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.
Ectopic Personhood
Bill Fortenberry
(This article was updated on June 20, 2012, to include answers to questions about the distinction between tubal pregnancies and abdominal pregnancies.)
One of the most ardently presented pro-choice arguments is the claim that abortion is sometimes necessary in order to save the life of the mother. This argument has been very effective over the years and has been used to persuade pro-life politicians to include a life of the mother exception to nearly every law designed to limit abortions. Very few politicians realize that the inclusion of a life of the mother exception is a tacit admission that the unborn child is not a person. Even more rare is the politician who realizes that Justice Blackmun cited this very exception to justify his decision in Roe v. Wade.
"If this suggestion of personhood is established, the appellant's case, of course, collapses, for the fetus' right to life would then be guaranteed specifically by the (Fourteenth) Amendment ... When Texas urges that a fetus is entitled to Fourteenth Amendment protection as a person, it faces a dilemma. Neither in Texas nor in any other State are all abortions prohibited. Despite broad proscription, an exception always exists. The exception contained in Art. 1196, for an abortion procured or attempted by medical advice for the purpose of saving the life of the mother, is typical. But if the fetus is a person who is not to be deprived of life without due process of law, and if the mother's condition is the sole determinant, does not the Texas exception appear to be out of line with the Amendment's command?" [1]
If we are ever to succeed in overcoming the Roe decision, then it is imperative that we answer the dilemma presented by Justice Blackmun. How can a personhood amendment be reconciled with the need to protect the life of the mother?
The solution to this dilemma is actually quite simple, but the majority of Americans find it so contrary to their perspective that they tend to reject it without even the slightest consideration. Surgeon General C. Everett Koop answered the dilemma in this way: “Protection of the life of the mother as an excuse for an abortion is a smoke screen. In my thirty-six years in pediatric surgery I have never known of one instance where the child had to be aborted to save the mother's life.”[2] Dr. Koop has been made the subject of much ridicule since making that statement, but is it possible that he is right? Most Americans would answer with an emphatic, “No,” but let us not be so hasty. Let’s take the time to consider the evidence before we arrive at our conclusion.
Without a doubt, the most frequently presented example of a case in which the mother’s life may be in danger if an abortion is not performed is the case of an ectopic pregnancy. An ectopic pregnancy is a pregnancy in which the child is growing in an area of the mother’s body other than the womb. In most of these cases, the child is found to be growing in one of the mother’s fallopian tubes. Occasionally the child will grow in the mother’s abdominal cavity, and on very rare occasions he will begin to develop inside of one of her ovaries. These pregnancies are generally assumed to be fatal unless an abortion is performed, and the explanation is given that it is better to save the mother by killing the unborn child than to do nothing and allow both of them to die.
When we take the time to examine scientific studies of ectopic pregnancies, however, an entirely different picture comes to light. To begin with, let’s consider the Center for Disease Control estimate of 108,800 ectopic pregnancies in America in 1992. [3] According to the above assumption, this number is equal to the number of women who would have died if abortion had not been available to them as a treatment. The CDC also reported an average of 26.3 ectopic related deaths per year from 1991 – 1999,[4] and the proponents of abortion tout these figures as proof that abortion is necessary to save thousands of lives per year. However, that boast is made in ignorance of several additional studies.
The actual danger that an ectopic pregnancy poses to the mother is that of a tubal rupture or some other kind of hemorrhage which could cause the mother to lose a vital amount of blood. However, the Cleveland Clinic Foundation reported that, from 1983 to 1996, they treated 62 patients who had experienced a tubal rupture.[5] Over a fourteen year period, this single hospital treated 4.4 ruptured ectopic pregnancies per year, but the CDC only reported 26.3 ectopic related deaths per year. If tubal ruptures were definitely fatal, then that would mean that this one hospital has witnessed 1/6 of all the ectopic related deaths in America. While this would be highly unlikely, it is certainly not impossible, and so we turn to the next study on our list.
The entire southern region of Israel only saw 13 pregnancy related deaths over a 23 year period extending from 1969 to 1991. [6] This comes to an average of .57 deaths per year. In 1991, the Soroka University Hospital in Be’er Sheva reported 148 ruptured ectopic pregnancies.[7] If we assume that every single one of the .57 pregnancy related deaths occurred at this one hospital and that all .57 of them were the result of ruptured ectopic pregnancies, we still would only be able to calculate a .4% chance that a ruptured ectopic pregnancy will cause the death of the mother (.57 deaths divided by 148 ruptures equals a .4% fatality rate). This means that at least 99.6% of all the ruptured ectopic pregnancies in southern Israel do not result in the death of the mother and that the claim that abortion must be performed in order to prevent death from a ruptured ectopic pregnancy is undoubtedly spurious.
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. 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."[8] According to the American Pregnancy Association, there are approximately 6 million pregnancies per year in the US.[9] 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.[10] If we assumed 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%.
Of course, this leads us to the question of how these mothers were able to survive such an ordeal. Nearly a century ago, a doctor in Germany reported success in using autotransfusion to treat ruptured ectopic pregnancies.[11] Autotransfusion involves siphoning the blood which has spilled into the abdominal cavity, running it through a filter and then pumping it back into the mother’s body. In 2002, a worldwide study of 632 ruptured ectopic pregnancies treated with autotransfusion reported only a single instance of death.[12] That’s a success rate of 99.84%. This study demonstrates that this non-abortive treatment is more successful than the preferred abortion method which has a success rate of just 99.6%.[13]
Clearly, we can see that ectopic pregnancies are not likely to be fatal to the mother, but what of the child? Those confronted with this evidence will undoubtedly ask if it is ethical to cause the mother to experience the pain of an ectopic pregnancy if there is no hope of her child’s survival. However, the assumption that the child cannot survive an ectopic pregnancy is just as groundless as the same claim about the mother.
The ability of the child to survive an ectopic pregnancy is a fact that is often hidden from the general public. WebMD,[14] Emedicine,[15] the Mayo Clinic[16] and even the US Department of Health’s web portal, PubMed Health,[17] all state on their websites that the child cannot survive an ectopic pregnancy. Ironically, the Department of Health’s online library, PubMed Central, contains several professional articles with titles such as “Full Term Intra-abdominal Pregnancy with Living Mother and Child,” but these are buried away in areas seldom seen by the public.[18]
In reality, there have been many reports of successful ectopic pregnancies. Two obstetricians in New York, Dr.’s Hellman and Simon, published details on 316 ectopic pregnancies which resulted in live births between 1809 and 1935.[19] (Only half of these children survived their first week of life, but these births occurred long before the development of the first neonatal intensive care unit. With modern technology, it is likely that many more would have survived.) For more recent examples, we can consider that in September of 1999, Ronan Ingram was successfully delivered via c-section. Ronan had implanted in one of his mother’s fallopian tubes which subsequently ruptured as he grew into the abdominal cavity.[20] Sage Dalton was born in July of 1999 after developing in the amniotic membrane outside her mother’s womb.[21] In May of 2008, Durga Thangarajah was born after spending a full nine months in her mother’s ovary.[22] And Billy Jones was born in 2008 after developing in his mother’s abdominal cavity.[23] The reports go on and on and on.[24] In spite of all the claims to the contrary, doctors are often amazed by the unborn child’s ability to develop and grow regardless of his location within his mother’s body.
Most of the doctors who have written about successful ectopic pregnancies have focused primarily on the details of one or two cases while repeating the claim that survival of the child is extremely rare and unlikely. There are a few, however, who have taken the initiative to study multiple cases, and their conclusions have been markedly different. A 1996 study from Chile, for example, found that out of 11 abdominal pregnancies, there were 7 live births with 5 of those children surviving the neonatal period.[25] Another study conducted in 2008 reviewed 158 abdominal pregnancies worldwide and found that 28% of the children survived the perinatal period but did not report on the actual number of live births.[26] These reports are consistent with a 2010 article which stated that the reported perinatal survival rate for abdominal pregnancies ranges from 5-60%.[27] With reported survival rates as high as 60%, it is difficult to imagine why so many doctors would refer to such cases with terminology approaching the miraculous.
Perhaps the explanation lies in the subtle distinction between tubal pregnancies and abdominal pregnancies. A tubal pregnancy is by far the most common type of ectopic pregnancy, and it occurs when the child implants and begins to grow in one of the mother's fallopian tubes. An abdominal pregnancy is a more rare type of pregnancy in which the child grows in the mother's abdominal cavity. Most of the reports of children surviving ectopic pregnancies refer to those pregnancies as abdominal pregnancies. This has led many people to believe that there is a major distinction between abdominal pregnancies and tubal pregnancies and that only those ectopic children which implant in the abdomen can survive. For example, the Association of Pro-Life Physicians has stated that "there are several cases in the medical literature where abdominal ectopic pregnancies have survived," but they followed that statement with the claim that "there are no cases of ectopic pregnancies in a fallopian tube surviving."[28]
The error in this belief is aptly explained in a 1982 article by Dr. J. F. Clark entitled "Embryo Transfer In Vivo." In that article, Dr. Clark demonstrated that, in a tubal pregnancy, the rupture of the fallopian tube does not kill the unborn child. In many cases, the child will detach from the ruptured tube on his own and reattach on another surface in the abdominal cavity.[29] This ability of the child to detach and reattach indicates that it may eventually be possible for doctors to transplant an ectopic pregnancy into the womb.[see addendum below] Unfortunately, the current acceptance of abortion as a method of treatment has caused this avenue of research to be largely abandoned. Nonetheless, the natural ability of the child to perform this feat has made it possible for a significant number of tubal pregnancies to result in live births.
It is possible to derive a rough calculation of the percentage of children who could survive a tubal pregnancy. There have been multiple studies of expectant management of ectopic pregnancies. (Expectant management refers to cases in which the doctor monitors the pregnancy closely but does not administer any direct treatment.) It has been discovered that a large percentage of ectopic pregnancies resolve on their own with the death of the child before he grows large enough to cause a rupture of the fallopian tube. In one study of 179 tubal pregnancies, it was found that 41.9% of all tubal pregnancies result in the death of the child at this stage.[30] This means that approximately 58% of the children continue to grow until they eventually rupture their mothers' fallopian tubes. Dr. Clark demonstrated that the rupture itself does not cause the death of the child and that he will subsequently implant on some other surface in the abdominal cavity. According to Dr. Clark, 42% of these children will implant on a surface that has enough of a blood supply for the unborn child to survive all the way to 28 weeks of gestation. At any point after 28 weeks, the child can be delivered alive via c-section with a very good chance for survival. (Deliveries as early as 21 weeks have been reported, but the majority of those children do not survive the neonatal period.) Given these two percentages, we can calculate that 24% of all tubal pregnancies could result in a live birth.
Thus, we can see that the distinction between tubal pregnancies and abdominal pregnancies is often one of progression only. Within the scientific literature, abdominal pregnancies are often separated into two classes - primary abdominal pregnancies in which the child initially implanted on a surface in the abdomen and secondary abdominal pregnancies in which the child initially implanted within the ovaries, tubes or uterus and then either grew into or reimplanted into the abdominal cavity. The vast majority of abdominal pregnancies are of the secondary classification as a result of the child's ability to reimplant in the abdomen after a tubal rupture.[31] In addition to this, Dr. Clark also wrote another article in which he described a tubal pregnancy that proceeded all the way to term without rupturing.[32] The claim that tubal pregnancies cannot survive is therefore proven false on two levels. It is possible but rare for the child to survive a tubal pregnancy without a rupture of the tubes, and there is at least a 24% chance that the child will survive in spite of a tubal rupture.
Unfortunately, as Dr. Clark pointed out, many cases of ectopic pregnancy are misdiagnosed; and the doctor does not realize that anything is wrong until after the child has already died. If these misdiagnosed ectopics were properly recognized prior to the 28th week, then the doctor would be able to closely monitor the condition of both the child and the mother so that a c-section delivery could be initiated immediately if the condition of either patient begins to worsen. In addition, the misdiagnosis of ectopic pregnancies has also caused the death of many children prior to their 28th week of development. This often occurs when the doctor diagnoses the pregnancy as a tumor and initiates surgery to remove it. The placenta is usually very thin in ectopic pregnancies, and the probing of the surgical instruments is often enough to puncture it and cause the death of the child before the doctor is even aware that he is there. As one author put it, "The deleterious effect of abdominal pregnancy on the mother and fetus is partly related to the morbidity of the surgical interventions."[33]
As we can see, ectopic pregnancies are not necessarily fatal for either the mother or the child. The mother’s survival is almost certain, and the survival of the child is at least possible if not probable. Dr. Koop was correct. The personhood of the unborn child does not conflict with the need to protect the life of the mother for the simple reason that abortion is never necessary for that protection. There are other solutions available. More than one obstetrician has recommended that women with ectopic pregnancies should be placed under the constant vigil of a well equipped hospital until their children have developed enough to be delivered alive rather than sacrificed unnecessarily.[34] Ectopic pregnancies can be survived, and we can prohibit all abortions without any exceptions.
Addendum:
Since writing this article, I have been made aware of two cases of successful transplants of ectopic pregnancies into the mother's womb. The first instance occurred in 1915 and was reported in volume 24 of the journal Surgery, Gynecology and Obstetrics. This report is available online from American Right to Life at: http://americanrtl.com/files/docs/Journal-Surg-Gyn-Obst-1917p578-579ectopic-transplant.pdf. The second instance took place much more recently in 1980. This case was reported in volume 163 of the American Journal of Obstetrics and Gynecology. The full text of this report is not available online, but a lengthy quotation can be found in the article "The Ethics of Ectopic Pregnancy" by Christopher Kaczor which is available online at: http://myweb.lmu.edu/ckaczor/ectopicpregnancylinacre.pdf. The quote is on the fourth page of Kaczor's article.
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[1] Roe v. Wade, 410 U.S. 113 (1973)
[2] C. Everett Koop, M. D., "A Physician Speaks About Abortion," http://www.pathlights.com/abortion/abort08.htm(accessed December 03, 2011)
[3] Center for Disease Control, “Current Trends Ecoptic Pregnancy.” http://www.cdc.gov/mmwr/preview/mmwrhtml/00035709.htm (accessed December 03, 2011)
[4] Center for Disease Control, “Pregnancy-Related Mortality Surveillance,“ http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5202a1.htm (accessed December 03, 2011)
[5] Tommaso Falcone, Edward J. Mascha, Jeffrey M. Goldberg, Lourdes L. Falconi, Geeta Mohla, and Marjan Attaran. “A Study of Risk Factors for Ruptured Tubal Ectopic Pregnancy,” Journal of Women's Health. May 1998, 7(4): 459-463. doi:10.1089/jwh.1998.7.459.
[6] J. R. Leiberman, D. Fraser, M. Mazor and M. Glezerman, “Maternal Mortality in Southern Israel,” Archives of Gynecology and Obstetrics, 252(4): 203-207, DOI: 10.1007/BF02426359
[7] M. Glezerman, F. Press and M. Carpman, "Culdocentesis is an Obsolete Diagnostic Tool in Suspected Ectopic Pregnancy," Archives of Gynecology and Obstetrics, 252(1): 5-9, DOI: 10.1007/BF02389600
[8] J. L. Tenore, “Ectopic Pregnancy,” Am Fam Physician. 2000 Feb 15;61(4):1080-1088.
[9] “Statistics,” American Pregnancy Association, http://www.americanpregnancy.org/main/statistics.html (accessed April 12, 2012).
[10] Chang J, Elam-Evans LD, Berg CJ, et al. “Pregnancy-related mortality surveillance—United States 1991–1999,” MMWR Surveill Summ 2003; 52:1–8.
[11] S Edwin Duncan, Gerald Klebanoff, Waid Rogers, "A Clinical Experience with Intraoperative Autotransfusion," Annals of Surgery 180(3): 296-304,
[12] D.O Selo-Ojemea, J.L Onwudea, U Onwudiegwu, "Autotransfusion for Ruptured Ectopic Pregnancy," International Journal of Gynecology & Obstetrics, 80(2): 103-110, DOI:10.1016/S0020-7292(02)00379-X
[13] Clarisa R Gracia M.D.a, Hillary A Brown M.D.b, Kurt T Barnhart M.D.M.S.C.E., "Prophylactic methotrexate after linear salpingostomy: a decision analysis," Fertility and Sterility, 76(6): 1191-1195, DOI:10.1016/S0015-0282(01)02906-5
[14] WebMD, “Ectopic Pregnancy – What Happens” May 06, 2011, http://www.webmd.com/baby/tc/ectopic-pregnancy-what-happens (accessed May 15, 2012)
[15] Sepilian, Vicken P, MD, MSc, “Ectopic Pregnancy” Medscape Reference, March 26, 2012, http://emedicine.medscape.com/article/258768-overview (accessed May 15, 2012)
[16] Mayo Clinic, “Ectopic Pregnancy” February 09, 2012, http://www.mayoclinic.com/health/ectopic-pregnancy/DS00622 (accessed May 15, 2012)
[17] PubMed Health, “Ectopic Pregnancy” February 21, 2010, http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001897/ (accessed May 15, 2012)
[18] Teh, Hu Sin “Full Term Intra-abdominal Pregnancy with Living Mother and Child,” PubMed Central, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2602194 (accessed May 15, 2012)
[19] Hellman, A. and J. H. Simon, "Full Term Intra-abdominal Pregnancy," American Journal of Surgery, 29:403, 1935.
[20] BBC News, "Doctors hail 'miracle' baby," http://news.bbc.co.uk/2/hi/health/443373.stm (accessed December 03, 2011)
[21] The American Registry for Diagnostic Medical Sonography, "Broadcast of “Miracle Ectopic Pregnancy” Brought Quick Response by ARDMS," Registry Reports, XVI(5):1
[22] Rebekah Cavanagh, "Miracle baby may be a world first," NT News, May 30, 2008, http://www.ntnews.com.au/article/2008/05/30/4247_ntnews.html (accessed December 03, 2011)
[23] Laura Collins, "Miracle baby Billy grew outside his mother's womb," http://www.dailymail.co.uk/femail/article-1050942/Miracle-baby-Billy-grew-outside-mothers-womb.html (accessed December 03, 2011)
[24] I have personally discovered more than 400 reports of live birth from ectopic pregnancy. A partial listing of those reports can be found at http://www.personhoodinitiative.com/successful-ectopic-pregnancies.html
[25] Theodore J. Dubinsky MD, Francisco Guerra MD, Gustavo Gormaz MD, Nabil Maklad MD, PhD, "Fetal survival in abdominal pregnancy: A review of 11 cases," Journal of Clinical Ultrasound, 24(9): 513–517, December 1996
[26] D Nkusu Nunyalulendho, EM Einterz, "Advanced abdominal pregnancy: case report and review of 163 cases reported since 1946," Rural and Remote Health, December 91, 2008
[27] Ayinur Nahar Hamid, Rokeya Begum, Zackya Sultana, Nargis Akhter, "Advanced Abdominal Pregnancy: A Case Report," Journal of Chittagong Medical College Teachers' Association, 21(1): 74-76, 2010
[28] The Association of Pro-Life Physicians, "Are There Rare Cases When an Abortion Is Justified?" http://www.prolifephysicians.org/rarecases.htm (accessed June 20, 2012)
[29] John F.J. Clark, MD, FACOG, "Embryo Transfer In Vivo," Journal of the National Medical Association, Vol. 74, No. 8, 1982 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2552973/pdf/jnma00062-0019.pdf)
[30] Elson J, Tailor A, Banerjee S, Salim R, Hillaby K, Jurkovic D, "Expectant management of tubal ectopic pregnancy: prediction of successful outcome using decision tree analysis," Ultrasound in Obstetrics and Gynecology, 2004 Jun, 23(6): 552-6 (http://www.ncbi.nlm.nih.gov/pubmed/15170794)
[31] Eric Delabrousse, Olivier Site, Arlette Le Mouel, Didier Riethmuller, Bruno Kastler, "Intrahepatic Pregnancy: Sonography and CT Findings," American Journal of Roentgenology 173: 1377-1378, November 1999
[32] JF Clark, MD, Department of Obstetrics and Gynecology, Howard University College of Medicine, Washington, D.C., "Follow-Up of Live Extra-Uterine Pregnancies," Journal of the Natinal Medical Association, January, 1974; 66(1): 69-70, 52 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2609142/)
[33] Amanda Cotter MD, Luis Izquierdo MD, Fernando Heredia MD, "Abdominal Pregnancy," TheFetus.net, 2002, accessed June 03, 2012 (http://www.sonoworld.com/fetus/page.aspx?id=1032)
[34] Mathias Sapuri and Cecil Klufio, "A case of advanced viable extrauterine pregnancy," Papua New Guinea Medical Journal, 40(1): 44-47, March 1997
One of the most ardently presented pro-choice arguments is the claim that abortion is sometimes necessary in order to save the life of the mother. This argument has been very effective over the years and has been used to persuade pro-life politicians to include a life of the mother exception to nearly every law designed to limit abortions. Very few politicians realize that the inclusion of a life of the mother exception is a tacit admission that the unborn child is not a person. Even more rare is the politician who realizes that Justice Blackmun cited this very exception to justify his decision in Roe v. Wade.
"If this suggestion of personhood is established, the appellant's case, of course, collapses, for the fetus' right to life would then be guaranteed specifically by the (Fourteenth) Amendment ... When Texas urges that a fetus is entitled to Fourteenth Amendment protection as a person, it faces a dilemma. Neither in Texas nor in any other State are all abortions prohibited. Despite broad proscription, an exception always exists. The exception contained in Art. 1196, for an abortion procured or attempted by medical advice for the purpose of saving the life of the mother, is typical. But if the fetus is a person who is not to be deprived of life without due process of law, and if the mother's condition is the sole determinant, does not the Texas exception appear to be out of line with the Amendment's command?" [1]
If we are ever to succeed in overcoming the Roe decision, then it is imperative that we answer the dilemma presented by Justice Blackmun. How can a personhood amendment be reconciled with the need to protect the life of the mother?
The solution to this dilemma is actually quite simple, but the majority of Americans find it so contrary to their perspective that they tend to reject it without even the slightest consideration. Surgeon General C. Everett Koop answered the dilemma in this way: “Protection of the life of the mother as an excuse for an abortion is a smoke screen. In my thirty-six years in pediatric surgery I have never known of one instance where the child had to be aborted to save the mother's life.”[2] Dr. Koop has been made the subject of much ridicule since making that statement, but is it possible that he is right? Most Americans would answer with an emphatic, “No,” but let us not be so hasty. Let’s take the time to consider the evidence before we arrive at our conclusion.
Without a doubt, the most frequently presented example of a case in which the mother’s life may be in danger if an abortion is not performed is the case of an ectopic pregnancy. An ectopic pregnancy is a pregnancy in which the child is growing in an area of the mother’s body other than the womb. In most of these cases, the child is found to be growing in one of the mother’s fallopian tubes. Occasionally the child will grow in the mother’s abdominal cavity, and on very rare occasions he will begin to develop inside of one of her ovaries. These pregnancies are generally assumed to be fatal unless an abortion is performed, and the explanation is given that it is better to save the mother by killing the unborn child than to do nothing and allow both of them to die.
When we take the time to examine scientific studies of ectopic pregnancies, however, an entirely different picture comes to light. To begin with, let’s consider the Center for Disease Control estimate of 108,800 ectopic pregnancies in America in 1992. [3] According to the above assumption, this number is equal to the number of women who would have died if abortion had not been available to them as a treatment. The CDC also reported an average of 26.3 ectopic related deaths per year from 1991 – 1999,[4] and the proponents of abortion tout these figures as proof that abortion is necessary to save thousands of lives per year. However, that boast is made in ignorance of several additional studies.
The actual danger that an ectopic pregnancy poses to the mother is that of a tubal rupture or some other kind of hemorrhage which could cause the mother to lose a vital amount of blood. However, the Cleveland Clinic Foundation reported that, from 1983 to 1996, they treated 62 patients who had experienced a tubal rupture.[5] Over a fourteen year period, this single hospital treated 4.4 ruptured ectopic pregnancies per year, but the CDC only reported 26.3 ectopic related deaths per year. If tubal ruptures were definitely fatal, then that would mean that this one hospital has witnessed 1/6 of all the ectopic related deaths in America. While this would be highly unlikely, it is certainly not impossible, and so we turn to the next study on our list.
The entire southern region of Israel only saw 13 pregnancy related deaths over a 23 year period extending from 1969 to 1991. [6] This comes to an average of .57 deaths per year. In 1991, the Soroka University Hospital in Be’er Sheva reported 148 ruptured ectopic pregnancies.[7] If we assume that every single one of the .57 pregnancy related deaths occurred at this one hospital and that all .57 of them were the result of ruptured ectopic pregnancies, we still would only be able to calculate a .4% chance that a ruptured ectopic pregnancy will cause the death of the mother (.57 deaths divided by 148 ruptures equals a .4% fatality rate). This means that at least 99.6% of all the ruptured ectopic pregnancies in southern Israel do not result in the death of the mother and that the claim that abortion must be performed in order to prevent death from a ruptured ectopic pregnancy is undoubtedly spurious.
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. 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."[8] According to the American Pregnancy Association, there are approximately 6 million pregnancies per year in the US.[9] 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.[10] If we assumed 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%.
Of course, this leads us to the question of how these mothers were able to survive such an ordeal. Nearly a century ago, a doctor in Germany reported success in using autotransfusion to treat ruptured ectopic pregnancies.[11] Autotransfusion involves siphoning the blood which has spilled into the abdominal cavity, running it through a filter and then pumping it back into the mother’s body. In 2002, a worldwide study of 632 ruptured ectopic pregnancies treated with autotransfusion reported only a single instance of death.[12] That’s a success rate of 99.84%. This study demonstrates that this non-abortive treatment is more successful than the preferred abortion method which has a success rate of just 99.6%.[13]
Clearly, we can see that ectopic pregnancies are not likely to be fatal to the mother, but what of the child? Those confronted with this evidence will undoubtedly ask if it is ethical to cause the mother to experience the pain of an ectopic pregnancy if there is no hope of her child’s survival. However, the assumption that the child cannot survive an ectopic pregnancy is just as groundless as the same claim about the mother.
The ability of the child to survive an ectopic pregnancy is a fact that is often hidden from the general public. WebMD,[14] Emedicine,[15] the Mayo Clinic[16] and even the US Department of Health’s web portal, PubMed Health,[17] all state on their websites that the child cannot survive an ectopic pregnancy. Ironically, the Department of Health’s online library, PubMed Central, contains several professional articles with titles such as “Full Term Intra-abdominal Pregnancy with Living Mother and Child,” but these are buried away in areas seldom seen by the public.[18]
In reality, there have been many reports of successful ectopic pregnancies. Two obstetricians in New York, Dr.’s Hellman and Simon, published details on 316 ectopic pregnancies which resulted in live births between 1809 and 1935.[19] (Only half of these children survived their first week of life, but these births occurred long before the development of the first neonatal intensive care unit. With modern technology, it is likely that many more would have survived.) For more recent examples, we can consider that in September of 1999, Ronan Ingram was successfully delivered via c-section. Ronan had implanted in one of his mother’s fallopian tubes which subsequently ruptured as he grew into the abdominal cavity.[20] Sage Dalton was born in July of 1999 after developing in the amniotic membrane outside her mother’s womb.[21] In May of 2008, Durga Thangarajah was born after spending a full nine months in her mother’s ovary.[22] And Billy Jones was born in 2008 after developing in his mother’s abdominal cavity.[23] The reports go on and on and on.[24] In spite of all the claims to the contrary, doctors are often amazed by the unborn child’s ability to develop and grow regardless of his location within his mother’s body.
Most of the doctors who have written about successful ectopic pregnancies have focused primarily on the details of one or two cases while repeating the claim that survival of the child is extremely rare and unlikely. There are a few, however, who have taken the initiative to study multiple cases, and their conclusions have been markedly different. A 1996 study from Chile, for example, found that out of 11 abdominal pregnancies, there were 7 live births with 5 of those children surviving the neonatal period.[25] Another study conducted in 2008 reviewed 158 abdominal pregnancies worldwide and found that 28% of the children survived the perinatal period but did not report on the actual number of live births.[26] These reports are consistent with a 2010 article which stated that the reported perinatal survival rate for abdominal pregnancies ranges from 5-60%.[27] With reported survival rates as high as 60%, it is difficult to imagine why so many doctors would refer to such cases with terminology approaching the miraculous.
Perhaps the explanation lies in the subtle distinction between tubal pregnancies and abdominal pregnancies. A tubal pregnancy is by far the most common type of ectopic pregnancy, and it occurs when the child implants and begins to grow in one of the mother's fallopian tubes. An abdominal pregnancy is a more rare type of pregnancy in which the child grows in the mother's abdominal cavity. Most of the reports of children surviving ectopic pregnancies refer to those pregnancies as abdominal pregnancies. This has led many people to believe that there is a major distinction between abdominal pregnancies and tubal pregnancies and that only those ectopic children which implant in the abdomen can survive. For example, the Association of Pro-Life Physicians has stated that "there are several cases in the medical literature where abdominal ectopic pregnancies have survived," but they followed that statement with the claim that "there are no cases of ectopic pregnancies in a fallopian tube surviving."[28]
The error in this belief is aptly explained in a 1982 article by Dr. J. F. Clark entitled "Embryo Transfer In Vivo." In that article, Dr. Clark demonstrated that, in a tubal pregnancy, the rupture of the fallopian tube does not kill the unborn child. In many cases, the child will detach from the ruptured tube on his own and reattach on another surface in the abdominal cavity.[29] This ability of the child to detach and reattach indicates that it may eventually be possible for doctors to transplant an ectopic pregnancy into the womb.[see addendum below] Unfortunately, the current acceptance of abortion as a method of treatment has caused this avenue of research to be largely abandoned. Nonetheless, the natural ability of the child to perform this feat has made it possible for a significant number of tubal pregnancies to result in live births.
It is possible to derive a rough calculation of the percentage of children who could survive a tubal pregnancy. There have been multiple studies of expectant management of ectopic pregnancies. (Expectant management refers to cases in which the doctor monitors the pregnancy closely but does not administer any direct treatment.) It has been discovered that a large percentage of ectopic pregnancies resolve on their own with the death of the child before he grows large enough to cause a rupture of the fallopian tube. In one study of 179 tubal pregnancies, it was found that 41.9% of all tubal pregnancies result in the death of the child at this stage.[30] This means that approximately 58% of the children continue to grow until they eventually rupture their mothers' fallopian tubes. Dr. Clark demonstrated that the rupture itself does not cause the death of the child and that he will subsequently implant on some other surface in the abdominal cavity. According to Dr. Clark, 42% of these children will implant on a surface that has enough of a blood supply for the unborn child to survive all the way to 28 weeks of gestation. At any point after 28 weeks, the child can be delivered alive via c-section with a very good chance for survival. (Deliveries as early as 21 weeks have been reported, but the majority of those children do not survive the neonatal period.) Given these two percentages, we can calculate that 24% of all tubal pregnancies could result in a live birth.
Thus, we can see that the distinction between tubal pregnancies and abdominal pregnancies is often one of progression only. Within the scientific literature, abdominal pregnancies are often separated into two classes - primary abdominal pregnancies in which the child initially implanted on a surface in the abdomen and secondary abdominal pregnancies in which the child initially implanted within the ovaries, tubes or uterus and then either grew into or reimplanted into the abdominal cavity. The vast majority of abdominal pregnancies are of the secondary classification as a result of the child's ability to reimplant in the abdomen after a tubal rupture.[31] In addition to this, Dr. Clark also wrote another article in which he described a tubal pregnancy that proceeded all the way to term without rupturing.[32] The claim that tubal pregnancies cannot survive is therefore proven false on two levels. It is possible but rare for the child to survive a tubal pregnancy without a rupture of the tubes, and there is at least a 24% chance that the child will survive in spite of a tubal rupture.
Unfortunately, as Dr. Clark pointed out, many cases of ectopic pregnancy are misdiagnosed; and the doctor does not realize that anything is wrong until after the child has already died. If these misdiagnosed ectopics were properly recognized prior to the 28th week, then the doctor would be able to closely monitor the condition of both the child and the mother so that a c-section delivery could be initiated immediately if the condition of either patient begins to worsen. In addition, the misdiagnosis of ectopic pregnancies has also caused the death of many children prior to their 28th week of development. This often occurs when the doctor diagnoses the pregnancy as a tumor and initiates surgery to remove it. The placenta is usually very thin in ectopic pregnancies, and the probing of the surgical instruments is often enough to puncture it and cause the death of the child before the doctor is even aware that he is there. As one author put it, "The deleterious effect of abdominal pregnancy on the mother and fetus is partly related to the morbidity of the surgical interventions."[33]
As we can see, ectopic pregnancies are not necessarily fatal for either the mother or the child. The mother’s survival is almost certain, and the survival of the child is at least possible if not probable. Dr. Koop was correct. The personhood of the unborn child does not conflict with the need to protect the life of the mother for the simple reason that abortion is never necessary for that protection. There are other solutions available. More than one obstetrician has recommended that women with ectopic pregnancies should be placed under the constant vigil of a well equipped hospital until their children have developed enough to be delivered alive rather than sacrificed unnecessarily.[34] Ectopic pregnancies can be survived, and we can prohibit all abortions without any exceptions.
Addendum:
Since writing this article, I have been made aware of two cases of successful transplants of ectopic pregnancies into the mother's womb. The first instance occurred in 1915 and was reported in volume 24 of the journal Surgery, Gynecology and Obstetrics. This report is available online from American Right to Life at: http://americanrtl.com/files/docs/Journal-Surg-Gyn-Obst-1917p578-579ectopic-transplant.pdf. The second instance took place much more recently in 1980. This case was reported in volume 163 of the American Journal of Obstetrics and Gynecology. The full text of this report is not available online, but a lengthy quotation can be found in the article "The Ethics of Ectopic Pregnancy" by Christopher Kaczor which is available online at: http://myweb.lmu.edu/ckaczor/ectopicpregnancylinacre.pdf. The quote is on the fourth page of Kaczor's article.
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[1] Roe v. Wade, 410 U.S. 113 (1973)
[2] C. Everett Koop, M. D., "A Physician Speaks About Abortion," http://www.pathlights.com/abortion/abort08.htm(accessed December 03, 2011)
[3] Center for Disease Control, “Current Trends Ecoptic Pregnancy.” http://www.cdc.gov/mmwr/preview/mmwrhtml/00035709.htm (accessed December 03, 2011)
[4] Center for Disease Control, “Pregnancy-Related Mortality Surveillance,“ http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5202a1.htm (accessed December 03, 2011)
[5] Tommaso Falcone, Edward J. Mascha, Jeffrey M. Goldberg, Lourdes L. Falconi, Geeta Mohla, and Marjan Attaran. “A Study of Risk Factors for Ruptured Tubal Ectopic Pregnancy,” Journal of Women's Health. May 1998, 7(4): 459-463. doi:10.1089/jwh.1998.7.459.
[6] J. R. Leiberman, D. Fraser, M. Mazor and M. Glezerman, “Maternal Mortality in Southern Israel,” Archives of Gynecology and Obstetrics, 252(4): 203-207, DOI: 10.1007/BF02426359
[7] M. Glezerman, F. Press and M. Carpman, "Culdocentesis is an Obsolete Diagnostic Tool in Suspected Ectopic Pregnancy," Archives of Gynecology and Obstetrics, 252(1): 5-9, DOI: 10.1007/BF02389600
[8] J. L. Tenore, “Ectopic Pregnancy,” Am Fam Physician. 2000 Feb 15;61(4):1080-1088.
[9] “Statistics,” American Pregnancy Association, http://www.americanpregnancy.org/main/statistics.html (accessed April 12, 2012).
[10] Chang J, Elam-Evans LD, Berg CJ, et al. “Pregnancy-related mortality surveillance—United States 1991–1999,” MMWR Surveill Summ 2003; 52:1–8.
[11] S Edwin Duncan, Gerald Klebanoff, Waid Rogers, "A Clinical Experience with Intraoperative Autotransfusion," Annals of Surgery 180(3): 296-304,
[12] D.O Selo-Ojemea, J.L Onwudea, U Onwudiegwu, "Autotransfusion for Ruptured Ectopic Pregnancy," International Journal of Gynecology & Obstetrics, 80(2): 103-110, DOI:10.1016/S0020-7292(02)00379-X
[13] Clarisa R Gracia M.D.a, Hillary A Brown M.D.b, Kurt T Barnhart M.D.M.S.C.E., "Prophylactic methotrexate after linear salpingostomy: a decision analysis," Fertility and Sterility, 76(6): 1191-1195, DOI:10.1016/S0015-0282(01)02906-5
[14] WebMD, “Ectopic Pregnancy – What Happens” May 06, 2011, http://www.webmd.com/baby/tc/ectopic-pregnancy-what-happens (accessed May 15, 2012)
[15] Sepilian, Vicken P, MD, MSc, “Ectopic Pregnancy” Medscape Reference, March 26, 2012, http://emedicine.medscape.com/article/258768-overview (accessed May 15, 2012)
[16] Mayo Clinic, “Ectopic Pregnancy” February 09, 2012, http://www.mayoclinic.com/health/ectopic-pregnancy/DS00622 (accessed May 15, 2012)
[17] PubMed Health, “Ectopic Pregnancy” February 21, 2010, http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001897/ (accessed May 15, 2012)
[18] Teh, Hu Sin “Full Term Intra-abdominal Pregnancy with Living Mother and Child,” PubMed Central, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2602194 (accessed May 15, 2012)
[19] Hellman, A. and J. H. Simon, "Full Term Intra-abdominal Pregnancy," American Journal of Surgery, 29:403, 1935.
[20] BBC News, "Doctors hail 'miracle' baby," http://news.bbc.co.uk/2/hi/health/443373.stm (accessed December 03, 2011)
[21] The American Registry for Diagnostic Medical Sonography, "Broadcast of “Miracle Ectopic Pregnancy” Brought Quick Response by ARDMS," Registry Reports, XVI(5):1
[22] Rebekah Cavanagh, "Miracle baby may be a world first," NT News, May 30, 2008, http://www.ntnews.com.au/article/2008/05/30/4247_ntnews.html (accessed December 03, 2011)
[23] Laura Collins, "Miracle baby Billy grew outside his mother's womb," http://www.dailymail.co.uk/femail/article-1050942/Miracle-baby-Billy-grew-outside-mothers-womb.html (accessed December 03, 2011)
[24] I have personally discovered more than 400 reports of live birth from ectopic pregnancy. A partial listing of those reports can be found at http://www.personhoodinitiative.com/successful-ectopic-pregnancies.html
[25] Theodore J. Dubinsky MD, Francisco Guerra MD, Gustavo Gormaz MD, Nabil Maklad MD, PhD, "Fetal survival in abdominal pregnancy: A review of 11 cases," Journal of Clinical Ultrasound, 24(9): 513–517, December 1996
[26] D Nkusu Nunyalulendho, EM Einterz, "Advanced abdominal pregnancy: case report and review of 163 cases reported since 1946," Rural and Remote Health, December 91, 2008
[27] Ayinur Nahar Hamid, Rokeya Begum, Zackya Sultana, Nargis Akhter, "Advanced Abdominal Pregnancy: A Case Report," Journal of Chittagong Medical College Teachers' Association, 21(1): 74-76, 2010
[28] The Association of Pro-Life Physicians, "Are There Rare Cases When an Abortion Is Justified?" http://www.prolifephysicians.org/rarecases.htm (accessed June 20, 2012)
[29] John F.J. Clark, MD, FACOG, "Embryo Transfer In Vivo," Journal of the National Medical Association, Vol. 74, No. 8, 1982 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2552973/pdf/jnma00062-0019.pdf)
[30] Elson J, Tailor A, Banerjee S, Salim R, Hillaby K, Jurkovic D, "Expectant management of tubal ectopic pregnancy: prediction of successful outcome using decision tree analysis," Ultrasound in Obstetrics and Gynecology, 2004 Jun, 23(6): 552-6 (http://www.ncbi.nlm.nih.gov/pubmed/15170794)
[31] Eric Delabrousse, Olivier Site, Arlette Le Mouel, Didier Riethmuller, Bruno Kastler, "Intrahepatic Pregnancy: Sonography and CT Findings," American Journal of Roentgenology 173: 1377-1378, November 1999
[32] JF Clark, MD, Department of Obstetrics and Gynecology, Howard University College of Medicine, Washington, D.C., "Follow-Up of Live Extra-Uterine Pregnancies," Journal of the Natinal Medical Association, January, 1974; 66(1): 69-70, 52 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2609142/)
[33] Amanda Cotter MD, Luis Izquierdo MD, Fernando Heredia MD, "Abdominal Pregnancy," TheFetus.net, 2002, accessed June 03, 2012 (http://www.sonoworld.com/fetus/page.aspx?id=1032)
[34] Mathias Sapuri and Cecil Klufio, "A case of advanced viable extrauterine pregnancy," Papua New Guinea Medical Journal, 40(1): 44-47, March 1997
