With the looming prospect of the Supreme Court ruling to overturn Roe v. Wade, several Republican-led states are lining up bills to restrict access to abortion. But enacting sweeping legislation could have unexpected consequences, such as hindering the treatment of ectopic pregnancies, which can threaten the life of the mother.
Ectopic pregnancies occur when a fertilized egg implants outside of the uterus. These pregnancies are never viable and do not result in a birth; delays in treatment can result in death. Although most ectopic pregnancies occur in the fallopian tube, an egg can also implant in the cervix, abdominal cavity, ovary, or even the scar from a cesarean section. If the tissue where the egg is implanted grows to a point of rupture, this can lead to internal bleeding and require immediate surgery. About 1 to 2 percent of pregnancies in the United States are ectopic, and ruptured ectopic pregnancies account for nearly 3 percent of pregnancy-related deaths.
“The biggest risk would be if the pregnancy grows to a point where whichever tissue it’s within can no longer support it or cannot keep it contained,” said Selina Sandoval, an OB-GYN in California and fellow with Physicians for Reproductive Health. “These patients can lose half their blood volume into their abdomen in a very quick amount of time. And as you can imagine, that can lead to death.”
Ectopic pregnancies can be treated through medication or surgery. If the ectopic pregnancy has not ruptured, patients can be treated with a medication called methotrexate to prevent the cells in the pregnancy from growing. People with ectopic pregnancies can also be treated with laparoscopic surgery, which becomes a necessity if the pregnancy ruptures.
Treatment of ectopic pregnancies is not always opposed by anti-abortion groups; the American Association of Pro-Life Obstetricians and Gynecologists said in a 2010 statement that it “does not consider treatment of ectopic pregnancy by standard surgical or medical procedures to be the moral equivalent of elective abortion.” A 2019 Georgia bill banning abortions after six weeks specifically excludes removal of ectopic pregnancies from the definition of “abortion.” Treatment of ectopic pregnancy is arguably completely separate from abortion care, as the medical definition of abortion involves removing an embryo or fetus from the uterus, and ectopic pregnancies occur when implantation happens outside of the uterus.
“To equate that care [for ectopic pregnancies] with abortion care is a very dangerous position to take, because this is very different,” said Beverly Gray, an OB-GYN and the founder of the Duke Reproductive Health Equity and Advocacy Mobilization team at Duke University, in a press call on Tuesday.
But some new bills restricting abortion access lack specificity that critics worry could affect treatment of people with ectopic pregnancies. A sweeping new bill under consideration in Louisiana would allow prosecutors to charge anyone who undergoes or provides an abortion with murder, which opponents worry could result in penalizing women who experience miscarriages or ectopic pregnancies. The legislation changes the legal definition of a “person” from a fertilized egg that has been implanted in the womb to simply a fertilized egg. Another bill banning abortion if the Supreme Court overturns Roe, under consideration in Ohio, would include exceptions for the life of the mother, but opponents say that the rules are too stringent and require physicians to jump through hoops that could delay treatment.
Some recently considered bills have explicitly attempted to limit treatment of ectopic pregnancies. Legislation introduced in Ohio in 2019 would have required doctors to attempt to “reimplant” an ectopic pregnancy, which is medically impossible. This year, a Missouri bill severely restricting abortion access appeared to ban treatment of ectopic pregnancies; this language was removed after public outcry, and the sponsor of the bill said that it had been misconstrued.
It’s possible that provisions that could affect treatment for an ectopic pregnancy stem from a misunderstanding on what that care entails. The Ohio lawmaker who helped write the 2019 bill calling for ectopic pregnancies to be reimplanted acknowledged that he had not consulted with physicians before he proposed it. “Giving them the benefit of doubt, I’m assuming that it’s coming from a place of not understanding medical treatment—which isn’t their job to understand, which is why they shouldn’t be passing bills affecting medical care,” Sandoval said.
But some lawmakers may be unwilling to make exceptions under any circumstances, even if there is no chance a pregnancy will be viable. During the state Senate debate for the Oklahoma bill, which allows some abortions in cases involving rape, incest, and medical emergencies, one state senator questioned why there should be exceptions for ectopic pregnancies.
“Ectopic pregnancy is an area where we can see very clearly areas where legislators have overstepped their understanding of medicine,” said Jonas Swartz, assistant professor in the Department of Obstetrics and Gynecology at Duke University, during the press call on Tuesday. “The discussion of ectopic pregnancy in the same realm as abortion is really dangerous, and does show us that as we restrict abortion, we’re creeping into other areas.”
Even if legislation does not include provisions specifically outlawing treatment of ectopic pregnancies, confusion can have a “chilling” effect for providers and patients, said Mary Ziegler, a professor at Florida State University and the author of several books on abortion rights in the U.S. This can result in delays that threaten the health of the mother.
“I think that there are going to be patients who may not seek care because they’re going to be afraid of criminal consequences for themselves, whether or not the law actually authorizes that. And I think there’ll be doctors who are afraid of the consequences who may not provide care because they’re afraid of something happening to them,” said Ziegler. “Sometimes it’s not just even a matter of what the law is, it’s what people think the law is, and how afraid they get as a result, that can have an effect on the kind of care people actually receive.”
The stringent abortion restrictions passed in Texas last year include exceptions for medical emergencies, for example, but does not define the term. In October, The Lily reported the story of one woman with an ectopic pregnancy who was denied treatment by her doctor—who was worried about being sued—and then turned away at an emergency room. Additionally, Kaiser Health News reported on Wednesday that a pharmacy had told many OB-GYNs in the Austin area in late 2021 that it would no longer fill the drug methotrexate, the medication used to treat ectopic pregnancies, because of the recent Texas law. While the director of the Texas Right to Life told KHN this was a misreading of the law, the confusion nonetheless was apparently enough to provide a roadblock to potentially life-saving care.
Most physicians agree that an ectopic pregnancy should be treated as soon as possible, before it ruptures; these restrictions could create uncertainty about how long doctors should wait before treating such an emergency.
Ectopic pregnancies can be diagnosed through ultrasounds or blood tests. Sandoval raised concerns about waiting to treat ectopic pregnancies that could not initially be seen on ultrasounds, even if all signs pointed to an unhealthy pregnancy. “Those patients will delay their care, presumably until the mass is, let’s say, large enough to be seen on ultrasound. That’s dangerous, delaying that care,” Sandoval said. “We don’t always have a black and white diagnosis for these pregnancies. But the standard of care is to treat them in a way that protects your patient’s health. And if we have bills that are outright banning abortion, this can affect the ability to do that.”
Laws restricting or outlawing abortion can also affect care for patients who have miscarriages, as miscarriages and abortions are treated similarly. Moreover, medical students in some states are already receiving limited training in abortion care, the Associated Press reported, which can have ripple effects for miscarriage treatment. There are also questions about what restrictive measures can mean for in vitro fertilization and contraceptive care.
Socially, laws outlawing abortion could also affect how people who have undergone miscarriages or ectopic pregnancies are treated. Women who have experienced a miscarriage or ectopic pregnancy are already more likely to develop post-traumatic stress, anxiety, and depression, according to a 2020 study by the American Journal of Obstetrics and Gynecology.
“People are not going to be believed, sometimes, when they say they’ve had a miscarriage or an ectopic pregnancy. There’s going to be people who are trying to smoke out people who are lying about an abortion. And I think that could be stigmatizing,” Ziegler said.