The inalienable right to life possessed by every human being is present from the moment of initial formation, and all human beings shall be entitled to the equal protection of persons under the law.
The Personhood Debates
Debate 10: Ectopic Pregnancies
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Susan
What percent of women with ectopic pregancies actually die from those pregnancies?
Francesca in 2004 a report was published accounting for 11 cases of maternal death in the previous 3 years (in the UK alone). You can quickly search for clinical publications and perhaps you'll find reports for other States. (http://jrsm.rsmjournals.com/content/99/2/90.full)
Bill In America, there is a .1% likelihood that an untreated ectopic pregnancy will result in the death of the mother. In other words, 99.9% of American women with untreated ectopic pregnancies survive the pregnancy. (Untreated ectopic pregnancies are those which are not treated prior to either delivery or rupture.)
http://www.abort73.com/end_abortion/is_abortion_ever_justified/
Francesca
But then treatment is necessary once it ruptures am i right?
Bill
That is correct.
Francesca
So I believe the eventual death caused by an ectopic pregnancy refers to the fact that if untreated and if it ruptures it is a life threatening situation. in the absence of medical intervention at some stage during an ectopic pregnancy, and certainly after rupture, the life of the mother is at serious risk. I think that medically is safer, for the mother, to avoid rupture.
I agree that the pregnancy itself is not the direct link to the risk of maternal death (ie if it was a poison the cause and effect would be direct), the risk is the internal bleeding caused by the tube rupturing, caused by the growing pregnancy. But the numbers should reflect deaths that are happening following an ectopic pregnancy if untreated at any stage.
Bill
The .1% figure includes all ectopic related maternal deaths which occurred within 1 year of either the rupture or the delivery of the child. There is a very successful, post-rupture treatment available. According to a world wide study of 632 cases, the use of autotransfusion has been 99.6% successful at preventing death in cases of ruptured ectopic pregnancy.
http://www.ijgo.org/article/S0020-7292%2802%2900379-X/abstract
Francesca
Yes, no doubt, but do you think it's worth going through such a major surgery when intervening before the ectopic ruptures is so much easier on the body? Have you found any case of tubal ectopic pregnacy which resulted in live birth?
Bill
Yes, there are many cases of tubal pregnancies which have resulted in live births. I have included several of them in my articles on ectopic pregnancies. Additionally, the term "abdominal pregnancy" often refers to a tubal pregnancy that has re-implanted in the abdomen after either rupturing or otherwise escaping from the fallopian tubes.
"Abdominal pregnancy may be classified as primary or secondary. The secondary type is much more frequent and is the result of extension of a tubal gestation onto the peritoneal surface after partial disruption of the initial implantation site in the follopian tube. Most of these reimplantations take place in the pelvis. Primary abdominal pregnancy is extremely uncommon."
( http://www.ajronline.org/content/173/5/1377.full.pdf)
Here is a recent example of a successful tubal pregnancy:
http://news.bbc.co.uk/2/hi/health/443373.stm
And here is an example of a successful ovarian pregnancy:
http://www.ntnews.com.au/article/2008/05/30/4247_ntnews.html
Francesca
I read the article, very interesting case and about one in 60 million like the doctor states. I suspect that when the pregnancy reimplants in the abdomen, it starts at the fimbrial end of of the tube (so not the least likely position for a tubal pregnancy) so much so that when it ruptures or it's naturally is expelled in the abdomen it doesn't cause severe blood loss. The most common cases of tubal ectopic pregnancies are in fact located in the ampullary region of the tube, the rupture of which would cause internal haemorrhage and potential death.
Bill
Yes, the doctor is referenced as saying that the child had a one in 60 million chance of surviving, but there is no explanation of how he arrived at that figure. The scientific literature, however, records an astounding number of such successes. For example, here are two more:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1582720/pdf/canmedaj00596-0056.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1562056/pdf/canmedaj00522-0133.pdf
Francesca
I read both papers with great interest. In the one from 1937, two cases are reported, in neither cases the baby survived, in the first one the pregnancy got to about 12 weeks. In the second case the pregnancy got to about 16 weeks (though the dates seem not to match up with the weeks). In the first case the mother almost died and in the second case she indeed died. In the 1946 paper the pregnancy got to full term but the baby died nonetheless and the mother almost died. So I'm not sure if you attached the wrong papers, because they don't actually seem to prove your point at all. Three cases reported in the two papers, none of them has a surviving baby.
Bill
Ah, yes, those were the wrong papers. Those two papers were actually from my list of papers which support the fact that most abdominal pregnancies begin as tubal pregnancies. Here are several from the correct list:
http://www.theprofesional.com/article/2006/Vol-13-No-02/Prof-1065.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2086722/pdf/brmedj04281-0010.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2098249/pdf/brmedj03046-0021.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2602194/pdf/yjbm00484-0042.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2160918/pdf/brmedj04044-0013a.pdf
http://humrep.oxfordjournals.org/content/14/5/1372.full
Francesca
2006 paper. Baby does not survive, mother is fine. Authors state high maternal death rate and that cases of abdominal pregnancies are 0.04% of all pregnancies and 5.6% of all ectopic pregnancies.
1938 paper. The delay necessary to obtain a living child is never justified in the face of the danger to the mother, the high foetal mortality, and the incidence of deformities. Maternal mortality 14-33%.
In the reported case, pregnancy does not get to term, surgery is needed due to poor health conditions of the mother, baby does not survive.
1960 paper. Authors acknowledge how lucky they were in not having a case of maternal death out of the 10 abdominal pregnancies they encountered. 4 of the 10 babies survived. They conclude that “While most cases should be dealt with by IMMEDIATE LAPAROTOMY, it may be justifiable on SOME occasions and with adequate safeguards to allow the pregnancy to continue until the foetus is certainly viable. “
The’s paper (maybe 1946). One case of living child and mother. Again they state how previous literature shows that perhaps in total there were 80 cases where both mother and child survive.
1942 paper. Live baby and mother. Author states this was likely a case of primary abdominal pregnancy (not generated by the rupturing of a tubal pregnancy). Author states how this is an unusual outcome where no harm was caused by this pregnancy to the mother, in fact he writes he could not find any other reported cases in the literature.
1999 paper. They state that cases of surviving ectopic tubal pregnancies documented in the literature are rare and accounting for about 10.6% of ALL recorded cases (435). They quote that “The incidence of abdominal pregnancy as reviewed in the world literature is as high as one in 8000, with a perinatal and maternal mortality of 75–95% and 2–18% respectively”. They report on one case of live twin heterotopic pregnancy. In total there have been 13 cases out of 589.
I would like to ask you a question. Have you ever found a physician who would try to carry a pregnancy to term should he discover early in the gestation that the location is abdominal? Of course I know that no physician would consciously wait to treat a tubal ectopic pregnancy till it rupture (i.e he/she would hope it won’t rupture during the wait and see period).
Also, I am not sure what your background is, but I would like to point out that cases reported in the literature are in fact JUST cases,if I it was the norm you wouldn’t read about it. None of the papers you reported invite or even suggest the possibility of willingly allow for a pregnancy outside the uterus to be carried to term as they life of the mother is at too great risk and the life of the foetus not a given, by any means.
Bill
You are missing the point, Francesca. For now, let's just take the numbers that you list at face value. What conclusion could be drawn from them? Can we conclude from these numbers that abortion in the case of ectopic pregnancy is justified? Not at all. You see, according to the figures that you just listed, the baby has a 5-25% chance of surviving a full term ectopic pregnancy while the mother has a 2-33% chance of not surviving such a pregnancy. If we take the median of those two ranges, we arrive at values of 15% and 17.5% respectively. This means that you are arguing for killing every single child discovered to be in an ectopic pregnancy simply because the likelihood of the mother dying is 0.167 times higher than the likelihood of the child surviving.
Now, let's take a closer look at those numbers. First and foremost, it is important to realize that the rates given for fetal mortality are not the same as rates for live birth. Fetal mortality is usually measured in terms of survival beyond a certain number of days. Most authors have followed Hellman and Simon's 1935 viability standard of survival beyond eight days. As far as I have been able to ascertain, the rates for live birth have always been high.
This, of course, brings us to the consideration of the treatment provided to these children after their birth, and on this consideration, the literature is remarkably silent. After reading hundreds of case reports, I have noticed that it is very, very unusual for those reports to include any reference to treatment provided to the newborn infant. In the vast majority of cases, the doctor simply states that the child was born alive, lists the weight and size as well as the APGAR score (usually in the 4-6 range indicating the need for medical intervention) and then states that the child was struggling to breath and that he died within a certain time frame. Given the scarcity of reports of medical intervention being provided for these children and the understanding that most laparotomies on ectopic patients are initiated with the intent of aborting the pregnancy, it is reasonable to conclude that most of these children were simply set aside and allowed to die.
Once it is established that the fetal mortality rate refers to the death of children outside of the womb, then it becomes necessary to consider other factors such as the time range included in the figures for fetal mortality. Most of the large studies include reports from as far back as 1809. Obviously, we would not expect the fetal mortality rate in the 21st century to be comparable to the rate of the 19th century. We must also consider the facilities in which each surgery was performed. Most full-term ectopic pregnancies occur in third world countries where early detection and abortion is not possible. There are very few maternity wards in third world countries that are equipped to handle ectopic pregnancies. Prior to the acceptance of abortion in America, there were several efforts to provide the necessary materials and training, but ever since abortion became the preferred treatment in America, the focus has been on early detection which has served to increase the mortality rate for the mother and the child due to shortages of both equipment and experience. Once we recognize that these children are dying after birth rather than before or even during birth, then there are many additional factors which should be studied but which are seldom even mentioned in the literature.
You see, the point which you are missing is that the children mentioned in all of these reports are people. They are not just masses of fetal tissue with no hope of survival. They are living, breathing people. Sure, some of them die at a young age, but that is true of all people. The unfortunate fact that some children will never live to see their first birthday does not in any way justify killing a child at any time prior to his natural death.
Furthermore, you are overlooking the fact that all of the figures for fetal and maternal mortality rates in these papers are given for the category of advanced abdominal pregnancy alone. As I noted in an earlier post, the total rate of maternal deaths from ectopic pregnancies which are not treated prior to rupture is 0.1%. The vast majority of these pregnancies resolve on their own with very little risk to the mother. That is why there are several physicians which have advocated for expectant management of ectopic pregnancies instead of early abortions. You can find a number of papers on this treatment plan through Google, but here is just one example: http://www.pngimr.org.pg/png_med_journal/Advanced%20viable%20-%20%20Mar%2097.pdf.
Susan
And have they managed such cases? What is the outcome of these managed ectopic pregnancies?
According to the above article: Maternal mortality is from severe
intraabdominal haemorrhage as well as
infection. In the USA Atrash et al. (3) reported
that the risk of dying from an abdominal
pregnancy is 8 times greater than the risk of
dying from a tubal pregnancy, and 90 times
greater than with a normal intrauterine
pregnancy.
Bill
Yes, there is a risk of death in ectopic pregnancy. I'm not saying that these pregnancies are joyful and pain free. I'm simply pointing out that they are far from unquestionably fatal for either the mother or the child. Consequently, the intentional killing of the child cannot be justified. Since survival is possible for both the mother and the child, the doctor must strive to the best of his ability to save both patients.
Susan
I believe every effort should be made to save both the mom and the baby. As a lifeguard I learned that there some situations that you are not able to save all. This is one time that the term "to save the life of the mother" may be accurate. I do feel however that clear information must be available so an informed decision can be made. Each person deserves this! Information in this area is so hard to come by. Each person deserves this!
Francesca
I am sorry I don't think I follow your logic at all. No doctor is taking chances if the mother life is at risk (even minimal). I know well what "expectant management" is and there is no one "advocating" for this as the NORMAL course of action in case of an ectopic pregnancy, you have this fact wrong. Expectant management is allowed ONLY when hcg levels and physical examination indicate that the mother is stable and that the pregnancy is resolving itself (meaning it's not progressing). Should HCG start rising and the mother's condition deteriorate (pain, unstable blood pressure etc) immediate intervention will take place. If the mother is well but HCG are rising nonetheless, MTX may be given to avoid surgery (and even MTX can only be given when specific parameters are met). If HCG are stable or low but mother's condition deteriorates, surgery is performed (there are cases of ruptured EP even with very low hcg). Certainly this is how it is done in Ireland and as one of the founder of Ectopic Pregnancy Ireland I can tell you I have my facts straight. Also I couldn't really find any reference to the mortality of 0.1% of all ectopic pregnancies for the mother, can you link me the source of this? Thanks.
Bill
Let me ask you this, Francesca. Do you think that expectant mothers should be permitted to abort their pregnancy at any time and for any reason that they choose?
The .1% figure was presented on the abort73 website linked in my first comme nt, and it is supported by my own calculations in which I arrived at a very generous figure of .4% for the Soroka University Hospital in Be'er Sheva. You can read and verify my calculations at:
http://www.personhoodinitiative.com/ectopic-personhood.html
By the way, if you are one of the founders of Ectopic Pregnancy Ireland, then perhaps you could correct an error on your groups website. On the "Medical Information and FAQ" page, your site states that "Unfortunately, an ectopic pregnancy cannot be saved ... If there is any risk of rupture, the pregnancy must be removed."
This is an incorrect statement. The article "Full Term Intra-abdominal Pregnancy" by Hellman and Simon documented 316 ectopic pregnancies of greater than 20 weeks gestation between the years of 1809 and 1933. 312 of those pregnancies resulted in a live birth, and 158 of the children survived more than eight days with many of them being reported to be both healthy and normal. The claim that an ectopic pregnancy cannot be saved is false.
http://www.archive.org/download/FullTermIntra-abdominalPregnancy/Abdominal_Pregnancy.pdf
Francesca
I personally would not abort a pregnancy. Imagine that my two ectopics happened after years of infertility and IVF treatments! The last thing I wanted was to lose those pregnancies! But when it came to evaluate the risk for my life, the doctors made it very clear that this could not progress, and having quite a solid scientific background myself I could only agree. I will check out that website now, I am not sure how they possibly came to that conclusion to be honest. For what concerns our website and the medical information, they have been written and verified by OBGYNs in the National Maternity Hospital in Dublin and while you may disagree, the fact that ectopic pregnancies cannot be saved is the general agreement among scientists and medical doctors. The occasional exception to the norm does not make the statement itself less valid. Miracles do happen sometimes (to others as far as I'm concerned) but it's unrealistic to give false hopes to those who are already going through an emotional and physical ordeal.
I read the article published on the abort73 website. I have a few comments. They make the assumption that deaths linked to ectopic pregnancies are associated to UNTREATED ruptured ectopic pregnancies. Where did they get this from? I think it's much more likely that those deaths are happening DESPITE medical medical intervention and so that the number would be much much higher if there was no medical intervention. Also, they say that 20% of ectopic pregnancies present as first symptom with the rupture of the tube (ie the woman didn't know she had an ectopic pregnancy till it ruptured) but this means that in fact 80% of ectopic pregnancies are discovered before the mother's life it at risk and medical intervention takes place (or the pregnancy resolves itself). Again they make the assumption that the deaths are among those 20% assuming they are untreated. But to be honest I find it difficult to believe that a medical report would deal with deaths linked to no medical intervention. Generally it's the complete opposite.
Bill
I'm not asking about your pregnancy in particular. I would like to know if you think that elective abortions should be permitted in general.
Francesca
I would say that I am pro-choice. Though I am not sure why this matters when we are discussing scientific/medical points. Do you think I ma bias because of this?
Bill
Thank you, Francesca. That helps me to understand your position better. Knowing that you see nothing wrong with a woman choosing abortion when there is no risk to her health makes it much easier to understand why you are so adamantly in favor of abortion in situations in which there is a substantial risk to the mother's health. As long as you maintain that the unborn child does not have an inherent right to live, it is unlikely that any amount of evidence will change your position on ectopic pegnancy. If you will permit me, therefore, I will switch tactics slightly and ask you when you believe that the right to life begins.
Susan
Personhood, I am hugely pro-life and am trying to figure this out for myself. I do believe that it is unfair to say all Frans thoughts are mearly because she is pro-choice, though some maybe. Although, I do believe your last question was important.
Francesca, I see that you might have had to make a personal choice in this area. If so, I am sorry for your loss.
Personhood, I do think this is a discussion worth having though I fear caution is in order due the risk to mom. As I said, I value the unborn.
Francesca
I have no problem in answering but I wouldn't want my points not to be addressed either. Susan thank you for your words, it was unbearably difficult, but I do have a one-year old now and he is the joy of my life!
I would certainly not say that I "see nothing wrong with a woman choosing abortion"! As I stated before, I would never make that choice for myself. I grew up in a Country where abortion is legal but never abused (like I think it may be in some parts of the States, ie used instead of contraception), now I live in a Country where it's not legal and I see people travelling abroad to terminate a pregnancy. I do think that there may be circumstances where a very painful decision appears like the only possible solution and I believe proper medical care should be available. Also legislation is different in different Countries on abortion too. Above all, i would NEVER consider terminating an ectopic pregnancy at the same level as terminating a normal pregnancy, never. And this is about ectopic pregnancies.
Bill
Ah, but if the purpose of permitting abortion for ectopic pregnancies is to save lives, then it is necessary to know if you consider the unborn child to have a right to life that is equal to that of the mother. Your position so far seems to be that the mother has a greater right to life than the child: that her survival should be the primary consideration. If a 30 year old woman and her 13 year old child were rushed into the hospital with one of them needing a lung transplant and the other needing a heart transplant, I am certain that you would oppose a decision by the doctor to kill the child in order to harvest his organs and save the 30 year old woman. If so, then there must be a point at which you consider the life of the mother and the life of the child to be equally worthy of protection. I would simply like to know when in the life of the child that point of equality materializes.
Just a few months ago, the Journal of Medical Ethics published an article entitled "After-birth abortion: why should the baby live?" In that article, the authors reached the following conclusion. "[W]e argue that, when circumstances occur after birth such that they would have justified abortion, what we call after-birth abortion should be permissible." The authors of this paper are not alone in that opinion. They cite the fact that this is already legal to some extent in the Netherlands, and they reference the works of other authors such as Tooley and Singer who have also argued in favor of infanticide. Do you agree with the conclusion of these authors? At what point in a child's life do you think that he gains a right to life that is equal to yours?
http://jme.bmj.com/content/early/2012/03/01/medethics-2011-100411.full.
Francesca
I am very familiar with the article that you have mentioned. No, I do not agree with that at all. Once a baby is born everything should be done for his well-being. I suppose I don't see this issue as just black and white like you seem to do. Maybe in your opinion a fertilised egg is already a potential child and as such should have rights. I don't see it the same way certainly at a cellular level. I also think that once a baby is able to survive outside the mother then no termination should be allowed (23-24 weeks gestation). If I have to give you and answer on when I think it is ok to terminate a pregnancy I am not able to do so, there are many reasons that would force a woman to consider this as the only possible solutions and I cannot just condemn them all without distinction. Again, may i point out that this conversation was not about my personal belief on normal pregnancies but on the medical treatment of ectopic pregnancies where the life of the mother is at risk and the foetus has almost no chance of survival?
Bill
I understand your hesitancy, but please bear with me and answer just one more question. If a mother is at 20 weeks of gestation, how certain do you think that a risk to her life must be in order to justify an abortion? If, for example, her doctor told her that she had a 50% chance of dying if she did not get an abortion, would you consider such an abortion to be justifiable? What about 20%, 10%, 1%, or even 0.05%?
Francesca
I have never heard of such a case to be honest. You remind me of an old boyfriend of mine who, to prove his point, would come up with surreal situations in which I had to make hypothetical choices base on which he would make assumption on my ethic and morality. 20 years have passed since then and I don't want to discuss science on highly impossible cases. Having said that, a mother would put the life of her child before hers generally speaking (pregnant women diagnosed with cancer would choose to delay treatments to allow the baby to live) when the child is healthy and will survive. In an ectopic pregnancy this is highly unlikely, termination happens generally within 7 weeks if spotted early.
Bill
Those are not surreal numbers at all. The papers that we just discussed listed maternal mortality rates ranging from 2% to 33% for advanced abdominal pregnancies and it was stated that these pregnancies are 8 times more deadly than tubal pregnancies. This figure would place the risk of death for tubal pregnancy at .25% to 4.125%. You seem to be claiming that risks this low are sufficient for justifying killing a child who has a chance of surviving the pregnancy. I'm simply wondering what the boundaries are for that justification. What is the lowest potential for maternal death that you think justifies killing a child at 20 weeks of gestation?
Francesca
Ok so this is completely different. In the case of an abdominal pregnancy something went wrong already and the intervention at such late stage generally happens to save the mother (and possibly the baby). We are talking of a very very small amount of cases in which early intervention was not possible and now, with an abdominal pregnancy, the life of the mother is at risk. With an abdominal pregnancy that far advanced, with a foetus still alive (we have read that in several cases the foetus is already dead) and with the mother medically stable, it is possible to see if the pregnancy could progress for a few more weeks under strict control to bring the baby to viability (or to term like in the UK case). if the mother's life is already in danger (i don't think there are sufficient cases to make a sound statistic on how likely the mother is to die), than surgery and still birth would be inevitable. Abdominal pregnancies are a very small proportion of all tubal pregnancies, intervening when the preganncy is still tubal (7-8 weeks gestation max, hopefully earlier than that as many EP don't get to 7 weeks) for me is a perfectly reasonable way to not expose the mother to any risk at all.
Bill
Okay, so your position seems to be that all ectopic pregnancies should be terminated by the eighth week of gestation so as to completely eliminate all risk of death to the mother and that this should done without regard for the child's chance of survival. Is that correct?
Francesca
Yes it is correct. Given the fact that a chance for the survival of an ectopic foetus is about 1 in 60 million (as per UK paper) I believe it's not worth risking the mother life.
Bill
Thank you for confirming that. Now, let's consider that figure of 1 in 60 million. If you would be so kind as to review the article again, I believe that you would notice that this figure is not enclosed in quotation marks. It would not be wise to just assume that the reporter correctly represented the doctor's statement, and even if we did make such an assumption, the article provides no evidence to support this claim. There were several additional oddities in this case in addition to the ectopic position of the child, and we do not know whether this figure refers to just the ectopic pregnancy or the combination of an ectopic pregnancy with an intrauterine pregnancy or the combination of an ectopic pregnancy with a double intrauterine pregnancy or any other number of factors. In short, the figure of 1 in 60 million is unreliable.
Given the uncertainty of this figure, if I could present you with a much higher, documented figure for the survival of the child, would you consider changing your position? If so, how high would that figure have to be for your position to change? If not, why not?
Susan
Do you have a documented survival rate for such children?
Francesca
So we are back to numbers. This is the same argument I posed to you a few posts back when I said that the assumptions made on abort73 website about the risk of death linked to an ectopic pregnancy are wrong and misleading as they are taking numbers of reported deaths and assume they are happening when no medical intervention takes place, while I believe those are in fact deaths registered despite medial intervention.
Bill
I noticed your comments about the abort73 article, but I chose to overlook that particular error until we could come back to it. Now, that the conversation has turned in that direction again, let me point out your mistake. You are correct in that the website is assuming that all of the reported deaths from ectopic pregnancy were deaths that resulted from a lack of treatment prior to rupture. Your mistake is that you have assumed that this fact supports your position. In reality, however, your insistence that the reported deaths most likely occurred in spite of medical treatment prior to rupture actually weakens your claim that early abortion is necessary to save the life of the mother.
Allow me to demonstrate why. The abort73 websites actually performs two separate calculations to derive two rates for maternal death if an ectopic pregnancy is not treated prior to rupture. In the first calculation, they assume that the AAFP figure of 3.8 maternal deaths per 10,000 ectopic pregnancies only refers to deaths which result from a lack of treatment prior to rupture. They then divide this number by the number of ectopic pregnancies per 10,000 which do not receive such treatment (7,250). This produces a maternal mortality rate of .05% for untreated ectopic pregnancies, but lets see how this rate would differ if we applied your reasoning.
If only half of the 3.8 maternal deaths reported by the AAFP were the result of a lack of treatment prior to rupture, then the rate of deaths which result in the absence of treatment prior to rupture would be .026% which is exactly half the rate that the abort73 site calculated (.052%). If all of those 3.8 maternal deaths had occurred in spite of treatment received prior to rupture, then that would necessarily mean that there were no deaths among the 72.5% of women whose ectopic pregnancy went untreated prior to rupture. Do you see how your claim is hurting your position? The more you insist that these ectopic related deaths occurred after treatment, the more you enforce the claim that the large number of women who did not receive treatment prior to rupture did not face much risk of dying at all.
It is important to note that the abort73 website supported their figure with an additional calculation based on reports from the CDC and that your objection has the same effect when applied to their second calculation as it has on the first. In addition to this, I presented you with my own calculations for the Soroka University Hospital in Be'er Sheva which provides an independent verification of the abort73 results. My calculation assumes that every single pregnancy related death in the entire southern region of Israel occurred as a result of a ruptured ectopic pregnancy in a single hospital. This is, of course, extremely far-fetched, but even with that assumption, I was only able to arrive at a maternal mortality rate of .4%. There is no possible way to manipulate the data from this region of Israel and arrive at a higher mortality rate for ruptured ectopic pregnancies. The rate of .4% is absurdly high, and it's absurdity indicates that even the calculations presented by abort73 are extremely generous to your position.
To present some numbers on the fetal survival rate, let me mention that according to Hellman and Simon, there were 50 live births from ectopic pregnancies in America from the years of 1910 - 1933 which gives us an average of 2.17 per year [1]. The Department of Health records that there were an average of 2,766,000 births per year during that same time period [2]. The Center for Disease Control has been tracking the number of ectopic pregnancies since 1970, and at that time, the rate of ectopic pregnancies per live birth was .05% [3]. If we assume that the ectopic rate was the same in 1910 as it was in 1970, then we can calculate that there were 1,383 ectopic pregnancies in America that year. If 2.17 of those resulted in a live birth, then the chance of a child being born alive from an ectopic pregnancy in 1910 was 1.6/1000.
By the way, this calculation is likely to be rather low since abortion was already an accepted treatment for ectopic pregnancies in 1910. Thus the likelihood of a child surviving until birth at that time was lessened by the number of children who were killed by other human beings. Furthermore, the ectopic pregnancy rate has been steadily climbing in this country for as long as it has been recorded. It is likely that the rate in 1910 was significantly lower than that of 1970 which would, of course, produce a corresponding increase in the rate of fetal survival.
[1] http://www.archive.org/download/FullTermIntra-abdominalPregnancy/Abdominal_Pregnancy.pdf
[2] http://www.infoplease.com/ipa/A0005067.html
[3] http://www.cdc.gov/mmwr/preview/mmwrhtml/00035709.htm
Francesca
I will probably have to write in more details early tomorrow from a laptop rather than the ipad, but i wanted to comment on your points. I think I may have been misunderstood on my previous post, I believe that the number of recorded deaths linked to ep are referring to medical intervention after rupture and not before. I am actually not aware of any case of death due to a pregnancy unless it caused internal bleeding (ie ruptured ectopic). My second point is on your calculations on the chance of live birth for an ectopic pregnancy. I believe that the estimated numbers of EP in 1970 are hugely underestimated as the current rate is about 2-3% of all pregnancies (and this is also underestimated). I agree that the rate is going up, but it couldn't possibly have been as low as .05% in 1970 or in 1910. Even if we say that the number back in 1930 was about 1%, the live birth per ep would have been about 0.08/1000 (if I have the math right). Also I think that we should really consider the number of pregnancies rather than live births which would give a more accurate view of the chance of survival of an ectopic pregnancy vs all the pregnancies.
Chris
Susan, I highly recommend speaking to your physician if you have questions on the fatality rate for untreated ectopics, rather than seeking the on-line advice of someone who has no medical training or experience whatsoever. The mortality rate for an untreated ectopic is absolutely NOT 0.1%.
The abort73 website from which this figure is being drawn is also (similar to this website we are on currently) not written by medical professionals. They derived their 0.1% figure through a highly flawed line of reasoning. I’ll explain.
They first seem to misunderstand the difference between the terms “untreated” and “expectant management”. In a certain percentage of cases, AFTER they have been examined and lab work (HCG level) and imaging have revealed they are appropriate candidates, women can be observed as their ectopic will most likely abort spontaneously (NOT carry through to completion). They are then followed along through repeat office visits and repeat blood work and, if necessary, repeat imaging. If they are not spontaneously aborting the ectopic, they are treated either medically or surgically. Referring to the expectant management approach as “untreated” with the assumption that they represent what will happen if all ectopics never sought medical care is flat out wrong.
Based on this misunderstanding, they then draw the flawed conclusion that all deaths from ectopics came from the “untreated” group. But the reality is that very few if any deaths came from the expectant management group. The vast majority of deaths from ectopics occur among those who either die prior to reaching the hospital or die despite the frantic efforts of physicians to try and save the patient once they arrive at the ER. The only calculation one can make from these figures is the mortality rate on ectopics that are TREATED and represent how good our current medical care is when we recognize ectopics and treat (including managing expectantly when appropriate) early. But you can make no assumption whatsoever on the fatality rate of untreated ectopics based on this data. You can’t make a high bound or low bound estimate at all. These represent patients who were TREATED, not untreated.
The second calculation they make is even more flawed. They begin by stating, incorrectly, that Emedicine reports that 20% of ruptured ectopics present with rupture as their initial symptom. In fact, the Emedicine article states that approximately 20% present hemodynamically compromised (not a “symptom”) which is "highly suggestive" of rupture. In my personal experience, the percentage is alot lower, and they dont directly cite their source for that figure, but we’ll go with it anyway.
Based on this, they make a rather mind-boggling non sequitur stating that these 20% represent “untreated” ruptures, and do their calculation based upon this. How could they possibly consider these as “untreated”? Is it their thought that we dont treat ruptured ectopics if they rupture prior to presenting to the ER? That we just say “well, I guess they made it this far, obviously they are going to be okay”? Seriously?
The mortality rate of an ectopic pregnancy is low thanks to the advances we have made in medical care, through early imaging and appropriate treatment (which sometimes involves only observation if the ectopic is deemed likely to abort spontaneously). The only way we could know what the fatality rate would be for untreated ectopics would be to stop treating and then just watch and count how many die. We obviously dont practice medicine that way. We just know that the mortality rate is very much significantly higher than 0.1%.
Of course, this is in contrast to the one in many millions chance that the fetus will survive to term if allowed to progress. Which is essentially a zero chance.
Again, please speak to medical professionals for advice on medical matters. Don’t go with on-line advice from people who have no medical training or experience whatsoever.
As far as your “supporting” calculation:
“The .1% figure was presented on the abort73 website linked in my first comment, and it is supported by my own calculations in which I arrived at a very generous figure of .4% for the Soroka University Hospital in Be'er Sheva. You can read and verify my calculations at:
http://www.personhoodinitiative.com/ectopic-personhood.html ”
I have already explained to you that you are misquoting that article on Soroka Hospital, that it definitively does NOT state that it treated 149 ectopics in 1992, or any other year for that matter. It absolutely does NOT state that.
And again, and I dont know why it is so necessary to keep repeating this, the article represents patients who were TREATED!!!
Maybe the misunderstanding comes from what you know of what happens when an ectopic ruptures. Is it your thought that whenever an ectopic ruptures, the woman just instantly drops dead on the spot? That if they make it to the ER that somehow means they are safe? Is that your understanding? A ruptured ectopic is similar to any other form of internal bleeding (although sometimes the bleeding is external). It can be rapid or slow or in some cases just tamponade itself and stop temporarily. In all cases, it is serious and potentially life threatening. But if they come to the hospital early, and the triage nurse and the ER doc and the gynecologist all do their jobs well, the patient can survive. And the mortality rate as a result is low.
But this idea that this tells us anything whatsoever about the mortality rate in a hypothetical “don’t treat” scenario is absurd.
Again, I have asked you several times now, what doctors have you spoken to that agree with what you are saying?
Bill
Hello again, Chris. Thank you for commenting. I had actually forgotten about your objection to the Soroka University numbers, and I appreciate the reminder. If you recall, I submitted the following response to you the last time that this came up:
"You are somewhat correct in your next point. The paper citing the ectopic pregnancies observed at Soroka University Hospital does not state that all of those observations were made in a single year, and I should not have relied on that assumption in my calculation. You are mistaken, however, to conclude that this would significantly affect the conclusion of this segment of my article.
Allow me to redo the calculations with your correction in mind. Soroka University Hospital was established in 1960, so we can safely conclude that the 148 ruptured ectopic pregnancies reported by that hospital occurred within a 31 year time period at an average of 4.8 per year. If we assume that every single pregnancy related death in southern Israel was one of these 148 women with ruptured ectopic pregnancies, then we can calculate that a maximum of 12% of ruptured tubal pregnancies result in the death of the mother. Of course, it is highly unlikely that every single pregnancy related death over a period of 23 years was the result of an ectopic pregnancy, and it is equally unlikely that every single one of those deaths occurred at Soroka University Hospital, so that 12% figure must be unrealistically high. Nevertheless, we can safely conclude that women in the southern region of Israel have a greater than 88% chance of surviving a ruptured ectopic pregnancy."
A more accurate percentage could be obtained by considering that deaths associated with ectopic pregnancies only make up about 6% of the yearly maternal deaths in America. If this figure, were to be applied to the maternal mortality rate of southern Israel, we would derive that there were .03 ectopic related deaths per year for that region. When that figure is divided by an average of 4.8 tubal ruptures per year, we arrive at the conclusion that a woman in southern Israel has a 99.4% chance of surviving an ectopic pregnancy which is not aborted prior to rupture.
In addition, we could calculate the maternal risk from the total number of heterotopic pregnancies (twins with one child in the womb and the other being ectopic) in America in 1992. According to Dr. Tenore of the Northwestern University Medical School in Chicago, this type of pregnancy occurs in 1 out of every 2,600 pregnancies, and 50% of them (1 out of every 5,200 pregnancies) "are identified only after tubal rupture." [1] According to the American Pregnancy Association, there are approximately 6 million pregnancies per year in the US. [2] Therefore, there are an average of 1,154 heterotopic pregnancies every year in America which are not even discovered much less treated prior to tubal rupture. The CDC reported that there are an average of 26.3 maternal deaths per year that are ectopic related. [3] If we assume that all of these ectopic related deaths were the result of an undiagnosed heterotopic pregnancy (a condition which only makes up 1% of the total number of ectopic pregnancies), then we would still arrive at a maternal survival rate of 97.7%.
We could go on and on and on. No matter how you look at the numbers, they simply do not support the claim that necessary in order to save the lives of thousands of women who have ectopic pregnancies every year. Furthermore, the fact that there are only 26.3 maternal deaths among the 1,154 heterotopic pregnancies which rupture prior to diagnosis each year proves that the reduced mortality rate is not the result of early detection. There must be a treatment other than early detection and abortion which is responsible for saving all of these lives each year.
According to the CDC, America began to see a rapid decrease in maternal mortality rates around 1920. [4] If you recall, I mentioned in my article on this topic that the use of autotransfusion to treat ruptured ectopic pregnancies was initiated by Dr. Theis in 1914. It is this process which is responsible for saving the lives of women who experience a ruptured ectopic pregnancy not early detection and abortion. In fact, I previously referenced a study of 632 cases of rupture in which autotransfusion was utilized. Of that number, there was only a single death which brings the success rate for this method to 99.84%. Clearly, Dr. Theis is the one who really deserves the credit for lowering the maternal mortality rate.
By the way, I have spoken about this with several doctors, but they are not doctors that you are likely to know personally, and I am certainly not prepared to announce their names to the general public. For now, you will simply have to be satisfied with references to the scientific literature. Speaking of which, I am still curious as to whether you have had time to review the works of Sittner as well as Hellman and Simon on this topic.
[1] http://www.aafp.org/afp/2000/0215/p1080.html
[2] http://www.americanpregnancy.org/main/statistics.html
[3] http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5202a1.htm
[4] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4838a2.htm#fig2
Chris
Again, you are looking at TREATED ectopics, not untreated ectopics. This does not at all reflect what would happen if we just ignored ectopics and let them play out waiting for them to either abort spontaneously or rupture (no one would realistically expect them to carry to competion). No matter how you wrestle with the numbers (or just plain misquote them as you did with the Soroka article), you are not at all supported by the medical community. And, again, I would highly encourage anyone reading this to get their advice from those who actually study and practice medicine instead of on-line advice from people with no medical background whatsoever.
Among the “several doctors” that you have “spoken to”, did any of them actually agree with you on this point? Or with any of your points for that matter? Or did you just “speak” to them?
I have no idea where you got this idea about auto-transfusions as some sort of fetus-sparing maneuver or even something that revolutionized the care of ectopics. Again, you should look at it the same way as giving an allogeneic blood transfusion. You avoid a lot of the pitfalls of a transfusion from another donor while gaining a bunch of new pitfalls, and you avoid straining the blood bank’s resources, but overall it’s not really any different than giving a regular transfusion. I’m really wondering who gave you this idea. Certainly not a physician. The “study” (it was actually a meta-analysis) you referenced was not designed to look at the effectiveness of auto-transfusion as compared to not treating ectopics. Or even comparing it to not using auto-transfusion while doing everything else the same. It was just making the point that it can be safely done instead of having to rely on transfusions from donors. Its point was that a lot of the worries associated with using it in the setting of a ruptured ectopic (i.e. amniotic fluid embolism, incompatibility with fetal blood, etc) weren’t as significant as many would worry about. It wasn’t a case-control study or a randomized clinical trial of some sort. Have you contacted the authors and asked them about your conclusions?
If you read the CDC article you cite, the explanation given for the drop in maternal mortality rate in the 1930’s and 40’s (not 20’s) was due in large part to the maternal mortality review committees being established as a result of national calls to action by the government, leading to widespread institutional practice guidelines. This plus the many additional medical advances such as antibiotics, oxytocin for labor induction, etc, around that time all played a role. Did someone tell you that “auto-transfusions” played a significant part in this?
I have no intention of reading through case reports from nearly a hundred years ago. And I have already explained to you previously how they are irrelevant in today’s day and age where we have the capability to diagnose ectopics early and thus save countless maternal lives. I am only commenting on your thread from a public health standpoint, since you are disseminating false information on a topic that you are not qualified to speak on as an authority. This is how false, and dangerous, rumors are started and propagated. Just like when people take advice from people like Jenny McCarthy or Michelle Bachmann on childhood vaccines, without speaking to their pediatricians on the matter, and thus put their children’s lives in danger. It’s careless and dangerous and puts lives at risk when people take it seriously.
Again, speak to physicians if you have questions on medical matters, not people with no medical training or experience whatsoever.
That’s all I have to say here.
Bill
That is a very interesting response, Chris. According to the article by Dr. Lenore, "Heterotopic pregnancy is extremely difficult to diagnose, and 50 percent of cases are identified only after tubal rupture." Would you mind describing how these women were able to receive treatment for their ectopic pregnancies before they were even diagnosed as ectopic?
I find your refusal to consider the works of Sittner and Hellman and Simon to be extremely interesting as well. If I recall correctly, you previously claimed that there were only "four ectopics that have resulted in the birth of a live baby, throughout the WORLD, throughout literally the HISTORY OF MANKIND." (emphasis yours) I presented several articles by Sittner as well as an article by Hellman and Simon as proof that there have been hundreds of live births from ectopic pregnancies. You made the counter argument that these articles were "just describing abdominal pregnancies, not on live births. Again, this was the number of abdominal pregnancies found, not those that resulted in live births. NOT...LIVE...BIRTHS!!!" (emphasis yours) And now, you are claiming in regards to these articles that you "have no intention of reading through case reports from nearly a hundred years ago." I find it absolutely fascinating that you are able to determine the contents of these articles without reading them. You really must explain how you obtained this ability. I can think of dozens of ways to put it to use in my own studies.
Susan
What percent of women with ectopic pregancies actually die from those pregnancies?
Francesca in 2004 a report was published accounting for 11 cases of maternal death in the previous 3 years (in the UK alone). You can quickly search for clinical publications and perhaps you'll find reports for other States. (http://jrsm.rsmjournals.com/content/99/2/90.full)
Bill In America, there is a .1% likelihood that an untreated ectopic pregnancy will result in the death of the mother. In other words, 99.9% of American women with untreated ectopic pregnancies survive the pregnancy. (Untreated ectopic pregnancies are those which are not treated prior to either delivery or rupture.)
http://www.abort73.com/end_abortion/is_abortion_ever_justified/
Francesca
But then treatment is necessary once it ruptures am i right?
Bill
That is correct.
Francesca
So I believe the eventual death caused by an ectopic pregnancy refers to the fact that if untreated and if it ruptures it is a life threatening situation. in the absence of medical intervention at some stage during an ectopic pregnancy, and certainly after rupture, the life of the mother is at serious risk. I think that medically is safer, for the mother, to avoid rupture.
I agree that the pregnancy itself is not the direct link to the risk of maternal death (ie if it was a poison the cause and effect would be direct), the risk is the internal bleeding caused by the tube rupturing, caused by the growing pregnancy. But the numbers should reflect deaths that are happening following an ectopic pregnancy if untreated at any stage.
Bill
The .1% figure includes all ectopic related maternal deaths which occurred within 1 year of either the rupture or the delivery of the child. There is a very successful, post-rupture treatment available. According to a world wide study of 632 cases, the use of autotransfusion has been 99.6% successful at preventing death in cases of ruptured ectopic pregnancy.
http://www.ijgo.org/article/S0020-7292%2802%2900379-X/abstract
Francesca
Yes, no doubt, but do you think it's worth going through such a major surgery when intervening before the ectopic ruptures is so much easier on the body? Have you found any case of tubal ectopic pregnacy which resulted in live birth?
Bill
Yes, there are many cases of tubal pregnancies which have resulted in live births. I have included several of them in my articles on ectopic pregnancies. Additionally, the term "abdominal pregnancy" often refers to a tubal pregnancy that has re-implanted in the abdomen after either rupturing or otherwise escaping from the fallopian tubes.
"Abdominal pregnancy may be classified as primary or secondary. The secondary type is much more frequent and is the result of extension of a tubal gestation onto the peritoneal surface after partial disruption of the initial implantation site in the follopian tube. Most of these reimplantations take place in the pelvis. Primary abdominal pregnancy is extremely uncommon."
( http://www.ajronline.org/content/173/5/1377.full.pdf)
Here is a recent example of a successful tubal pregnancy:
http://news.bbc.co.uk/2/hi/health/443373.stm
And here is an example of a successful ovarian pregnancy:
http://www.ntnews.com.au/article/2008/05/30/4247_ntnews.html
Francesca
I read the article, very interesting case and about one in 60 million like the doctor states. I suspect that when the pregnancy reimplants in the abdomen, it starts at the fimbrial end of of the tube (so not the least likely position for a tubal pregnancy) so much so that when it ruptures or it's naturally is expelled in the abdomen it doesn't cause severe blood loss. The most common cases of tubal ectopic pregnancies are in fact located in the ampullary region of the tube, the rupture of which would cause internal haemorrhage and potential death.
Bill
Yes, the doctor is referenced as saying that the child had a one in 60 million chance of surviving, but there is no explanation of how he arrived at that figure. The scientific literature, however, records an astounding number of such successes. For example, here are two more:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1582720/pdf/canmedaj00596-0056.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1562056/pdf/canmedaj00522-0133.pdf
Francesca
I read both papers with great interest. In the one from 1937, two cases are reported, in neither cases the baby survived, in the first one the pregnancy got to about 12 weeks. In the second case the pregnancy got to about 16 weeks (though the dates seem not to match up with the weeks). In the first case the mother almost died and in the second case she indeed died. In the 1946 paper the pregnancy got to full term but the baby died nonetheless and the mother almost died. So I'm not sure if you attached the wrong papers, because they don't actually seem to prove your point at all. Three cases reported in the two papers, none of them has a surviving baby.
Bill
Ah, yes, those were the wrong papers. Those two papers were actually from my list of papers which support the fact that most abdominal pregnancies begin as tubal pregnancies. Here are several from the correct list:
http://www.theprofesional.com/article/2006/Vol-13-No-02/Prof-1065.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2086722/pdf/brmedj04281-0010.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2098249/pdf/brmedj03046-0021.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2602194/pdf/yjbm00484-0042.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2160918/pdf/brmedj04044-0013a.pdf
http://humrep.oxfordjournals.org/content/14/5/1372.full
Francesca
2006 paper. Baby does not survive, mother is fine. Authors state high maternal death rate and that cases of abdominal pregnancies are 0.04% of all pregnancies and 5.6% of all ectopic pregnancies.
1938 paper. The delay necessary to obtain a living child is never justified in the face of the danger to the mother, the high foetal mortality, and the incidence of deformities. Maternal mortality 14-33%.
In the reported case, pregnancy does not get to term, surgery is needed due to poor health conditions of the mother, baby does not survive.
1960 paper. Authors acknowledge how lucky they were in not having a case of maternal death out of the 10 abdominal pregnancies they encountered. 4 of the 10 babies survived. They conclude that “While most cases should be dealt with by IMMEDIATE LAPAROTOMY, it may be justifiable on SOME occasions and with adequate safeguards to allow the pregnancy to continue until the foetus is certainly viable. “
The’s paper (maybe 1946). One case of living child and mother. Again they state how previous literature shows that perhaps in total there were 80 cases where both mother and child survive.
1942 paper. Live baby and mother. Author states this was likely a case of primary abdominal pregnancy (not generated by the rupturing of a tubal pregnancy). Author states how this is an unusual outcome where no harm was caused by this pregnancy to the mother, in fact he writes he could not find any other reported cases in the literature.
1999 paper. They state that cases of surviving ectopic tubal pregnancies documented in the literature are rare and accounting for about 10.6% of ALL recorded cases (435). They quote that “The incidence of abdominal pregnancy as reviewed in the world literature is as high as one in 8000, with a perinatal and maternal mortality of 75–95% and 2–18% respectively”. They report on one case of live twin heterotopic pregnancy. In total there have been 13 cases out of 589.
I would like to ask you a question. Have you ever found a physician who would try to carry a pregnancy to term should he discover early in the gestation that the location is abdominal? Of course I know that no physician would consciously wait to treat a tubal ectopic pregnancy till it rupture (i.e he/she would hope it won’t rupture during the wait and see period).
Also, I am not sure what your background is, but I would like to point out that cases reported in the literature are in fact JUST cases,if I it was the norm you wouldn’t read about it. None of the papers you reported invite or even suggest the possibility of willingly allow for a pregnancy outside the uterus to be carried to term as they life of the mother is at too great risk and the life of the foetus not a given, by any means.
Bill
You are missing the point, Francesca. For now, let's just take the numbers that you list at face value. What conclusion could be drawn from them? Can we conclude from these numbers that abortion in the case of ectopic pregnancy is justified? Not at all. You see, according to the figures that you just listed, the baby has a 5-25% chance of surviving a full term ectopic pregnancy while the mother has a 2-33% chance of not surviving such a pregnancy. If we take the median of those two ranges, we arrive at values of 15% and 17.5% respectively. This means that you are arguing for killing every single child discovered to be in an ectopic pregnancy simply because the likelihood of the mother dying is 0.167 times higher than the likelihood of the child surviving.
Now, let's take a closer look at those numbers. First and foremost, it is important to realize that the rates given for fetal mortality are not the same as rates for live birth. Fetal mortality is usually measured in terms of survival beyond a certain number of days. Most authors have followed Hellman and Simon's 1935 viability standard of survival beyond eight days. As far as I have been able to ascertain, the rates for live birth have always been high.
This, of course, brings us to the consideration of the treatment provided to these children after their birth, and on this consideration, the literature is remarkably silent. After reading hundreds of case reports, I have noticed that it is very, very unusual for those reports to include any reference to treatment provided to the newborn infant. In the vast majority of cases, the doctor simply states that the child was born alive, lists the weight and size as well as the APGAR score (usually in the 4-6 range indicating the need for medical intervention) and then states that the child was struggling to breath and that he died within a certain time frame. Given the scarcity of reports of medical intervention being provided for these children and the understanding that most laparotomies on ectopic patients are initiated with the intent of aborting the pregnancy, it is reasonable to conclude that most of these children were simply set aside and allowed to die.
Once it is established that the fetal mortality rate refers to the death of children outside of the womb, then it becomes necessary to consider other factors such as the time range included in the figures for fetal mortality. Most of the large studies include reports from as far back as 1809. Obviously, we would not expect the fetal mortality rate in the 21st century to be comparable to the rate of the 19th century. We must also consider the facilities in which each surgery was performed. Most full-term ectopic pregnancies occur in third world countries where early detection and abortion is not possible. There are very few maternity wards in third world countries that are equipped to handle ectopic pregnancies. Prior to the acceptance of abortion in America, there were several efforts to provide the necessary materials and training, but ever since abortion became the preferred treatment in America, the focus has been on early detection which has served to increase the mortality rate for the mother and the child due to shortages of both equipment and experience. Once we recognize that these children are dying after birth rather than before or even during birth, then there are many additional factors which should be studied but which are seldom even mentioned in the literature.
You see, the point which you are missing is that the children mentioned in all of these reports are people. They are not just masses of fetal tissue with no hope of survival. They are living, breathing people. Sure, some of them die at a young age, but that is true of all people. The unfortunate fact that some children will never live to see their first birthday does not in any way justify killing a child at any time prior to his natural death.
Furthermore, you are overlooking the fact that all of the figures for fetal and maternal mortality rates in these papers are given for the category of advanced abdominal pregnancy alone. As I noted in an earlier post, the total rate of maternal deaths from ectopic pregnancies which are not treated prior to rupture is 0.1%. The vast majority of these pregnancies resolve on their own with very little risk to the mother. That is why there are several physicians which have advocated for expectant management of ectopic pregnancies instead of early abortions. You can find a number of papers on this treatment plan through Google, but here is just one example: http://www.pngimr.org.pg/png_med_journal/Advanced%20viable%20-%20%20Mar%2097.pdf.
Susan
And have they managed such cases? What is the outcome of these managed ectopic pregnancies?
According to the above article: Maternal mortality is from severe
intraabdominal haemorrhage as well as
infection. In the USA Atrash et al. (3) reported
that the risk of dying from an abdominal
pregnancy is 8 times greater than the risk of
dying from a tubal pregnancy, and 90 times
greater than with a normal intrauterine
pregnancy.
Bill
Yes, there is a risk of death in ectopic pregnancy. I'm not saying that these pregnancies are joyful and pain free. I'm simply pointing out that they are far from unquestionably fatal for either the mother or the child. Consequently, the intentional killing of the child cannot be justified. Since survival is possible for both the mother and the child, the doctor must strive to the best of his ability to save both patients.
Susan
I believe every effort should be made to save both the mom and the baby. As a lifeguard I learned that there some situations that you are not able to save all. This is one time that the term "to save the life of the mother" may be accurate. I do feel however that clear information must be available so an informed decision can be made. Each person deserves this! Information in this area is so hard to come by. Each person deserves this!
Francesca
I am sorry I don't think I follow your logic at all. No doctor is taking chances if the mother life is at risk (even minimal). I know well what "expectant management" is and there is no one "advocating" for this as the NORMAL course of action in case of an ectopic pregnancy, you have this fact wrong. Expectant management is allowed ONLY when hcg levels and physical examination indicate that the mother is stable and that the pregnancy is resolving itself (meaning it's not progressing). Should HCG start rising and the mother's condition deteriorate (pain, unstable blood pressure etc) immediate intervention will take place. If the mother is well but HCG are rising nonetheless, MTX may be given to avoid surgery (and even MTX can only be given when specific parameters are met). If HCG are stable or low but mother's condition deteriorates, surgery is performed (there are cases of ruptured EP even with very low hcg). Certainly this is how it is done in Ireland and as one of the founder of Ectopic Pregnancy Ireland I can tell you I have my facts straight. Also I couldn't really find any reference to the mortality of 0.1% of all ectopic pregnancies for the mother, can you link me the source of this? Thanks.
Bill
Let me ask you this, Francesca. Do you think that expectant mothers should be permitted to abort their pregnancy at any time and for any reason that they choose?
The .1% figure was presented on the abort73 website linked in my first comme nt, and it is supported by my own calculations in which I arrived at a very generous figure of .4% for the Soroka University Hospital in Be'er Sheva. You can read and verify my calculations at:
http://www.personhoodinitiative.com/ectopic-personhood.html
By the way, if you are one of the founders of Ectopic Pregnancy Ireland, then perhaps you could correct an error on your groups website. On the "Medical Information and FAQ" page, your site states that "Unfortunately, an ectopic pregnancy cannot be saved ... If there is any risk of rupture, the pregnancy must be removed."
This is an incorrect statement. The article "Full Term Intra-abdominal Pregnancy" by Hellman and Simon documented 316 ectopic pregnancies of greater than 20 weeks gestation between the years of 1809 and 1933. 312 of those pregnancies resulted in a live birth, and 158 of the children survived more than eight days with many of them being reported to be both healthy and normal. The claim that an ectopic pregnancy cannot be saved is false.
http://www.archive.org/download/FullTermIntra-abdominalPregnancy/Abdominal_Pregnancy.pdf
Francesca
I personally would not abort a pregnancy. Imagine that my two ectopics happened after years of infertility and IVF treatments! The last thing I wanted was to lose those pregnancies! But when it came to evaluate the risk for my life, the doctors made it very clear that this could not progress, and having quite a solid scientific background myself I could only agree. I will check out that website now, I am not sure how they possibly came to that conclusion to be honest. For what concerns our website and the medical information, they have been written and verified by OBGYNs in the National Maternity Hospital in Dublin and while you may disagree, the fact that ectopic pregnancies cannot be saved is the general agreement among scientists and medical doctors. The occasional exception to the norm does not make the statement itself less valid. Miracles do happen sometimes (to others as far as I'm concerned) but it's unrealistic to give false hopes to those who are already going through an emotional and physical ordeal.
I read the article published on the abort73 website. I have a few comments. They make the assumption that deaths linked to ectopic pregnancies are associated to UNTREATED ruptured ectopic pregnancies. Where did they get this from? I think it's much more likely that those deaths are happening DESPITE medical medical intervention and so that the number would be much much higher if there was no medical intervention. Also, they say that 20% of ectopic pregnancies present as first symptom with the rupture of the tube (ie the woman didn't know she had an ectopic pregnancy till it ruptured) but this means that in fact 80% of ectopic pregnancies are discovered before the mother's life it at risk and medical intervention takes place (or the pregnancy resolves itself). Again they make the assumption that the deaths are among those 20% assuming they are untreated. But to be honest I find it difficult to believe that a medical report would deal with deaths linked to no medical intervention. Generally it's the complete opposite.
Bill
I'm not asking about your pregnancy in particular. I would like to know if you think that elective abortions should be permitted in general.
Francesca
I would say that I am pro-choice. Though I am not sure why this matters when we are discussing scientific/medical points. Do you think I ma bias because of this?
Bill
Thank you, Francesca. That helps me to understand your position better. Knowing that you see nothing wrong with a woman choosing abortion when there is no risk to her health makes it much easier to understand why you are so adamantly in favor of abortion in situations in which there is a substantial risk to the mother's health. As long as you maintain that the unborn child does not have an inherent right to live, it is unlikely that any amount of evidence will change your position on ectopic pegnancy. If you will permit me, therefore, I will switch tactics slightly and ask you when you believe that the right to life begins.
Susan
Personhood, I am hugely pro-life and am trying to figure this out for myself. I do believe that it is unfair to say all Frans thoughts are mearly because she is pro-choice, though some maybe. Although, I do believe your last question was important.
Francesca, I see that you might have had to make a personal choice in this area. If so, I am sorry for your loss.
Personhood, I do think this is a discussion worth having though I fear caution is in order due the risk to mom. As I said, I value the unborn.
Francesca
I have no problem in answering but I wouldn't want my points not to be addressed either. Susan thank you for your words, it was unbearably difficult, but I do have a one-year old now and he is the joy of my life!
I would certainly not say that I "see nothing wrong with a woman choosing abortion"! As I stated before, I would never make that choice for myself. I grew up in a Country where abortion is legal but never abused (like I think it may be in some parts of the States, ie used instead of contraception), now I live in a Country where it's not legal and I see people travelling abroad to terminate a pregnancy. I do think that there may be circumstances where a very painful decision appears like the only possible solution and I believe proper medical care should be available. Also legislation is different in different Countries on abortion too. Above all, i would NEVER consider terminating an ectopic pregnancy at the same level as terminating a normal pregnancy, never. And this is about ectopic pregnancies.
Bill
Ah, but if the purpose of permitting abortion for ectopic pregnancies is to save lives, then it is necessary to know if you consider the unborn child to have a right to life that is equal to that of the mother. Your position so far seems to be that the mother has a greater right to life than the child: that her survival should be the primary consideration. If a 30 year old woman and her 13 year old child were rushed into the hospital with one of them needing a lung transplant and the other needing a heart transplant, I am certain that you would oppose a decision by the doctor to kill the child in order to harvest his organs and save the 30 year old woman. If so, then there must be a point at which you consider the life of the mother and the life of the child to be equally worthy of protection. I would simply like to know when in the life of the child that point of equality materializes.
Just a few months ago, the Journal of Medical Ethics published an article entitled "After-birth abortion: why should the baby live?" In that article, the authors reached the following conclusion. "[W]e argue that, when circumstances occur after birth such that they would have justified abortion, what we call after-birth abortion should be permissible." The authors of this paper are not alone in that opinion. They cite the fact that this is already legal to some extent in the Netherlands, and they reference the works of other authors such as Tooley and Singer who have also argued in favor of infanticide. Do you agree with the conclusion of these authors? At what point in a child's life do you think that he gains a right to life that is equal to yours?
http://jme.bmj.com/content/early/2012/03/01/medethics-2011-100411.full.
Francesca
I am very familiar with the article that you have mentioned. No, I do not agree with that at all. Once a baby is born everything should be done for his well-being. I suppose I don't see this issue as just black and white like you seem to do. Maybe in your opinion a fertilised egg is already a potential child and as such should have rights. I don't see it the same way certainly at a cellular level. I also think that once a baby is able to survive outside the mother then no termination should be allowed (23-24 weeks gestation). If I have to give you and answer on when I think it is ok to terminate a pregnancy I am not able to do so, there are many reasons that would force a woman to consider this as the only possible solutions and I cannot just condemn them all without distinction. Again, may i point out that this conversation was not about my personal belief on normal pregnancies but on the medical treatment of ectopic pregnancies where the life of the mother is at risk and the foetus has almost no chance of survival?
Bill
I understand your hesitancy, but please bear with me and answer just one more question. If a mother is at 20 weeks of gestation, how certain do you think that a risk to her life must be in order to justify an abortion? If, for example, her doctor told her that she had a 50% chance of dying if she did not get an abortion, would you consider such an abortion to be justifiable? What about 20%, 10%, 1%, or even 0.05%?
Francesca
I have never heard of such a case to be honest. You remind me of an old boyfriend of mine who, to prove his point, would come up with surreal situations in which I had to make hypothetical choices base on which he would make assumption on my ethic and morality. 20 years have passed since then and I don't want to discuss science on highly impossible cases. Having said that, a mother would put the life of her child before hers generally speaking (pregnant women diagnosed with cancer would choose to delay treatments to allow the baby to live) when the child is healthy and will survive. In an ectopic pregnancy this is highly unlikely, termination happens generally within 7 weeks if spotted early.
Bill
Those are not surreal numbers at all. The papers that we just discussed listed maternal mortality rates ranging from 2% to 33% for advanced abdominal pregnancies and it was stated that these pregnancies are 8 times more deadly than tubal pregnancies. This figure would place the risk of death for tubal pregnancy at .25% to 4.125%. You seem to be claiming that risks this low are sufficient for justifying killing a child who has a chance of surviving the pregnancy. I'm simply wondering what the boundaries are for that justification. What is the lowest potential for maternal death that you think justifies killing a child at 20 weeks of gestation?
Francesca
Ok so this is completely different. In the case of an abdominal pregnancy something went wrong already and the intervention at such late stage generally happens to save the mother (and possibly the baby). We are talking of a very very small amount of cases in which early intervention was not possible and now, with an abdominal pregnancy, the life of the mother is at risk. With an abdominal pregnancy that far advanced, with a foetus still alive (we have read that in several cases the foetus is already dead) and with the mother medically stable, it is possible to see if the pregnancy could progress for a few more weeks under strict control to bring the baby to viability (or to term like in the UK case). if the mother's life is already in danger (i don't think there are sufficient cases to make a sound statistic on how likely the mother is to die), than surgery and still birth would be inevitable. Abdominal pregnancies are a very small proportion of all tubal pregnancies, intervening when the preganncy is still tubal (7-8 weeks gestation max, hopefully earlier than that as many EP don't get to 7 weeks) for me is a perfectly reasonable way to not expose the mother to any risk at all.
Bill
Okay, so your position seems to be that all ectopic pregnancies should be terminated by the eighth week of gestation so as to completely eliminate all risk of death to the mother and that this should done without regard for the child's chance of survival. Is that correct?
Francesca
Yes it is correct. Given the fact that a chance for the survival of an ectopic foetus is about 1 in 60 million (as per UK paper) I believe it's not worth risking the mother life.
Bill
Thank you for confirming that. Now, let's consider that figure of 1 in 60 million. If you would be so kind as to review the article again, I believe that you would notice that this figure is not enclosed in quotation marks. It would not be wise to just assume that the reporter correctly represented the doctor's statement, and even if we did make such an assumption, the article provides no evidence to support this claim. There were several additional oddities in this case in addition to the ectopic position of the child, and we do not know whether this figure refers to just the ectopic pregnancy or the combination of an ectopic pregnancy with an intrauterine pregnancy or the combination of an ectopic pregnancy with a double intrauterine pregnancy or any other number of factors. In short, the figure of 1 in 60 million is unreliable.
Given the uncertainty of this figure, if I could present you with a much higher, documented figure for the survival of the child, would you consider changing your position? If so, how high would that figure have to be for your position to change? If not, why not?
Susan
Do you have a documented survival rate for such children?
Francesca
So we are back to numbers. This is the same argument I posed to you a few posts back when I said that the assumptions made on abort73 website about the risk of death linked to an ectopic pregnancy are wrong and misleading as they are taking numbers of reported deaths and assume they are happening when no medical intervention takes place, while I believe those are in fact deaths registered despite medial intervention.
Bill
I noticed your comments about the abort73 article, but I chose to overlook that particular error until we could come back to it. Now, that the conversation has turned in that direction again, let me point out your mistake. You are correct in that the website is assuming that all of the reported deaths from ectopic pregnancy were deaths that resulted from a lack of treatment prior to rupture. Your mistake is that you have assumed that this fact supports your position. In reality, however, your insistence that the reported deaths most likely occurred in spite of medical treatment prior to rupture actually weakens your claim that early abortion is necessary to save the life of the mother.
Allow me to demonstrate why. The abort73 websites actually performs two separate calculations to derive two rates for maternal death if an ectopic pregnancy is not treated prior to rupture. In the first calculation, they assume that the AAFP figure of 3.8 maternal deaths per 10,000 ectopic pregnancies only refers to deaths which result from a lack of treatment prior to rupture. They then divide this number by the number of ectopic pregnancies per 10,000 which do not receive such treatment (7,250). This produces a maternal mortality rate of .05% for untreated ectopic pregnancies, but lets see how this rate would differ if we applied your reasoning.
If only half of the 3.8 maternal deaths reported by the AAFP were the result of a lack of treatment prior to rupture, then the rate of deaths which result in the absence of treatment prior to rupture would be .026% which is exactly half the rate that the abort73 site calculated (.052%). If all of those 3.8 maternal deaths had occurred in spite of treatment received prior to rupture, then that would necessarily mean that there were no deaths among the 72.5% of women whose ectopic pregnancy went untreated prior to rupture. Do you see how your claim is hurting your position? The more you insist that these ectopic related deaths occurred after treatment, the more you enforce the claim that the large number of women who did not receive treatment prior to rupture did not face much risk of dying at all.
It is important to note that the abort73 website supported their figure with an additional calculation based on reports from the CDC and that your objection has the same effect when applied to their second calculation as it has on the first. In addition to this, I presented you with my own calculations for the Soroka University Hospital in Be'er Sheva which provides an independent verification of the abort73 results. My calculation assumes that every single pregnancy related death in the entire southern region of Israel occurred as a result of a ruptured ectopic pregnancy in a single hospital. This is, of course, extremely far-fetched, but even with that assumption, I was only able to arrive at a maternal mortality rate of .4%. There is no possible way to manipulate the data from this region of Israel and arrive at a higher mortality rate for ruptured ectopic pregnancies. The rate of .4% is absurdly high, and it's absurdity indicates that even the calculations presented by abort73 are extremely generous to your position.
To present some numbers on the fetal survival rate, let me mention that according to Hellman and Simon, there were 50 live births from ectopic pregnancies in America from the years of 1910 - 1933 which gives us an average of 2.17 per year [1]. The Department of Health records that there were an average of 2,766,000 births per year during that same time period [2]. The Center for Disease Control has been tracking the number of ectopic pregnancies since 1970, and at that time, the rate of ectopic pregnancies per live birth was .05% [3]. If we assume that the ectopic rate was the same in 1910 as it was in 1970, then we can calculate that there were 1,383 ectopic pregnancies in America that year. If 2.17 of those resulted in a live birth, then the chance of a child being born alive from an ectopic pregnancy in 1910 was 1.6/1000.
By the way, this calculation is likely to be rather low since abortion was already an accepted treatment for ectopic pregnancies in 1910. Thus the likelihood of a child surviving until birth at that time was lessened by the number of children who were killed by other human beings. Furthermore, the ectopic pregnancy rate has been steadily climbing in this country for as long as it has been recorded. It is likely that the rate in 1910 was significantly lower than that of 1970 which would, of course, produce a corresponding increase in the rate of fetal survival.
[1] http://www.archive.org/download/FullTermIntra-abdominalPregnancy/Abdominal_Pregnancy.pdf
[2] http://www.infoplease.com/ipa/A0005067.html
[3] http://www.cdc.gov/mmwr/preview/mmwrhtml/00035709.htm
Francesca
I will probably have to write in more details early tomorrow from a laptop rather than the ipad, but i wanted to comment on your points. I think I may have been misunderstood on my previous post, I believe that the number of recorded deaths linked to ep are referring to medical intervention after rupture and not before. I am actually not aware of any case of death due to a pregnancy unless it caused internal bleeding (ie ruptured ectopic). My second point is on your calculations on the chance of live birth for an ectopic pregnancy. I believe that the estimated numbers of EP in 1970 are hugely underestimated as the current rate is about 2-3% of all pregnancies (and this is also underestimated). I agree that the rate is going up, but it couldn't possibly have been as low as .05% in 1970 or in 1910. Even if we say that the number back in 1930 was about 1%, the live birth per ep would have been about 0.08/1000 (if I have the math right). Also I think that we should really consider the number of pregnancies rather than live births which would give a more accurate view of the chance of survival of an ectopic pregnancy vs all the pregnancies.
Chris
Susan, I highly recommend speaking to your physician if you have questions on the fatality rate for untreated ectopics, rather than seeking the on-line advice of someone who has no medical training or experience whatsoever. The mortality rate for an untreated ectopic is absolutely NOT 0.1%.
The abort73 website from which this figure is being drawn is also (similar to this website we are on currently) not written by medical professionals. They derived their 0.1% figure through a highly flawed line of reasoning. I’ll explain.
They first seem to misunderstand the difference between the terms “untreated” and “expectant management”. In a certain percentage of cases, AFTER they have been examined and lab work (HCG level) and imaging have revealed they are appropriate candidates, women can be observed as their ectopic will most likely abort spontaneously (NOT carry through to completion). They are then followed along through repeat office visits and repeat blood work and, if necessary, repeat imaging. If they are not spontaneously aborting the ectopic, they are treated either medically or surgically. Referring to the expectant management approach as “untreated” with the assumption that they represent what will happen if all ectopics never sought medical care is flat out wrong.
Based on this misunderstanding, they then draw the flawed conclusion that all deaths from ectopics came from the “untreated” group. But the reality is that very few if any deaths came from the expectant management group. The vast majority of deaths from ectopics occur among those who either die prior to reaching the hospital or die despite the frantic efforts of physicians to try and save the patient once they arrive at the ER. The only calculation one can make from these figures is the mortality rate on ectopics that are TREATED and represent how good our current medical care is when we recognize ectopics and treat (including managing expectantly when appropriate) early. But you can make no assumption whatsoever on the fatality rate of untreated ectopics based on this data. You can’t make a high bound or low bound estimate at all. These represent patients who were TREATED, not untreated.
The second calculation they make is even more flawed. They begin by stating, incorrectly, that Emedicine reports that 20% of ruptured ectopics present with rupture as their initial symptom. In fact, the Emedicine article states that approximately 20% present hemodynamically compromised (not a “symptom”) which is "highly suggestive" of rupture. In my personal experience, the percentage is alot lower, and they dont directly cite their source for that figure, but we’ll go with it anyway.
Based on this, they make a rather mind-boggling non sequitur stating that these 20% represent “untreated” ruptures, and do their calculation based upon this. How could they possibly consider these as “untreated”? Is it their thought that we dont treat ruptured ectopics if they rupture prior to presenting to the ER? That we just say “well, I guess they made it this far, obviously they are going to be okay”? Seriously?
The mortality rate of an ectopic pregnancy is low thanks to the advances we have made in medical care, through early imaging and appropriate treatment (which sometimes involves only observation if the ectopic is deemed likely to abort spontaneously). The only way we could know what the fatality rate would be for untreated ectopics would be to stop treating and then just watch and count how many die. We obviously dont practice medicine that way. We just know that the mortality rate is very much significantly higher than 0.1%.
Of course, this is in contrast to the one in many millions chance that the fetus will survive to term if allowed to progress. Which is essentially a zero chance.
Again, please speak to medical professionals for advice on medical matters. Don’t go with on-line advice from people who have no medical training or experience whatsoever.
As far as your “supporting” calculation:
“The .1% figure was presented on the abort73 website linked in my first comment, and it is supported by my own calculations in which I arrived at a very generous figure of .4% for the Soroka University Hospital in Be'er Sheva. You can read and verify my calculations at:
http://www.personhoodinitiative.com/ectopic-personhood.html ”
I have already explained to you that you are misquoting that article on Soroka Hospital, that it definitively does NOT state that it treated 149 ectopics in 1992, or any other year for that matter. It absolutely does NOT state that.
And again, and I dont know why it is so necessary to keep repeating this, the article represents patients who were TREATED!!!
Maybe the misunderstanding comes from what you know of what happens when an ectopic ruptures. Is it your thought that whenever an ectopic ruptures, the woman just instantly drops dead on the spot? That if they make it to the ER that somehow means they are safe? Is that your understanding? A ruptured ectopic is similar to any other form of internal bleeding (although sometimes the bleeding is external). It can be rapid or slow or in some cases just tamponade itself and stop temporarily. In all cases, it is serious and potentially life threatening. But if they come to the hospital early, and the triage nurse and the ER doc and the gynecologist all do their jobs well, the patient can survive. And the mortality rate as a result is low.
But this idea that this tells us anything whatsoever about the mortality rate in a hypothetical “don’t treat” scenario is absurd.
Again, I have asked you several times now, what doctors have you spoken to that agree with what you are saying?
Bill
Hello again, Chris. Thank you for commenting. I had actually forgotten about your objection to the Soroka University numbers, and I appreciate the reminder. If you recall, I submitted the following response to you the last time that this came up:
"You are somewhat correct in your next point. The paper citing the ectopic pregnancies observed at Soroka University Hospital does not state that all of those observations were made in a single year, and I should not have relied on that assumption in my calculation. You are mistaken, however, to conclude that this would significantly affect the conclusion of this segment of my article.
Allow me to redo the calculations with your correction in mind. Soroka University Hospital was established in 1960, so we can safely conclude that the 148 ruptured ectopic pregnancies reported by that hospital occurred within a 31 year time period at an average of 4.8 per year. If we assume that every single pregnancy related death in southern Israel was one of these 148 women with ruptured ectopic pregnancies, then we can calculate that a maximum of 12% of ruptured tubal pregnancies result in the death of the mother. Of course, it is highly unlikely that every single pregnancy related death over a period of 23 years was the result of an ectopic pregnancy, and it is equally unlikely that every single one of those deaths occurred at Soroka University Hospital, so that 12% figure must be unrealistically high. Nevertheless, we can safely conclude that women in the southern region of Israel have a greater than 88% chance of surviving a ruptured ectopic pregnancy."
A more accurate percentage could be obtained by considering that deaths associated with ectopic pregnancies only make up about 6% of the yearly maternal deaths in America. If this figure, were to be applied to the maternal mortality rate of southern Israel, we would derive that there were .03 ectopic related deaths per year for that region. When that figure is divided by an average of 4.8 tubal ruptures per year, we arrive at the conclusion that a woman in southern Israel has a 99.4% chance of surviving an ectopic pregnancy which is not aborted prior to rupture.
In addition, we could calculate the maternal risk from the total number of heterotopic pregnancies (twins with one child in the womb and the other being ectopic) in America in 1992. According to Dr. Tenore of the Northwestern University Medical School in Chicago, this type of pregnancy occurs in 1 out of every 2,600 pregnancies, and 50% of them (1 out of every 5,200 pregnancies) "are identified only after tubal rupture." [1] According to the American Pregnancy Association, there are approximately 6 million pregnancies per year in the US. [2] Therefore, there are an average of 1,154 heterotopic pregnancies every year in America which are not even discovered much less treated prior to tubal rupture. The CDC reported that there are an average of 26.3 maternal deaths per year that are ectopic related. [3] If we assume that all of these ectopic related deaths were the result of an undiagnosed heterotopic pregnancy (a condition which only makes up 1% of the total number of ectopic pregnancies), then we would still arrive at a maternal survival rate of 97.7%.
We could go on and on and on. No matter how you look at the numbers, they simply do not support the claim that necessary in order to save the lives of thousands of women who have ectopic pregnancies every year. Furthermore, the fact that there are only 26.3 maternal deaths among the 1,154 heterotopic pregnancies which rupture prior to diagnosis each year proves that the reduced mortality rate is not the result of early detection. There must be a treatment other than early detection and abortion which is responsible for saving all of these lives each year.
According to the CDC, America began to see a rapid decrease in maternal mortality rates around 1920. [4] If you recall, I mentioned in my article on this topic that the use of autotransfusion to treat ruptured ectopic pregnancies was initiated by Dr. Theis in 1914. It is this process which is responsible for saving the lives of women who experience a ruptured ectopic pregnancy not early detection and abortion. In fact, I previously referenced a study of 632 cases of rupture in which autotransfusion was utilized. Of that number, there was only a single death which brings the success rate for this method to 99.84%. Clearly, Dr. Theis is the one who really deserves the credit for lowering the maternal mortality rate.
By the way, I have spoken about this with several doctors, but they are not doctors that you are likely to know personally, and I am certainly not prepared to announce their names to the general public. For now, you will simply have to be satisfied with references to the scientific literature. Speaking of which, I am still curious as to whether you have had time to review the works of Sittner as well as Hellman and Simon on this topic.
[1] http://www.aafp.org/afp/2000/0215/p1080.html
[2] http://www.americanpregnancy.org/main/statistics.html
[3] http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5202a1.htm
[4] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4838a2.htm#fig2
Chris
Again, you are looking at TREATED ectopics, not untreated ectopics. This does not at all reflect what would happen if we just ignored ectopics and let them play out waiting for them to either abort spontaneously or rupture (no one would realistically expect them to carry to competion). No matter how you wrestle with the numbers (or just plain misquote them as you did with the Soroka article), you are not at all supported by the medical community. And, again, I would highly encourage anyone reading this to get their advice from those who actually study and practice medicine instead of on-line advice from people with no medical background whatsoever.
Among the “several doctors” that you have “spoken to”, did any of them actually agree with you on this point? Or with any of your points for that matter? Or did you just “speak” to them?
I have no idea where you got this idea about auto-transfusions as some sort of fetus-sparing maneuver or even something that revolutionized the care of ectopics. Again, you should look at it the same way as giving an allogeneic blood transfusion. You avoid a lot of the pitfalls of a transfusion from another donor while gaining a bunch of new pitfalls, and you avoid straining the blood bank’s resources, but overall it’s not really any different than giving a regular transfusion. I’m really wondering who gave you this idea. Certainly not a physician. The “study” (it was actually a meta-analysis) you referenced was not designed to look at the effectiveness of auto-transfusion as compared to not treating ectopics. Or even comparing it to not using auto-transfusion while doing everything else the same. It was just making the point that it can be safely done instead of having to rely on transfusions from donors. Its point was that a lot of the worries associated with using it in the setting of a ruptured ectopic (i.e. amniotic fluid embolism, incompatibility with fetal blood, etc) weren’t as significant as many would worry about. It wasn’t a case-control study or a randomized clinical trial of some sort. Have you contacted the authors and asked them about your conclusions?
If you read the CDC article you cite, the explanation given for the drop in maternal mortality rate in the 1930’s and 40’s (not 20’s) was due in large part to the maternal mortality review committees being established as a result of national calls to action by the government, leading to widespread institutional practice guidelines. This plus the many additional medical advances such as antibiotics, oxytocin for labor induction, etc, around that time all played a role. Did someone tell you that “auto-transfusions” played a significant part in this?
I have no intention of reading through case reports from nearly a hundred years ago. And I have already explained to you previously how they are irrelevant in today’s day and age where we have the capability to diagnose ectopics early and thus save countless maternal lives. I am only commenting on your thread from a public health standpoint, since you are disseminating false information on a topic that you are not qualified to speak on as an authority. This is how false, and dangerous, rumors are started and propagated. Just like when people take advice from people like Jenny McCarthy or Michelle Bachmann on childhood vaccines, without speaking to their pediatricians on the matter, and thus put their children’s lives in danger. It’s careless and dangerous and puts lives at risk when people take it seriously.
Again, speak to physicians if you have questions on medical matters, not people with no medical training or experience whatsoever.
That’s all I have to say here.
Bill
That is a very interesting response, Chris. According to the article by Dr. Lenore, "Heterotopic pregnancy is extremely difficult to diagnose, and 50 percent of cases are identified only after tubal rupture." Would you mind describing how these women were able to receive treatment for their ectopic pregnancies before they were even diagnosed as ectopic?
I find your refusal to consider the works of Sittner and Hellman and Simon to be extremely interesting as well. If I recall correctly, you previously claimed that there were only "four ectopics that have resulted in the birth of a live baby, throughout the WORLD, throughout literally the HISTORY OF MANKIND." (emphasis yours) I presented several articles by Sittner as well as an article by Hellman and Simon as proof that there have been hundreds of live births from ectopic pregnancies. You made the counter argument that these articles were "just describing abdominal pregnancies, not on live births. Again, this was the number of abdominal pregnancies found, not those that resulted in live births. NOT...LIVE...BIRTHS!!!" (emphasis yours) And now, you are claiming in regards to these articles that you "have no intention of reading through case reports from nearly a hundred years ago." I find it absolutely fascinating that you are able to determine the contents of these articles without reading them. You really must explain how you obtained this ability. I can think of dozens of ways to put it to use in my own studies.