, as we found during our Abortion Pill Webcast and interview of OB/GYN Dr. Ingrid Skop, ready access to abortion pills can cause ectopic pregnancies to go missed and untreated, which can prove deadly for the women who use them. 

Still, for the woman facing the emotional turmoil and physical pain of a confirmed ectopic pregnancy, the recent foreboding headlines equating ectopic pregnancy in our post-Roe world with a death sentence can be scary. And the misinformation equating elective abortion with ectopic pregnancy treatment is especially concerning for two reasons: One, that it may discourage women from seeking out the life-saving care they need in the event of an ectopic pregnancy, and two, that it may discourage physicians from providing such treatment out of a misinformed fear of repercussions. But that is why Natural Womanhood exists, to give women the information they deserve, and to let them know that when it comes to their reproductive health, there are always options beyond abortion (and birth control). The same is true for the treatment of ectopic pregnancies.

But before we discuss these options, it is important to first say this: ectopic pregnancies are not viable pregnancies. There is no chance of an ectopic pregnancy being brought to term, and no chance that the embryo will survive. In these sad cases, the only life that can be saved is that of the mother. Still, because these treatments involve (an unavoidable) loss of life, if possible, one should be thoughtful about how an ectopic pregnancy is resolved, which is why this article will also address the moral considerations for each of the available options for ectopic pregnancy treatment.

There are four legal, medically appropriate ectopic pregnancy treatment options (and none of them are abortion)

There are four legal, medically acceptable paths by which an ectopic pregnancy can be treated in order to save the life of the mother. The first two, expectant management and salpingectomy, are generally considered morally permissible by all providers and ethicists, that is, they are not morally wrong or prohibited actions.

The second two, salpingostomy and methotrexate, have been considered morally permissible by some medical ethicists, and morally impermissible/prohibited by others. I will include all four below so that women can make informed, thoughtful decisions surrounding ectopic pregnancies with their providers and/or partners.

(Editor’s note: the source for these treatment options and their descriptions is the physician’s online reference, UptoDate.)     

Option 1: Expectant management

While ectopic pregnancies are a serious medical condition warranting continued monitoring, immediate intervention is not always necessary. Sometimes, the embryo developing outside the uterus will die on its own, and the mother’s body will miscarry the embryo naturally.

With the expectant management approach, the woman is closely monitored to ensure that the ectopic pregnancy is not progressing. This is primarily done via ultrasound and serum monitoring of hCG levels, to ensure that they continue to decrease and, eventually, become undetectable. 

Not every woman is a good candidate for the expectant management approach, especially if she is unwilling or unable to keep up with the required monitoring, if her hCG levels are too high to begin with (or do not continue decreasing), if pain is worsening, or if there are signs of rupture.

Some women with ectopic pregnancies may prefer the expectant management option, while others may be uncomfortable with the continued risks of rupture. However, when medically appropriate, expectant management is a morally permissible means of responding to an ectopic pregnancy.      

Option 2: Salpingectomy

In a total salpingectomy, the fallopian tube in which the embryo is implanted is completely removed. In a partial salpingectomy, the portion of the tube containing the embryo is removed from the mother’s body, and the cut ends are closed (similar to a tubal ligation procedure), leaving open the possibility of reconnecting the tubes (tubal anastomosis) in the future. The procedure can be performed laparoscopically, via electrosurgery, or via laparotomy.    

Fortunately, as long as the other fallopian tube remains healthy, intact, and patent (open), removal of the fallopian tube which contains the embryo should not impede future fertility. Removal of both tubes, however, results in sterilization of the patient.  

Whether partial or full, a salpingectomy procedure performed to treat an ectopic pregnancy results in the foreseeable, indirect death of the embryo. This is considered morally permissible under what is known by ethicists as the principle of double effect (PDE). To qualify as permissible under PDE, an action must meet the following requirements [1] :

  • The intended effect must be a good one.
  • The harmful effect must be foreseen but not intended.
  • The harmful effect must not be a way of producing the good effect.
  • The good effect must, on balance, outweigh the harmful effect.

Although the death of the embryo in a salpingectomy is foreseeable (albeit deeply regrettable), because it is also indirect and unintended, and balanced by the intended good effect (saving the life of the mother), there is broad consensus that this procedure is a medically sound and morally permissible means of treating an ectopic pregnancy. 

Option 3: Salpingostomy

In a salpingostomy procedure, a longitudinal slit is made in the fallopian tube, and the embryo itself is removed. 

Because the action of directly removing the embryo from the tube results in the death of the embryo, there is a question about the moral permissibility of the salpingostomy procedure.* Salpingostomy is considered morally impermissible by many Catholic and Christian ethicists, but some have argued otherwise (see: https://journals.sagepub.com/doi/10.1179/002436309803889106 [2]). 

In general, where a surgical approach is indicated, salpingectomy is the preferred option. However, if a woman’s unaffected fallopian tube is already damaged (or if she lacks a second tube), a salpingostomy may be encouraged to allow for the possibility of future conception/pregnancy. 

Option 4: Methotrexate (MTX)

If an ectopic pregnancy is detected early enough, or if surgical intervention is contraindicated, the pharmacological option of methotrexate (MTX) injection will likely be discussed. 

From the physician resource, UptoDate

“MTX is a folic acid antagonist widely used for treatment of neoplasia, severe psoriasis, and rheumatoid arthritis. It inhibits deoxynucleic acid (DNA) synthesis and cell reproduction, primarily in actively proliferating cells such as malignant cells, trophoblasts, and fetal cells. MTX is rapidly cleared by the kidneys, with 90 percent of an intravenous dose excreted unchanged within 24 hours of administration.”

MTX for ectopic pregnancy is typically given via intramuscular injection, although it may also be administered orally, intravenously, or directly injected into the embryo/pregnancy sac transvaginally or transabdominally. 

Like salpingostomy, the moral permissibility of MTX is disputed amongst ethicists,* as its administration is generally considered to result in the direct death of the embryo. Although, again, some have argued for a reconsideration of its permissibility [2]. 

Understanding the controversies surrounding salpingostomy and MTX as treatments for ectopic pregnancy

Please note that although I have referenced the Catholic perspective behind the morality of each of these treatment options, it is not the only perspective on this subject. However, because I, like many of our readers at Natural Womanhood, am Catholic, and because there is strong scholarship to support the thinking behind the Catholic perspective on ectopic pregnancy treatment, I believe it is a strong source for formulating one’s thoughts on the subject, regardless of one’s religion or creed.

In that vein, it is important to note that the Magisterium (the teaching authority of the Catholic Church) has not made any definitive statements regarding the moral permissibility of MTX or salpingostomy (as contrasted with the Magisterium’s unequivocal assertion that “Direct abortion, that is to say, abortion willed either as an end or a means, is gravely contrary to the moral law“).

Furthermore, all four of the approaches to ectopic pregnancy treatment discussed above are legal in all 50 states in the United States. Therefore, there is no (and never has been any) legal or medical impediment to women accessing life-saving ectopic pregnancy treatment, regardless of the legality of abortion; the recent overturn of Roe v Wade has not changed that reality—because, it bears repeating, treatment for ectopic pregnancy is not abortion, neither legally-, medically-, nor morally-speaking.

For those looking for guidance on the conscientious resolution of ectopic pregnancy, the National Catholic Bioethics Center (NCBC) has applied the tenets of Catholic ethics and moral philosophy to these procedures in order to reason through their moral permissibility. Again, regardless of one’s religious affiliation, many may find the NCBC’s resources and scholarship on these issues helpful in making ethical decisions about the treatment of ectopic pregnancy:

*From the National Catholic Bioethics Center, via this link [3]: 

“Some Catholic ethicists argue that salpingostomy and the use of methotrexate are morally permissible under the principle of double effect. They argue that both procedures directly intend the removal of the exact cause of the condition, i.e., the trophoblast rapidly dividing in the wrong place, and not the embryonic child itself. This argument assumes that the trophoblast is not an organ of the embryo and therefore can be an object of moral focus apart from the developing embryo.”

A note about the connection between IUDs and ectopic pregnancy risk

As a final note, we want to address the connection between ectopic pregnancy risk and intrauterine devices (IUDs)

Amidst all the furor over ectopic pregnancy treatments, abortion, and the overturn of Roe v Wade, and even despite reports of more women seeking out IUDs over misguided fears that “they’re coming for birth control next,” little or no mention has been made of the connection between IUD use and ectopic pregnancies. Yet, this is important information for women looking to avoid unintended pregnancies, ectopic or otherwise.

According to the American College of Obstetricians and Gynecologists (ACOG), IUD use does not increase a woman’s risk of having an ectopic pregnancy. However, ACOG also acknowledges, if a woman does get pregnant while the IUD is in place, her chances of the pregnancy being ectopic are much higher than for the average woman. And, it should be noted, a just-published 2022 Swedish study found that while overall (absolute) risk of ectopic pregnancy among women using IUDs is low, the risk was 20x higher during the first year of use in the lowest dose IUD, compared to the highest dose IUD [4]. Finally, while there’s little other research on the topic of IUDs and ectopic pregnancy risks, and much of it is more than 25 years old, one 2004 study (cited by ACOG) found that over half (53%) of pregnancies that occurred in women with an IUD were ectopic [5]. 

When it comes to the tragedy of an ectopic pregnancy, know that you have options

To sum, an ectopic pregnancy is scary and undoubtedly tragic, and many women have conflicting feelings about treatment. However, when faced with this unexpected emergency, women are encouraged to seek immediate help, and should know that the preservation of their life is of paramount importance. While the life of the embryo has moral value regardless of where it has implanted, medical science cannot yet save the life of an ectopically implanted embryo; only the life of the mother can be saved.

Again, the recent overturn of Roe has not changed your access to life-saving treatment, as abortion is not (and never has been) the standard of care for an ectopic pregnancy. There are multiple options for treatment available, and if possible, discerning the most ethical course of action for the resolution of an ectopic pregnancy should be done with one’s partner, healthcare provider, and spiritual advisor. 

References:

[1] Kendall, C.E. “A double dose of double effect.” Journal of Medical Ethics, vol. 26, issue 3 (2000): pp. 204-06. http://dx.doi.org/10.1136/jme.26.3.204

[2] Kaczor, Christopher. “The ethics of ectopic pregnancy: a critical reconsideration of salpingostomy and methotrexate.” The Linacre Quarterly, vol. 76, issue 3 (2009): pp. 265-82. https://doi.org/10.1179/002436309803889106

[3] Ethicists of the NCBC. “The management of ectopic pregnancy.” February 2013. The National Catholic Bioethics Center. https://www.ncbcenter.org/resources-and-statements-cms/summary-ectopic-pregnancy

[4] Elgemark, Karin et al. “The 13.5-mg, 19.5-mg, and 52-mg Levonorgestrel-Releasing Intrauterine Systems and Risk of Ectopic Pregnancy.” Obstetrics and gynecology vol. 140, no. 2 (2022): pp. 227-33. doi:10.1097/AOG.0000000000004846

[5] Backman, Tiina et al. “Pregnancy during the use of levonorgestrel intrauterine system.” American journal of obstetrics and gynecology vol. 190, no. 1 (2004): pp. 50-4. doi:10.1016/j.ajog.2003.07.021

Additional Reading:

The abortion pill crisis, a Natural Womanhood webcast featuring Lila Rose

Considering tubal ligation reversal: here’s what you need to know

Bayer finally pays for Essure damages, but women’s injuries still go ignored

Considering endometrial ablation to fix heavy periods? Read this first

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  1. Comment by Lynn on July 21, 2022 at 6:27 pm

    Unfortunately, in Missouri, physician friends are telling me that because Treatments for ectopic pregnancy are defined as abortion because the baby dies, they are being required to wait to provide that treatment until the mothers life is clearly in danger.

  2. Comment by Grace Emily Stark on July 22, 2022 at 11:52 am

    That doesn’t seem right to me, given that treatment of ectopic pregnancy per the ICD-10 codes does not fall under the heading of Abortion. See: https://icd10monitor.com/the-medicine-and-icd-10-coding-of-abortion/#:~:text=Treatment%20of%20an%20ectopic%20pregnancy,in%20the%20section%20of%20Abortion.

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