Ectopic pregnancy treatment highlights health risks of abortion ban

Malta’s ban on abortion could be leading some doctors to treat ectopic pregnancies by surgically removing a woman’s fallopian tube, as a legal way out to terminate a pregnancy ‘indirectly’.

But pro-choice doctors claim that in certain specific cases, the use of methotrexate medication to target the embryo can terminate the pregnancy while preserving the fallopian tube, allowing the possibility of future pregnancies.

The choice that faces doctors in Malta in the way they treat ectopic pregnancies is now part of the abortion debate that has been ongoing for the main part of 2020. Last week, the treatment for ectopic pregnancy in Malta was the subject to criticism after this newspaper found that doctors required government approval to administer methotrexate, but that government body only works until 2:30pm.

An ectopic pregnancy is any pregnancy implanted outside the cavity of the uterus, most commonly in the fallopian tube. In most cases, the embryo is either absent or non-viable, but can be fatal if left untreated.

A spokesperson for Doctors for Choice has told MaltaToday that the occurrence of an ectopic pregnancy in the UK is approximately 11 out of 1,000 pregnancies. “Gynaecologists in Malta generally use the ethical ‘principle of double-effect’ as a legal loophole to treat these cases by removing the fallopian tube surgically,” the pro-choice organisation said.

“This is considered to be an ‘indirect termination of pregnancy’ because it is done to save the life of the mother. But in select cases, for example in unruptured ectopic pregnancy, low pregnancy hormone (HCG) levels, no significant pain and so on, evidence-based guidelines in the rest of the civilised world recommend the use of methotrexate.”

Doctors for Choice say methotrexate is referred because it targets the embryo ‘directly’ by stopping cells from multiplying. “While this will terminate the pregnancy, it will preserve the fallopian tube and allow the possibility of future pregnancies,” the NGO said.

“Randomised controlled trials comparing methotrexate with laparoscopic surgery have shown that, in selected cases, methotrexate is equally successful to surgery and leads to better reproductive outcomes.”

The NGO wants the law to change so that access to this medication, which technically causes an abortion, can be provided in a timely fashion. “We are pleased to see that the Maltese health service has finally admitted to using a drug to terminate the pregnancy, albeit ectopic ones. What needs to follow is a revision of the law to clearly specify the definition of induced abortion and the conditions under which it can be performed legally.”

Another pro-choice campaign, the online platform Break the Taboo Malta, which showcases stories of women affected by the abortion ban, brought to light the story of a woman administered methotrexate treatment two days after her ectopic pregnancy was diagnosed.

The woman had been told her treatment had to be approved by a board, which approval only arrived 48 hours after diagnosis.

Yet despite a government claim that the “board” does not exist, information sourced by this newspaper confirms that doctors must send an exceptional treatment form to the Directorate for Pharmaceutical Affairs by email, where a person responsible then gives the green light to a pharmacist to prepare the medication.

But since this authority works until 2:30pm, if paperwork does not arrive to them by then, they would approve it the next day. There is also an issue on the weekends, as the board does not meet on Sundays.

Doctors for Choice said that they understand why some doctors might feel uncomfortable prescribing methotrexate. “Unlike surgical removal of the tube which indirectly ends the pregnancy, this medication directly destroys the pregnancy, whether viable or not, so doctors may rightly feel that the principle of double effect might not apply.”

Indeed, Articles 241 and 243 of the Criminal Code criminalise any way of inducing a miscarriage, which would be an abortion, even to save the life of the mother. “So does that mean that in the eyes of the law, using such medication to terminate an ectopic pregnancy is illegal, because it is used to directly terminate the pregnancy?”

The Doctors for Choice spokesperson said it believed that the healthcare system could not be guided by vague, unclear or questionable legal frameworks. “It hinders the work of doctors and puts patients’ lives at risk... doctors who circumvent the law in this way are at risk of losing their medical license.

“While we are pleased to note that local gynaecologists are finally following evidence-based guidelines in the treatment of ectopic pregnancy, there should be no reason for the delay in deciding whether to use a medication that is in widespread use in the rest of the EU,” the NGO said.

Doctors for Choice said if the patient fits the criteria, she should receive the treatment. “Having said that, one would suppose that had her medical condition worsened during the waiting period; then a surgical approach would have been taken.”

Believing women is crucial

The case of the patient denied methotrexate for 48 hours has highlighted another case of women being given short shrift in medico-legal situations.

The pro-life medical organisation Doctors for Life criticised the pro choice medical organisation, saying they had spread misinformation over the women’s case, since doctors gauge the level of seriousness of each individual ectopic case.

Doctors for Choice insist that the delayed treatment reflects a lack of belief in women presenting with an ectopic pregnancy. “This very same organization that claims that life should be protected from the moment of conception, issues a statement that – aren’t we fortunate – no pregnant woman has died in pregnancy in the past 10 years. Apparently, in their eyes, high quality care can be equated to ‘not dying in pregnancy’.”

A Doctors for Life member has also stated online that in Malta surgery was the preferred route because “methotrexate may leave the woman with a damaged tube, this putting her at risk of a recurrent ectopic.”

Doctors for Choice claim this is a misrepresentation of facts, insisting that medical management by methotrexate offers several benefits over surgical treatment. “It is less invasive, less expensive, can be given on an outpatient basis and does not need expertise like laparoscopy. Future reproductive expectations are better with methotrexate with higher intrauterine pregnancy rates and lower ectopic rates subsequently.”

Doctors for Choice also say studies of tubal patency after methotrexate show more than 75% cases have no evidence of scarring. “There is no way of knowing whether the tubal defects identified after methotrexate treatment of an ectopic pregnancy, are a consequence of the treatment or were already present before the pregnancy, and were thus the cause of the ectopic pregnancy.”