At 3 a.m. on June 23, Kathryn Sanders went to the ER in Missoula, MT, worried about the sharp pain she was experiencing on her right side. “I was cramping and was definitely in pain, similar to period cramps,” she says. At the hospital, she was given a pregnancy test, which was positive, then an ultrasound. “During the ultrasound, the doctor came in and told me, basically in one breath: ‘You’re pregnant, it’s ectopic, it’s dangerous, it’s not viable, we need to operate.'” By 7 a.m., Sanders was having surgery to remove the ectopic pregnancy and her right fallopian tube.
Only one to two percent of pregnancies are ectopic, but they account for up to 10 percent of maternal pregnancy-related deaths. An ectopic pregnancy occurs when a fertilized egg implants anywhere other than the lining of the uterus. More than 90 percent of the time, this happens in a fallopian tube (which is also known as a tubal pregnancy), but it can also implant on the cervix, a scar from a previous Cesarean section, an ovary, or the abdominal cavity.
These pregnancies are never viable and have dire consequences if left untreated, says Ketly Michel, MD, an ob-gyn at Rosh Maternal & Fetal Medicine in New York City. In Sanders’s case, the growing embryo had already ruptured her fallopian tube, causing potentially life-threatening bleeding. Nontubal ectopic pregnancies can also damage the cervix, uterus, and ovaries, resulting in life-threatening hemorrhages.
Recently, ectopic pregnancies have made their way into the spotlight — not because of any advancements in diagnosis or treatment, but because the overturn of Roe v. Wade has raised the question of whether the treatment for ectopic pregnancies could, or should, be considered abortion.
Many physicians don’t consider the treatment of ectopic pregnancy to be an abortion at all, in large part because “it’s never a pregnancy that’s going to continue to go on to be a normal baby, and it has a high chance of causing significant harm or even death,” says Roxanne Jamshidi, MD, director of the Department of General Obstetrics and Gynecology at George Washington University School of Medicine and Health Sciences.
However, the criminal abortion bans that have taken effect since the overruling of Roe are complicating things, says Cary Franklin, professor of law at UCLA School of Law and faculty director of the Center on Reproductive Health, Law, and Policy. States with the most restrictive abortion bans offer exceptions when the pregnancy endangers the life of the pregnant person, but not all states include exceptions when the health of the pregnant person is at risk. “Healthcare providers are being asked to guess or predict what counts as a ‘life-threatening’ medical emergency,” Franklin explains. “The parameters of that category are not well-defined enough for providers to feel confident that they won’t run afoul of these new criminal abortion bans — particularly given the zealousness with which lawmakers in some states are trying to crack down on abortion.”
“That term (‘life-threatening’) is very open to interpretation, and many doctors and hospital administrators are risk averse,” she says. “They have a lot at stake: they can face loss of their medical licenses, significant financial penalties, and even prison if a state official decides that they performed an abortion on a patient that wasn’t near enough to death to qualify for this vague exception.”
There have already been reports of physicians delaying ectopic pregnancy care out of a concern for its legality, and accounts of doctors being pressured to consult and seek second opinions from other physicians or even lawyers before providing care. These delays are life-threatening.
The fact that ectopic pregnancies (and the people who’ve had them) have been drawn into the abortion debate shows how damaging restrictions on reproductive healthcare access can be — and how important it is to leave healthcare decisions up to patients themselves and their doctors, not legislators.
How Are Ectopic Pregnancies Treated?
There are two treatment options available for ectopic pregnancy, according to the American College of Obstetricians and Gynecologists: medication and surgery.
Ectopic pregnancies that are caught early are often treated with medication, Dr. Michel says. Usually, it’s a chemotherapy drug called methotrexate. The drug, which is typically given as an injection and is also used to treat certain autoimmune conditions, stops cells from growing. The remains are then absorbed by the body over a period of four to six weeks. When it’s effective, methotrexate can treat an ectopic pregnancy without necessitating the removal of the fallopian tube.
For more advanced ectopic pregnancies, in situations where a fallopian tube has ruptured, or for patients who have a preexisting condition that interferes with the use of methotrexate, surgery is typically needed, says Kecia Gaither, MD, ob-gyn, director of Perinatal Services and Maternal Fetal Medicine at NYC Health + Hospitals/Lincoln in the Bronx. In these cases, part or all of the fallopian tube may be removed; this can have consequences for future fertility, making it more difficult to get pregnant or necessitating in vitro fertilization.
Ectopic pregnancies that occur outside of the fallopian tube, which have a higher risk of fatality than tubal pregnancies, may be treated medically or with surgery, depending on the location and progression, reports the journal “Fertility Research and Practice”.
Does What We Call Ectopic Pregnancy Treatment Matter?
Many healthcare professionals, including Dr. Michel, Dr. Jamshidi, and Dr. Gaither, don’t consider the treatment for ectopic pregnancy an abortion. They take that stance for several reasons: the pregnancy doesn’t occur in the uterus; the treatments are different than what’s used for miscarriages or elective abortions; the pregnancies themselves are never viable and will threaten the life of the pregnant person if not treated.
Heather Bartos, MD, an ob-gyn who practices in Texas, which she calls “ground zero in all this,” says that even medical language differentiates ectopic pregnancies. “The medical term for any pregnancy loss comes from the Latin abortiōnem. So when we talk about a miscarriage, it’s a spontaneous abortion. When we talk about a fetus that stops developing without naturally miscarrying, we call it a missed abortion,” she explains. “I’ve had women calling to yell at me because on their insurance, it says ‘abortion’ and they’re like, ‘I didn’t have an abortion!’ But that’s just the medical terminology for a loss of a pregnancy. And then, of course, there are elective abortions.”
Ectopic pregnancies, however, are classified differently. “Ectopics are always outside of the uterus. It’s not in a conducive environment to grow. So we’ll usually categorize that separately, as an ectopic pregnancy,” Dr. Bartos says. “We do remove those pregnancies. But that’s always to save the life of the mother.”
All that aside, the very question of whether or not ectopic pregnancy treatment is technically an abortion is “a distraction from the care of the patient,” says Moira Rashid, MD, a family physician specializing in reproductive health and family planning, and co-chief medical officer at Choix, a telemedicine clinic providing sexual and reproductive healthcare, including abortion care.
“Before Roe fell, I have never once been asked, ‘Is the treatment of ectopic pregnancy an abortion or not?’ It’s irrelevant,” Dr. Rashid says. “The fact is that ectopic pregnancies are not viable. They will never be viable. They have to be treated. Yes, technically it’s ending a pregnancy. But in my personal experience treating ectopic pregnancy, whether or not it’s an abortion has never come up. The conversations I have about it are, ‘This can become an emergency very quickly and needs to be treated right now.'”
Some people who’ve had ectopic pregnancies, however, do refer to the procedure as an abortion. Shannon* was given methotrexate to treat an ectopic pregnancy about four years ago. At the time, she says, none of her physicians called the treatment an abortion. “I think they saw it as, they’re treating me, and what’s happening inside of me could be life or death, and they have to save me,” Shannon says. It was only after the Supreme Court was on the cusp of overturning Roe v. Wade, bringing the conversation around abortion to a fever pitch in the US, that Shannon began asking herself whether the treatment she received could be considered an abortion.
Now, she does say she’s had an abortion, and has used her personal experience as a reason she supports abortion rights in conversations with others. But, she adds, “I’m glad [my doctors] didn’t call it a medical abortion, because it would’ve made me also feel guilty in a situation where I had no control over what would happen next. I would’ve felt like it was me making the decision, if that makes sense,” Shannon says.
Sanders, too, believes she had a life-saving abortion, although her doctors never used the term. Since Roe was overturned, she’s concerned that certain restrictive state laws could affect the care needed for ectopic pregnancies. (The laws in Montana, where she lives, do not consider the removal of an ectopic pregnancy an abortion.)
Dr. Bartos says this kind of reaction is understandable, considering how much conversation is currently taking place around reproductive rights. “I think a lot of people are wanting to be part of the movement, and also to say ‘I had this done and it meant something,'” she says.
Ultimately, however, Dr. Rashid emphasizes that the question of “is it or isn’t it?” is beside the point. And the fact that the question is even being asked is evidence of how far-reaching the damaging effects of restrictive abortion bans really are, she says.
Why Are Ectopic Pregnancy Treatments Affected by Abortion Bans?
Some state laws make clear that the removal of an ectopic pregnancy is not considered an abortion at all.
But restrictive abortion laws are as dangerous for what they don’t say as what they do: unclear or ambiguous wording, as well as overly severe punishments, have tangible consequences on physicians’ actions and people’s ability to access care. For instance, Texas law permits the treatment of ectopic pregnancy. But at least one hospital allegedly directed a physician to hold off treating a person experiencing one until the ectopic pregnancy had ruptured, putting her future fertility, and her life, at risk, reports The Dallas Morning News.
“I think we’re in a really scary legal situation in a lot of states, with doctors being threatened with life in prison or loss of their licensure, which means loss of your career, essentially,” Dr. Rashid says. “That level of government interference is just completely unacceptable. This is what happens when politicians get involved in medical care that they don’t understand.”
Sarah Yamaguchi, MD, FACOG, a board-certified gynecologist at DTLA Gynecology who’s affiliated with Good Samaritan Hospital in Los Angeles, agrees. “Lawmakers are encroaching more and more into medical decisions, and since they often don’t understand the law they are passing, it’s hard for medical professionals to interpret what they are saying since it didn’t make sense in the first place,” she says.
Case in point: in 2019, Rep. Candice Keller and former Rep. Ron Hood introduced a bill that would require doctors to “reimplant an ectopic pregnancy” into the uterus or face charges of “abortion murder.” Reimplantation of an embryo is medically impossible.
“There should be nothing legislative about this whatsoever,” Dr. Jamshidi says. “It’s truly just pure medical care. The fact that health care providers even have to think for a second about, ‘Am I allowed to do this?’ is so against your entire being of what it is to be a healthcare provider.”
Franklin believes one option is for lawmakers to include specific exemptions in abortion bans for ectopic pregnancy treatment, though that solution isn’t foolproof. “At least a few of these bans already do contain specific exemptions and I have read multiple accounts of doctors still refusing to provide [treatment] to people with ectopic pregnancies because they don’t feel confident about the scope of these exceptions, particularly against the backdrop of the new anti-abortion regimes some states are implementing,” she says. “I think the only real solution is [to] repeal these criminal bans. As long as they remain in place, I think women and other pregnant people will continue to face uncertainty and in some instances denials of treatment.”
This is why it’s so essential to vote in the gubernatorial elections on Nov. 8. In an exclusive interview with POPSUGAR, Vice President Kamala Harris stated that President Joe Biden is prepared to sign legislation that would protect access to reproductive care — but in order to get the legislation passed, he needs two more Democratic senators elected to the US Senate.
The fact is, the state of abortion access in the US right now requires physicians to be not only well-informed but also fearless, to some extent. “In the beginning, it was scary,” says Dr. Bartos of the first weeks after Texas’s SB8 bill took effect. “Every single person can sue you for $10,000 for any step you take to help provide treatment — even the Uber driver that takes you to the hospital. It’s a bounty on our heads,” she says.
But over time, that fear ebbed. “I wouldn’t be afraid to treat ectopic pregnancy. I would certainly document my ass off — but I’ve done that for years,” Dr. Bartos says. She believes most of the doctors she knows personally feel the same way, but acknowledges that she works in a major metropolitan area; in more rural areas of Texas, doctors may be more reluctant to provide reproductive healthcare. “At the end of the day, we’re gonna treat who we need to treat,” she says. “Maybe it’s just because we’re Texans and we’re like, damnit, we’re gonna do what we need to do.”
— Additional reporting by Mirel Zaman, Taylor Andrews, and Lauren Mazzo
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