report on ectopic pregnancy

Gonzalo Herranz.
department Bioethics Department, University of Navarra.
August 1990.

I. From a medical point of view, what is the case of ectopic pregnancy, especially intratubal, in which a non-viable foetus-embryo is abnormally placed? Is it always non-viable?

In my view, the biomedical data relevant for a moral analysis of ectopic pregnancy (EP) are asked here. These data can be grouped under the following three headings:

1. Incidence.

2. Maternal morbidity and mortality.

3. Embryo-fetal morbidity and mortality.

1. Incidence

For two decades now, the incidence of EE has been growing at an alarming rate in all industrialised countries (USA, UK, France, Sweden, Finland, etc.). In the United States, for example, the number of cases rose from 17,800 in 1970 to 78,400 in 1985.

The epidemic of sexually transmitted diseases that began in the 1960s and employment of intrauterine devices are blamed as the main causes of this higher incidence. Other factors blamed are certain medical interventions (ovulation induction; administration of oestrogens or gestagens - the progestin-only mini-pill, for example -, fivet, induced abortion, tubal repair surgery) or certain circumstances that occur in women (the tendency to delay having children, the previous presentation of another EE or infertility).

The topographical distribution of EPs can be schematicised as follows: 98% of EPs are tubal based, 1% develop in the ovary and a further 1% implant primarily or secondarily in the abdomen. A negligible issue implants in the uterine cervix, the broad ligament, in a rudimentary uterine horn and in other exceptional locations.

2. Maternal morbidity and mortality due to EE

The main adverse consequences of EE for women are the risk of death due to intraperitoneal haemorrhage, and loss or decrease in fertility.

The absolute and relative maternal mortality fees caused by EE has been declining over the last two decades, despite the aforementioned sharp increase in the incidence of EE. It has fallen from 35 deaths per 10,000 cases of EE in 1970 to 4.2 deaths per 10,000 cases in 1985. This decrease is attributed to earlier and more efficient diagnosis of EE and the application of modern treatment methods. One hundred years ago, the mortality caused by advanced tubal EP was 69%.

The maternal mortality rate associated with abdominal pregnancy varies widely between institutions. Figures of up to 20% have been reported, which is easy to understand considering the risk of catastrophic haemorrhage, coagulation disorders, sepsis and postoperative bowel fistulae.

Despite modern advances in diagnosis and treatment, women who have previously had an EE have reduced fertility: only 30 to 50% of them go on to have full-term pregnancies. This explains why the primary concern of many gynaecologists today is to develop or apply techniques (microsurgical, pharmacological) to promote the subsequent fertility of these women. Unfortunately, many of these techniques involve the direct destruction of the non-viable ectopic embryo.

3. Mortality and embryo-fetal viability

We do not know the real incidence of EE. More than fifteen years ago, there was no means of early diagnosis of EE and only cases with clinical manifestations could be considered. With the refinement of diagnostic methods and their application to groups of women at high risk for EoE, it is now possible to diagnose EoE very early and to follow its course very closely.

In this way, it has been possible to establish that the issue number of early EE who, without clinical manifestations or with very slight symptomatology, suffer a process of spontaneous tubal abortion is much higher than previously assumed.

On the other hand, there is a widespread, almost dominant tendency among doctors to avoid, by means of immediate treatment, all risks to the life and fertility of the mother that EE entails, by immediately destroying - surgically or pharmacologically - the embryo developing in the tube. This behaviour makes it impossible to obtain data modern information about the spontaneous development of the EP and the viability of the embryo.

Thus, the ordinary, common fate of the tubal EP today is the death of the embryo, whether spontaneous or medically induced. The cases in which the foetus reaches a stage of viability in the primitive tubal site are extremely rare. And when the embryo, partially detached from its tubal seat, implants secondarily in the abdomen, few foetuses reach viability and even fewer are extracted alive: of these, barely a quarter make it beyond the perinatal stage because of the serious anomalies they present, generally related to oligohydramnios.

It can therefore be concluded that the number of ectopic foetuses that reach viability is extremely low issue and that many of these foetuses have severe alterations, often incompatible with life. From a statistical point of view, embryofetal viability is a factor of little relevance to the technical judgement of the EP.

II. What are the practiced and/or practicable avenues of solution in the light of present medical science, including medical conditions readily available in the common hospital setting?

1. The current state of the art

EE will often continue to present itself to the physician in the form of an urgent clinical episode of intra-abdominal haemorrhage. The doctor can then assume that the embryo is dead and will intervene to remove the embryonic remains and the perforated and bleeding tube. This will avert the immediate and serious threat to the mother's life. On this point, there is an almost universal agreement among doctors and moralists.

But, as noted above, the procedures for the diagnosis of EP have been considerably improved in recent years, and it has become possible, through serial quantitative determination of serum beta-hCG and high-resolution transvaginal ultrasound, to diagnose EP early, before it has shown clinical symptoms or signs of impending rupture. They also allow an increasingly better understanding of the evolutionary possibilities of EE and its varied clinical course, the determination of the viability status of the embryo and the diagnosis of its death, and a better individualisation of the treatment to be administered to each patient.

These techniques should be part of the services provided by modern hospitals, as they are required by the current state of the art. Together with data of the general and haemodynamic condition of the mother, they provide a solid basis for the expectant mother approach, which, as will be pointed out below, makes maximum respect for the life of the embryo compatible with the protection of the mother's life.

The dominant trend on the professional internship is informed, however, by the imperative of efficiency, not by the obligation to respect. The priority goal of "scientistic" doctors (and fearful of being taken to court for malpractice) today seems to consist, first and foremost, in saving the life of the mother by eliminating the ectopic embryo, regardless of whether the embryo is alive or dead. However, technical advances have added another important aspect to the doctor's work, goal , which is to ensure the woman's subsequent fertility. To this end, surgical interventions are used which are not only early, but also minimally traumatic: salpingectomy is rejected as too aggressive and mutilating, and conservative surgical procedures are applied, by laparotomy or even laparoscopy, such as partial resection of the tube, linear salpingotomy, salpingostomy or infundibular expression. And the potential value of some experimental pharmacological treatments, both general (methotrexate, RU-486) and by intratubal gestational sac injection (methotrexate, potassium chloride, prostaglandin), is beginning to be tested.

2. Is there a need to review the application of the concept of indirect abortion to this case?

The introduction of conservative surgical treatments makes it necessary, in my opinion, to review the applicability to the case of the EE of the concept of indirect abortion, which is enshrined in a strong current within Catholic Moral Theology.

Indeed, the acceptance of the removal of the tube containing a living embryo was based on the application of the principle of double effect, which requires that the primary action and intention of the physician be directed at removing a pathological, damaged organ that threatens the life of the pregnant woman; only indirectly does the physician intend and cause the removal and death of the foetus and the good effect is not a consequence of the bad and unwanted effect. The reason for allowing indirect abortion must be - it is added - very serious and proportionate: the imminent threat to the life of the mother. According to the interpretation of a large sector of Catholic theologians and doctors, it was not necessary, for the conditions of moral licitness to be met, for the tube to have ruptured or for the embryo to have died: if the tubal wall is thinned, it is already a threat to the mother's life and can lawfully be removed; in other words, a tube occupied by an EP is equated with a malignant tumour that has to be removed to safeguard the mother's life, even if at this precise moment it does not imminently threaten it. At the same time, these same moralists and doctors, in pointing out the precise limits of their action, established that it was illicit to open the tube and remove the foetus, since the mother's life would not then be saved by an indifferent act (i.e. the removal of a diseased organ), but by the direct destruction of the foetus. This would be a direct abortion and therefore gravely immoral.

Modern conservative surgical techniques and ongoing pharmacological trials, which directly kill the embryo and its sheaths, are based on the consideration that, before the rupture of the tube, the life-threatening element for the mother is not the tubal wall containing the EP, but the ectopic embryo with its sheaths. Once one or the other is removed, not only is the threat to the mother's life resolved, but the tubal tissues are repaired in such a way that in most cases good tubal function and the corresponding fertility of the woman can be preserved.

Is it possible, in the face of these approaches, to continue to apply the concept of the moral licitness of indirect abortion, when one of its premises - the pathological nature of the tubal tissue before rupture, the presumption that the tube itself is "hic et nunc" pathologically affected in such a way that surgical intervention on it is appropriate - can be judged invalid by current scientific data ?

The idea of equating the tubal tissue on which an EE nests with cancer is hardly sustainable today.

III. What solutions does the right conscience of a Christian doctor suggest in dilemmatic situations?

From agreement it seems to me that the attitude of a Christian doctor should conform to the following principles:

1. Respect for all human life

The first moral principle that is imposed on the physician is to respect human life from its beginning, as even the Declaration of Oslo of the World Medical Association association proclaims, paradoxically, on therapeutic abortion. The Christian physician must live this obligation with the utmost sincerity and show the utmost, delicate and attentive respect for both the life of the embryo and the life of the mother. Such respect is due equally to every living human being, whether its life expectancy is counted in years or in hours or minutes; whether its chronological age is measured in decades or in days; whether that life takes place in daylight or in the mother's womb, or whether it develops in the cavity of the uterus or occupies an ectopic site.

2. Expectant management today

The behaviour of the Christian doctor will be modulated by this respect. He will respect the living ectopic embryo by adopting the classic attitude of expectant management, which he will now practise with the invaluable help of modern technology financial aid . He is obliged to be an expert in the diagnosis of EP: he will take into account the epidemiological data , he will monitor the evolution of EP by means of serial dosages of hormonal markers of embryo-fetal viability or ultrasound diagnosis. When he has evidence of embryo death, his close monitoring of each case will help him to decide whether to intervene to remove the embryo or to refrain from doing so. When, in the course of expectant management, the first signs of haemodynamic instability appear, indicating not only clinical urgency but also certain embryo death, he will provide the emergency financial aid .

Expectant management has been practised in large series of EP cases without maternal deaths. It is a treatment of accepted professional quality: it saves useless laparotomies and laparoscopies. It also has its costs: maintaining an alarming status which can last a few hours or a few days or weeks with consequent hospitalisation of the woman.

Such a wait-and-see attitude therefore excludes surgical or pharmacological solutions that involve seeking the immediate and direct death of the embryo: as long as the embryo is alive and the gestation does not yet disturb the haemodynamic stability of the mother, the doctor must maintain a tolerant attitude towards the EE. The various forms of "aggressive" treatment, i.e. that which directly or indirectly seeks the death of the still-living embryo, are born of a mentality which is not unrelated either to the spread of utilitarian ideology or to an all too easy acceptance of the licitness of indirect abortion.

3. The important preventive aspect

EE is reaching the dimensions of a major epidemic. As in all other epidemics, physicians have a dual duty. They must first provide effective and timely care to women affected by EE. But they must strive, once the factors influencing its spread have been identified, to institute appropriate preventive measures to eradicate this life- and fertility-threatening entity from its victims.

The Christian doctor finds here a particularly suitable field for his task of committee: the fight against this epidemic obliges him to be an expert in informing about the biological, human and ethical aspects of sexually transmitted diseases, intrauterine devices and other contraceptive procedures and to help, with skill professional and moral wisdom, his patients to make the right decisions.

4. What would be the echo of a magisterial declaration affirming respect for the ectopic embryo?

It seems to me superfluous to warn that a solemn reaffirmation of respect for the life of the ectopic embryo will not find a favourable echo in some quarters, inside and outside the Church. Any moral opinion which today reaffirms unconditional respect for the ectopic human embryo will be received with scandal by those who, in an inflationist interpretation of therapeutic abortion, have opted for the efficient prevention of risk and discomfort through the elimination of nascent life.

A moral judgement that, consistent with the ethics of respect for the weakest and most hopeless lives, recommends expectant monitoring of the EE, with its "impractical and uneconomical" consequences, and forbids the quick and efficient solution of selectively destroying the embryo, will be branded as radical vitalism.

A moral judgement that seriously purifies the broadened notion of indirect abortion of its inevitable opportunism, that reformulates in modern norms, enriched by scientific progress, the tradition of the intangibility of prenatal life, will be branded as retrograde or intolerant by those who are comfortably ensconced in a controlled permissiveness.

However, I think that many will rejoice to see the intangibility of all human life reaffirmed once again and to see how scientific progress is making the Christian doctrine of respect for life easier to understand and to fulfil.

After all, as the Holy Father John Paul II pointed out in his address of 25 October 1978, "Prudent is not - as is often believed - he who knows how to get by in life and make the most of it, but he who is able to build his whole life according to the voice of his right conscience and the demands of right morality".

Bibliography

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4. Dorfman SF. Epidemiology of ectopic pregnancy. Clin Obstet Gynecol 1987;1:165.

5. Fernandez H, Rainhorn JD, Papiernik E, Bellet D, Frydman R. Spontaneous resolution of ectopic pregnancy. Obstet Gynecol 1988;71:171.

6. Garcia AJ, Aubert JM, Sama J, Josimovich JB. Expectant management of presumed ectopic pregnancies. Fertil Steril 1987;48: 395.

7. Hallatt JG, Grove JA. Abdominal pregnancy: A study of twenty-one consecutive cases. Am J Obstet Gynecol 1985;152:444.

8. Leach RE, Ory SJ. Management of ectopic pregnancy. Am Fam Phys 1990:41:1215.

9. Lund J. Early ectopic pregnancy. J Obstet Gynecol Br Emp 1955;62:70.

10. Marchbanks PA, Annegers JF, Coulam CB, Strathy JH, Kurland LT. Risk factors for ectopic pregnancy. A population-based study. JAMA 1988;259:1823.

11. Marshall J. The ethics of medical practice. London: Darton, Longman & Todd, 1960:110.

12. Mashiach S, Carp HJA, Serr DM. Nonoperative management of ectopic pregnancy. J Reprod Med 1982;27:127.

13. McCarthy DG. The new dilemma of ectopic pregnancies. Ethics & Medics 1983;8(7):3.

14. McCarthy DG. Physicians' reactions in ectopic pregnancy survey. A further look at a new dilemma. Ethics & Medics 1984;9(5):3.

15. McCarthy DG. Ethicists' reactions to ectopic pregnancy survey. Part II. Ethics & Medics 1984;9(9):2.

16. McFadden CJ. Medical ethics. 6 ed. Philadelphia: F.A. Davis Co., 1968:193.

17. Ory SJ. Ectopic pregnancy: Current evaluation and treatment. Mayo Clin Proc 1989;64:874.

18. Ory SJ. Nonsurgical treatment of ectopic pregnancy. Fertil Steril 1986;46:767.

19. Pansky M, Bukovsky I, Golan A, et al. Tubal patency after local methotrexate injection for tubal pregnancy. Lancet 1989;2:967.

20. Paquin J. Morale et Médecine. 3 ed. Montreal: L'Immaculée Conception. committee des Hôpitaux du Québec, 1960:224.

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23. Sauer MV, Greenberg LH, Gorrill MJ, et al. Nonsurgical management of unruptured ectopic pregnancy: an extended clinical trial. Fertil Steril 1987;48:752.

24. Shapiro BS. Non-surgical treatment of ectopic pregnancy. Clin Obstet Gynecol 1987;1:215.

25. Taylor RN. Ectopic pregnancy and reproductive technology. JAMA 1988;259:1862.

26. Thorburn J, Friberg B, Schubert W, Wassen AC, Lindblom B. Background factors and management of ectopic pregnancy in Sweden. Changes over a decade. certificate Obstet Gynecol Scand 1987;66:597.

27. Vermesh M. Conservative management of ectopic gestation. Fertil Steril 1989;51:559.

bibliography additional information on ectopic pregnancy

1. Technical updates

A good starting point is the review Vermesh M. Conservative management of ectopic gestation. Fertil Steril 1989;51:559-67, especially the evaluation on expectant management (the armed expectation of classical deontology).

2. Deontological assessments

There is a curious silence on topic in modern Italian manuals on Bioethics: Sgreccia, Tettamanzi, Spinsanti, Perico, d'Avanzo. Nor does ectopic pregnancy appear in the Bibliography on Bioethics. Among the more than 2000 articles, from journals and monographs, entered into our computer, not one has appeared that deals specifically with this topic . We have only found two articles (which have not yet been sent to us) published in Ethics and Medics (A Catholic perspective on Moral Issues in the Health and the Life Sciences) in May and September 1984.

There should not, therefore, be many recent programs of study on topic. In reality, recently introduced procedures (whether conservative surgery or pharmacological agents) involve the direct and intended death of the embryo and are therefore excluded from Christian morality. They seek, through the evacuation or destruction of the embryo and its sheaths, both to reduce maternal mortality through tubal rupture and haemorrhage, and to preserve the patency of the tube and thus promote the woman's subsequent fertility. As with many other problems, technical progress has been achieved by deliberately ignoring the human condition of the embryo and proceeding with strictly utilitarian criteria.

I think that today the expectant mother attitude, which consists of refraining from intervening until the imminent rupture of the tube or the death of the embryo, is still defensible. Such an attitude imposes some discomfort, but it allows the human life of the embryo to be respected, some of them to be saved, and can avoid serious risks to the life of the mother. Modern techniques gain comfort, safety and better prognosis for the mother, but at the price of deliberate destruction of embryonic life.

Classical Catholic doctrine is set out in:

Basso DM. Nacer y morir con dignidad. programs of study de Bioética contemporánea. Buenos Aires; Consorcio de Médicos Católicos, 1989: 390.

Bon H. Compendium of Catholic Medicine. Madrid; Fax, 1942:432-5.

McFadden CJ. Medical Ethics, 6th ed. Philadelphia; FA Davis, 1968: 193-7.

Paquin J. Morale et Médecine. 3rd ed. Montréal; L'Immaculée Conception, 1960: 224-6.

Peiró F. Deontología médica. 5th ed. Madrid; Marbán, 1954: 309-313.

Sarmiento A, Adeva I, Escós J, Ética profesional de la enfermera. Pamplona; Eunsa, 1977: 210-1.