Ectopic pregnancy clarifications

I fully expected to receive some criticism for my post on Ectopic Pregnancy and the Sanctity of Life, and I felt the need to moderate with a heavier hand than usual since many of the negative comments I received on this post seemed to center around the same few misunderstandings.  Although I have no problem with publishing dissenting comments (and I did publish most of them on that post), I felt that it was not helpful to have many angry and upset women using the same straw man arguments against assertions that I never made.  In light of that, I’d like to clarify a couple of points.

Emergency medical care

Many women commented and/or emailed to tell me that my post and my conclusion were dangerous because they had a ruptured tube and nearly died, or would have died had they not sought immediate medical attention.

Maybe I wasn’t clear enough, but I never suggested that a woman with an ectopic pregnancy should avoid medical care, and I certainly didn’t intend that a woman whose tube has ruptured should hesitate to get emergency care. Although tens of thousands of women in the US experience tubal rupture each year and only about 30 die, I never denied that such a situation requires immediate medical attention.

We would personally pursue any treatment for both the mother and the baby that would treat both as viable patients, even if it only gave the baby infinitesimally small odds of survival. We seek to preserve both lives no matter how feeble our efforts are instead of self-consciously ending one life.  At the present, this might mean no more than waiting for surgery until we had an indication that the child had died – a ruptured tube and/or internal bleeding would be a very good sign that it was time to proceed. In the near future, we might have more and better options.

The point was that those of us who call ourselves pro-life and and object to legalized abortion must re-evaluate the practice of automatically terminating an ectopic pregnancy in the hopes of preventing tubal rupture. The advice given to us by the medical community is not generally based upon a Christian view of the sanctity of life, nor is it necessarily borne out in statistics.

Statistics

This brings me to a second misunderstanding that arose in several comments: the source of my statistics. I’m not sure why; I depended heavily upon:

  • the CDC
  • WHO (World Health Organization)
  • well established medical sites which provided references for their information
  • medical journals which provided information on individual cases and other statistics that were otherwise difficult to find
  • big-name online news sources that provided documentation of infant survival stories.
  • Wikipedia was also cited for its broader information, definitions, and multiple additional resources.

Interestingly, those who objected to my statistics either didn’t provide any conflicting information at all, or else they made broad statements without citing any source at all.

And while we’re on the topic of statistics, I think this puts things in perspective:

Many commentors who had experienced ectopic pregnancies were told by their doctors that they were lucky to be alive.

According to the CDC, from 1985-1995 an average of 83 people died in the US each year from lightning strike.  Also according to the CDC, from 1991-1999, an average of 26 people died each year from ectopic pregnancies, from among the 20-40,000 that ruptured each year.

A US resident has a 3 times greater chance of dying by lightning strike than by ectopic pregnancy.

I don’t believe in luck; I believe that God is sovereign over every sparrow that falls, every hair of our heads, and every pregnancy no matter how it begins or ends.  But if I did believe in luck, I would not feel lucky to be alive after an ectopic pregnancy; rather, I would believe that it takes a pretty strong dose of bad luck to be one of those unfortunates who died.

Terminology: Abortion

A third problem was that the use of the term abortion provoked a strong reaction from some readers. Let me remind you that I did not choose the term. That is how the procedure is described in the medical community. I didn’t do it for shock value, but for accuracy. If you find it shocking, maybe this is another reason to reconsider the standard preventative treatment.

The past

Lastly, if you have suffered an ectopic pregnancy in the past and dealt with it by terminating the pregnancy, please understand, I didn’t research and write my post to make you feel guilty about the past.  We have all made poor choices, often under poor advice with the best intentions. If a decision is made in ignorance on our part on the bad or immoral advice of a doctor then the doctor will stand before God for the advice he or she gave. This is why we are warned to “let not many of you become teachers for teachers have a stricter judgment.”

But we are still accountable for our decision, and because all of our decisions are inescapably moral – Christ said you are either with me or against me –there is no neutrality in life.  If any of us makes a decision that is sinful- and preemptively taking an innocent human life is a sin – we must repent.  After all, if we confess our sins he is faithful and just to forgive us our sins and to cleanse us from all unrighteousness.

If you have read all of this and you still feel angry, attacked, or condemned by my words, please take a moment to read my Standard Disclaimer.

The Point

I didn’t aim to judge or condemn, but to share some information that I found highly encouraging: that contrary to popular practice and opinion, there is an alternative to automatically and immediately terminating the pregnancy.  Of course, there always was an alternative – but I found great encouragement in seeing the statistics show that once again, the wisdom of this world is foolishness with God.

Ectopic pregnancy and the sanctity of life

As Christians, we are unabashedly, 100% pro-life. We believe that life begins at conception; that every human life is created in the image of God; and that abortion is wrong in every case. This is where we differ from many other “pro-lifers” who are willing to grant that abortion may be merited in certain cases.

Abortion is murder – even in cases of rape, incest and when the life of the mother may be at stake. We must never reason from difficult cases to make ethical judgments and we must understand that modern bioethics and medical ethics are not reasoning from God’s law.

Doug Phillips recently broached the question of ethical treatment of ectopic (tubal) pregnancy on his blog when he posed the following question from the Witherspoon School of Law and Public Policy:

A mother conceives a child. The doctor tells the parents that they have a tubal pregnancy and that the baby has little to no chance of survival, but its continued life poses a threat to the life of the mother. What are the relevant biblical principles? What facts must be determined to make a biblical ethical decision? What medical options might be available. Is killing the baby through abortion defensible through Scripture? If so, defend your position? If not, defend your position? Are there other options?

Certain loud sectors of the blogosphere accused him of endangering the lives of countless women because he suggested they might not need to automatically and immediately abort an ectopic pregnancy.

I was intrigued by this question and the possibilities it presented, and I was not ready to accept the assumption that failure to aggressively treat an ectopic pregnancy amounts to suicide.  I stayed up until 1:00 that evening researching the subject, and here is what I learned.

ECTOPIC PREGNANCY

Ectopic pregnancy is a pregnancy in which the fertilized egg implants outside of the uterus. In 95-98% of cases, it implants inside the fallopian tube – this is why it is commonly referred to as tubal pregnancy. Other possible locations are in the cervix, an ovary, or in the abdomen where it will attach to a blood supply such as the bowel or liver.

TREATMENT OPTIONS

The standard treatment for ectopic pregnancy follows one of 3 courses: chemically induced abortion (usually by means of a drug called methotrexate); removal of the entire fallopian tube which contains the baby or a the affected portion of the tube; or removal of the baby and subsequent repair of the affected fallopian tube.

All 3 approaches directly result in the inevitable death of the child.

However, there is at least one more option: Wait. Be ready, but wait. Treat the mother if necessary but do not kill the child. No abortion.

The primary argument against the Watchful Waiting method of treatment is that it is dangerous to the mother. Alarmists will try to equate it to a death sentence – and for what? The child was doomed from the start, right?

No. The outcome is not so easily predicted as some would have you think.

PROGNOSIS/OUTCOME

Yes, there is a high likelihood that the child will die. How high? Nobody really knows, because nobody seems to recommend this approach. There was recently a documented case of anundiagnosed ectopic pregnancy that was delivered by c-section at full term. There are others as well: A baby born in 2000 was attached to the mother’s bowel, as was this one in 2005. This 1999 triplet developed in the fallopian tube, while his two sisters grew in the uterus. The triplet article states that there are 60-100 cases of babies growing outside the womb and surviving.

update: Here are 5 more documented cases of ectopic survivors. Thank you to Christina for the link.

Yes, these cases made headlines and amazed the whole world, but how many more cases would do so if we didn’t diagnose and automatically abort them? This site seems to indicate that the prognosis for the ectopic child is not entirely hopeless, at least in the case of abdominal pregnancy:

Prognostic: The abdominal pregnancy is associated with high maternal (0-20%) and perinatal (40-95%) mortality. Maternal mortality is about 5.1:1.000 compared with 0.7:1.000 in other ectopic gestations. The perinatal mortality has been traditionally high. However recent progresses have result in a 70-80% increase in the survival in fetuses older then 30 weeks…

But what about the mother? Is it right to sacrifice her life with so little hope of gaining the life of the child? In the case of abdominal pregnancies that are allowed to continue, the article above goes on to state that:

Mortality and maternal morbidity are directly related to the removal of the placenta during childbirth. The remove of the placenta depends on the degree of invasion, the location of insertion, the involvement of the other organs and the surgical access to the placental blood supply. If it is possible, the complete placental extraction should be done. If not, the placenta should be left at the place, following by occlusion of the umbilical cord. The subsequent management is expectant. The placental reabsorption can be accelerated with methotrexate, selective arterial embolization and secondary laparotomy.

So the life of the mother may be in danger, but she is far from doomed! There are procedures for dealing with the risks of advanced abdominal pregnancy – procedures which allow for the possible survival of the child!

For those pregnancies which implant in the fallopian tube (far more common than abdominal pregnancy), the dangers are surprisingly moderate. Although many will succumb to scare tactics, a plain reading of the statistics can be very reassuring.

STATISTICS

  • Currently, up to 1 of every 50-60 pregnancies is estimated to be ectopic.***
  • Over 100,000 ectopic pregnancies were reported in the US in 1992.
  • 1 out of 2000 ectopic pregnancies ended in the death of the mother for the 1970’s and 1980’s. The mortality rate has fallen even lower in recent years due to advances in medical care. Recent estimates put it at ~3 in 10,000.
  • At least 14 studies have documented that 68 to 77 percent of ectopic pregnancies resolve without intervention (American Academy of Family Physicians).
  • Tubal rupture occurs in approximately 20% of cases. The statistics seem to indicate that this is the number of women whose initial symptom is tubal rupture, i.e. they receive no treatment at all prior to rupture. Studies indicate that another 10-30% may experience rupture while under medical care.
  • Contrary to popular belief, death from rupture is rare where medical attention is available. In the US, 25-50 women die from ectopic pregnancy each year out of about 100,000 reported cases.

Let’s do the math, shall we? In spite of the fact that hospitalization and surgical treatment pose risks of their own and many women have surgery without having experienced tubal rupture, we will generously assume that all of the reported deaths occur among those women who didn’t receive treatment until after rupture.

If there are 100,000 ectopic pregnancies reported each year and 20% of them result in rupture of the fallopian tube, then about 20,000 women are treated annually in the US for actual tubal rupture. A total maternal death toll of 50 would mean that 1 in 400 of those who experienced tubal rupture died. That’s a death rate of 0.25%.

Since rates of ectopic pregnancies have continued to increase rapidly while mortality rates for the mothers are decreasing, actual current numbers would look far better: a death toll of 25 (the number reported in 1992, the most recent I could find) would bring the chance of death after rupture down to 1 in 800, or 0.125% (20,000 ruptures divided by 25 deaths).

A mother who is aware of the situation and under a physician’s watchful care would likely fare even better. If we accept 40% as the rate of eventual tubal rupture (20% happening initially and the other 20% occurring during treatment and medical care), then we have a death toll of 25 out of 40,000 cases of rupture, or a 1 in 1,600 chance of death.

CONCLUSION

The chance of death for a mother who chooses not to abort an ectopic pregnancy appears to be something less than 0.25% – possibly as little as 0.06%, or about four times the risk of full-term labor and delivery.

Does this sound like a death sentence for those who would refuse to abort an ectopic pregnancy? Or does this sound like a reason to reconsider the standard course of action in a difficult situation?

We should always question the presuppositions of the scientific community – from stem cells to aborting tubal pregnancies – because they DO NOT reason from a Christian foundation. Once we begin to question them and their assumptions we start to realize that they are not as sure of their conclusions (or shouldn’t be) as they claim to be.

As Christians, we must always begin with God’s word and work from there. Some decisions will be easy and others will be difficult, but all must begin from the same foundation: God’s Word is authoritative and sufficient for every facet of life.

When we start from this presupposition, we just might find that the difficult decisions aren’t so difficult after all.

REFERENCES

CDC Ectopic Pregnancy Surveillance 1970-1978

Medline Plus Medical Encyclopedia

Ectopic Pregnancy: Dr. El-Mowafi

Ectopic Pregnancy on Wikipedia

Time and Risk of Ruptured Pregnancy

Study: An Institutional Review of the Management of Ectopic Pregnancy

Fast Facts on Ectopic Pregnancy

eMedicine: Ectopic Pregnancy

Ectopic Pregnancy: Risk Factors

*** Figures from the 1940’s estimated that about 1 in 30,000 pregnancies was ectopic. This number has skyrocketed due to common risk factors: hormonal birth control and IUDs, tubal ligations, STDs, PID (Pelvic Inflammatory Disease, usually a result of STD caused by promiscuity), in vitro fertilization, and abortions – all practices which many Christians find ethically questionable or morally wrong.

follow up here: Ectopic Pregnancy Clarifications