What is Ectopic Pregnancy and Will the Roe Decision Affect Treatment?

In the wake of the Supreme Court overturning Roe v. Wade, which eliminated the constitutional right to abortion access, women and health care providers nationwide are asking how the ruling will affect reproductive health care more broadly.

Thirteen states have trigger laws that ban abortion immediately and that took effect after the Supreme Court’s decision, or soon will. Those laws allow exemptions if an abortion is needed to prevent a pregnant woman from dying.

But women’s health care providers say the recent ruling has raised questions about their ability to treat ectopic pregnancy, a life-threatening complication. The American College of Obstetricians and Gynecologists has warned that abortion bans — even those with an exception for ectopic pregnancies — can create confusion and impede a patient’s timely access to care.

“We’re already seeing on Twitter and elsewhere physicians being scared to treat ectopic pregnancies,” said Dr. Aileen Gariepy, director of complex family planning at Weill Cornell Medicine in New York City. “As doctors, our job is to follow science and evidence-based medicine, it is keeping up-to-date and doing what’s right for the patient. It is not the nuances of how state legislatures wrote something.”

An ectopic pregnancy occurs when a fertilized egg implants in the wrong place in a woman’s body. So instead of attaching to the lining of the uterus, where it can survive, it grows elsewhere.

More than 90 percent of the time, in an ectopic pregnancy, the fertilized egg implants in one of a woman’s fallopian tubes, which connect the ovaries to the uterus. The fallopian tubes are thin and full of blood vessels. If they burst open, as can happen when a fertilized egg grows in the tube, that can cause major internal bleeding.

In rare cases, an ectopic pregnancy can implant elsewhere, such as the ovary, cervix or even a previous Cesarean-section scar.

Ectopic pregnancy is rare. National estimates that have relied on hospital and insurance records suggest that between 1 and 2 percent of pregnancies in the United States are ectopic.

Because ectopic pregnancy occurs when a fertilized egg gets stuck on its way to the uterus, the risk is higher in women whose fallopian tubes are scarred or have been damaged by inflammation. For instance, women who have had surgery on a fallopian tube or who have had certain sexually transmitted infections, like chlamydia, may be at higher risk.

Other potential risk factors include fertility treatments such as in vitro fertilization.

But the American College of Obstetricians and Gynecologists notes that roughly half of women who have an ectopic pregnancy do not have any known risk factors.

Ectopic pregnancies are never viable, said Dr. Beverly Gray, an associate professor in the department of obstetrics and gynecology and founder of the Duke Reproductive Health Equity and Advocacy Mobilization team. A fertilized egg cannot survive outside of the uterus.

“There is no way to reimplant them,” she explained. “There is no way that pregnancy will survive.”

A woman with an ectopic pregnancy may have a positive pregnancy test, but that is simply because the body is making human chorionic gonadotropin, the pregnancy hormone, Dr. Gariepy said, not because the pregnancy is proceeding normally.

And when a fertilized egg implants in the fallopian tube, it puts a woman’s life at risk.

“I sort of think of it as a ticking time bomb,” Dr. Gray said, adding that in her experience, the condition is usually diagnosed between the fifth and eighth weeks of a pregnancy. “This is a pregnancy that as it continues to grow will cause the tube to rupture and cause basically uncontrolled bleeding.”

Dr. Gariepy said that in rare cases, the body will expel an ectopic pregnancy on its own. But for the vast majority of women, the only options are medication to remove the pregnancy or surgery.

If an ectopic pregnancy is diagnosed within a few days or weeks of implantation — at a point when there is no dangerous bleeding — doctors tend to use a medication known as methotrexate. It is given through an injection and stops cells from growing to end the pregnancy, which is then reabsorbed by the body over several weeks. Methotrexate is not the same drug used for a medication abortion, which involves taking two different drugs — mifepristone and misoprostol — 24 to 48 hours apart in order to block progesterone and start uterine contractions.

Another early treatment option is laparoscopic surgery, in which a doctor makes a small incision in the abdomen and uses a thin tube equipped with a camera lens and light to see the area. The practitioner may remove the pregnancy alone, or both the pregnancy and fallopian tube.

But if the pregnancy continues to grow, it can rupture the fallopian tube and cause heavy, life-threatening bleeding. In those cases, emergency surgery is required.

Early warning signs of an ectopic pregnancy include light vaginal bleeding and pelvic or low-back pain or cramping. Those symptoms overlap closely with common signs of early pregnancy, which can be confusing to women.

Dr. Gariepy also noted that some women are asymptomatic at first, which is one reason routine prenatal screening is important in early pregnancy.

“It can be when you go to your first prenatal appointment and — if this was a desired pregnancy — you’re hoping to see a small gestational sac, and we don’t see a growing pregnancy in the uterus,” she said.

As an ectopic pregnancy grows, the symptoms become more serious. Women may experience sudden and severe pain in the abdomen or pelvis, shoulder pain or weakness, and fainting. Women experiencing any of those symptoms should go to the emergency room immediately.

Again, the 13 current state-level abortion bans make exemptions for medical emergencies.

Still, the American College of Obstetricians and Gynecologists, which deems abortion an “essential component” of health care, has warned that bans can impede treatment of ectopic pregnancy — even if a specific exclusion is included. Bans have the potential to create confusion for patients and health care providers, the group says.

Though those concerns are purely speculative, Dr. Gariepy said she believes they are on doctors’ minds.

“That confusion is really scary to a lot of people who don’t know what to do, or whether or not they can treat ectopic pregnancies,” she said.

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