Ectopic Pregnancy Surgery / Abortion

[Keg]

OK - first off, no flaming please (yeah right, *dons flame-******ant suit* ), but I had a thought during lecture today.

I'm vehemently pro-life (*sprays self with asbestos*), and during our lecture on pregnancy physiology this morning, the lecturer discussed ectopic pregnancies and the removal of babies that were developing outside the uterus. I know that this is entirely different than abortion, mainly because of the extreme danger that the mother is in, but this whole thing made me examine my beliefs regarding this surgery and where it fits into my anti-abortion ideas, especially when the physician (Vice Chair of OB/Gyn Research here) gave an anecdote about an abdominally implanted baby (on the colon) that was carried until 31 weeks, was surgically removed, and both mother and baby survived with no ill effects upon either (this happened last year).

So two questions, I guess - the first to third/fourth years, and the second in general:

1) Do OB/Gyn rotations require that students assist with removal of ectopically implanted babies?

2) Is anyone else having a hard time differentiating this from abortion, on a basic level, and having qualms about participating in this aspect of OB/Gyn surgery?

OK - so, as I said, hopefully no flaming, but as a realist, let's just keep it civil. Thanks!

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[deleted109597]

1. They like you to, because it is a learning experience. That being said, those that want to go into OB are more likely to jump on it.
2. No. Tubals *will* rupture, and mom is likely to die. Abdominal ectopics are sometimes ok, and sometimes are very bad too. It is entirely different.

 

[Wanna_B_Scutty]

OK - first off, no flaming please (yeah right, *dons flame-******ant suit* ), but I had a thought during lecture today.

I'm vehemently pro-life (*sprays self with asbestos*), and during our lecture on pregnancy physiology this morning, the lecturer discussed ectopic pregnancies and the removal of babies that were developing outside the uterus. I know that this is entirely different than abortion, mainly because of the extreme danger that the mother is in, but this whole thing made me examine my beliefs regarding this surgery and where it fits into my anti-abortion ideas, especially when the physician (Vice Chair of OB/Gyn Research here) gave an anecdote about an abdominally implanted baby (on the colon) that was carried until 31 weeks, was surgically removed, and both mother and baby survived with no ill effects upon either (this happened last year).

So two questions, I guess - the first to third/fourth years, and the second in general:

1) Do OB/Gyn rotations require that students assist with removal of ectopically implanted babies?

2) Is anyone else having a hard time differentiating this from abortion, on a basic level, and having qualms about participating in this aspect of OB/Gyn surgery?

OK - so, as I said, hopefully no flaming, but as a realist, let's just keep it civil. Thanks!

Hey Keg,

I share your beliefs about abortion, so no worries about flaming from me!

That said, regarding your questions:
1) The conscience clause laws that protect med students/staff from participating in abortions do not specify exceptions for ectopic pregnancies. Thus, your decision to not participate in an ectopic abortion might not make you particularly popular (even with the pro-life contingent), but I don't believe that anyone could actually force you to do this. Here are the texts of the relevant laws:

Complete Text of the Hyde-Weldon Amendment
(1) None of the funds made available in this Act [the federal Health and Human Services appropriations bill for Fiscal Year 2005] may be made available to a Federal agency or program, or to a State or local government, if such agency, program, or government subjects any institutional or individual health care entity to discrimination on the basis that the health care entity does not provide, pay for, provide coverage of, or refer for abortions. (2) In this subsection, the term "health care entity" includes an individual physician or other health care professional, a hospital, a provider-sponsored organization, a health maintenance organization, a health insurance plan, or any other kind of health care facility, organization, or plan.

1995 Medical Training Nondiscrimination Act
`SEC. 245. (a) IN GENERAL- The Federal Government, and any State that receives Federal financial assistance, may not subject any health care entity to discrimination on the basis that--
`(1) the entity refuses to undergo training in the performance of induced abortions, to provide such training, to perform such abortions, or to provide referrals for such abortions;
`(2) the entity refuses to make arrangements for any of the activities specified in paragraph (1); or
`(3) the entity attends (or attended) a postgraduate physician training program, or any other program of training in the health professions, that does not (or did not) require, provide or arrange for training in the performance of induced abortions, or make arrangements for the provision of such training.
`(b) ACCREDITATION OF POSTGRADUATE PHYSICIAN TRAINING PROGRAMS-
`(1) IN GENERAL- With respect to the State government involved, or the Federal Government, restrictions under subsection (a) include the restriction that, in granting a legal status to a health care entity (including a license or certificate), or in providing to the entity financial assistance, a service, or another benefit, the government may not require that the entity be an accredited postgraduate physician training program, or that the entity have completed or be attending such a program, if the applicable standards for accreditation of the program include the standard that the program must require, provide or arrange for training in the performance of induced abortions, or make arrangements for the provision of such training.
`(2) RULE OF CONSTRUCTION- With respect to subclauses (I) and (II) of section 705(a)(2)(B)(i) (relating to a program of insured loans for training in the health professions), the requirements in such subclauses regarding accredited internship or residency programs are subject to paragraph (1) of this subsection.
`(c) DEFINITIONS- For purposes of this section:
`(1) The term `financial assistance', with respect to a government program, includes governmental payments provided as reimbursement for carrying out health-related activities.
`(2) The term `health care entity' includes an individual physician, a postgraduate physician training program, and a participant in a program of training in the health professions.
`(3) The term `postgraduate physician training program' includes a residency training program.'.

2) Yes, participating in this kind of abortion would still bother me. However, my pro-life beliefs and goals stem from a desire to maximize life in all cases. In such a case as this one, where the death of the mother from medical complications is such a strong possibility, I believe that the right thing is to secure at least one of these two lives- even when that means sacrificing the other one. Most pro-life physican's groups agree with this position (see http://www.prolifephysicians.org/ ). That said, I'm sure I'd cry buckets afterward.

Good luck to you as you work out your feelings on this issue. PM me if you would like to discuss this more privately.

 

[Winged Scapula]

I think the first place to start would be your definition of what constitutes a "baby". Extra-uterine gestations are pretty rare and I would be suprised if you saw one:

a) during your OB-Gyn rotation
b) that was large enough, like the one you described, to be recognizable as a "baby" and to be able to sustain life outside of the abdomen

I assisted on a number of D&Cs during medical school but I am fairly sure that if I had objected to it, it would not have been required. The school cannot make you do anything which you might object to based on religious or ethical reasons.

As I noted above, the vast majority of pregnancy terminations you will see (if any, should you so desire), will be the "routine" 1st trimester D&Cs. In the case of ectopics, if the tube has ruptured, there really is nothing to see, as the pregnancy isn't usually viable and the mother's life may be in danger from bleeding - it can be pretty impressive; if the fertilized egg has implanted itself outside of the uterus, what you "see" obviously depends on the gestational date. Most women with ectopics do not continue to have a viable fetus which you would recognize, at least visually, as a baby. Of course, if you define life as starting when sperm meets egg, then you will undoubtedly recognize any fertilized egg as a "baby". Again, extrauterine implantation is rare and tubal rupture with extrauterine implantation and carrying the fertilized egg to a viable gestational age is even rarer still.

Political discussions aside, you can elect not to participate in any activity which offends your beliefs, including this area of Ob-Gyn.

 

[54578]

I read this post and thought it said Erotic.....

I need a girlfriend

 

[OncoCaP]

I read this post and thought it said Erotic.....

I need a girlfriend

Ha! There probably was some eros at some point along the way to that pregnacy.

Maybe SDN needs to open a dating forum for all the singles ....

 

[stiffany]

Can an ectopic pregnancy where the fetus is situated in a tube end in a "successful" birth outcome in general? Wouldn't the tube be increasingly likely to rupture as the baby got bigger since it wouldn't have the elasticity of the uterus (and therefore to allow the pregnancy to progress would not only endanger the mother but also the baby)? I just don't see how there's an alternate to termination in this case?

 

[Winged Scapula]

Can an ectopic pregnancy where the fetus is situated in a tube end in a "successful" birth outcome in general? Wouldn't the tube be increasingly likely to rupture as the baby got bigger since it wouldn't have the elasticity of the uterus (and therefore to allow the pregnancy to progress would not only endanger the mother but also the baby)? I just don't see how there's an alternate to termination in this case?

A tubal pregnancy, a form of ectopic pregnancy, is generally not viable for the reasons you list. The tube cannot compensate for the growing fetus and ruptures and in the process, there is generally a fair bit of blood loss and loss of the pregnancy (which is generally not viable at the point the tube ruptures). Most women are not aware of having an ectopic pregnancy until they become symptomatic (essentially peritoneal signs, possible vaginal bleeding); if they do become aware prior to rupture and get to medical attention in time, the current standard of treatment is salpingectomy which effectively terminates the pregnancy. Some centers will attempt salpingotomies in which the tube is opened, the gestational products removed and the tube repaired. Lots more work obviously.

 

[Wanna_B_Scutty]

Ha! There probably was some eros at some point along the way to that pregnacy.

Maybe SDN needs to open a dating forum for all the singles ....

Actually, there is one! For all your dating pleasure (well... not yours... you're married, I believe), visit:
http://forums.studentdoctor.net/forumdisplay.php?f=173

So sad I have a boyfriend. If I were a single gal on the prowl, you know where I'd be found!

 

[stiffany]

A tubal pregnancy, a form of ectopic pregnancy, is generally not viable for the reasons you list. The tube cannot compensate for the growing fetus and ruptures and in the process, there is generally a fair bit of blood loss and loss of the pregnancy (which is generally not viable at the point the tube ruptures). Most women are not aware of having an ectopic pregnancy until they become symptomatic (essentially peritoneal signs, possible vaginal bleeding); if they do become aware prior to rupture and get to medical attention in time, the current standard of treatment is salpingectomy which effectively terminates the pregnancy. Some centers will attempt salpingotomies in which the tube is opened, the gestational products removed and the tube repaired. Lots more work obviously.

Thanks for the response. But an abdominal pregnancy can be viable? What provides the developing embryo and later fetus with nourishment in that case since there's no uterine lining for implantation and subsequent development involved? Wouldn't the mother still incure an incredible risk of damage and possible quick demise should things go wrong?

 

[OncoCaP]

Actually, there is one! For all your dating pleasure (well... not yours... you're married, I believe), visit:
http://forums.studentdoctor.net/forumdisplay.php?f=173

So sad I have a boyfriend. If I were a single gal on the prowl, you know where I'd be found!

Yeah, I'm married. Life is good. I would give up medicine and become a junior high algebra teacher before I would give up my marriage (hopefully it won't come to that). http://www.psychpage.com/family/mod_couples_thx/waitgalligher.html

That General Discussion forum has some potential for the single folks. Hopefully it won't lead to any ectopic pregnancies!!

 

[deleted109597]

Thanks for the response. But an abdominal pregnancy can be viable? What provides the developing embryo and later fetus with nourishment in that case since there's no uterine lining for implantation and subsequent development involved? Wouldn't the mother still incure an incredible risk of damage and possible quick demise should things go wrong?

The answer to the nourishment is that the little parasite is able to leech on whatever it attaches to, and the fetal component will bore into anything. Same thing as accreta, those blasts can go straight into muscle, hollow viscous organs, you name it.
And yes, there is still risk to the mother, but often, abdominal ectopics aren't found early simply because they don't rupture like a tubal. Thus, they are much further along in there development when the US tech tries to find them. Sometimes, depending where they attach (abdominal muscles), there can be a viable outcome. Other times (colon, small bowel), they can't.
You better believe there is a whole host of people in the OR when they try to pump out an abdominal ectopic, because anything that can go wrong will go wrong.

 

[SMRT]

A tubal pregnancy, a form of ectopic pregnancy, is generally not viable for the reasons you list. The tube cannot compensate for the growing fetus and ruptures and in the process, there is generally a fair bit of blood loss and loss of the pregnancy (which is generally not viable at the point the tube ruptures). Most women are not aware of having an ectopic pregnancy until they become symptomatic (essentially peritoneal signs, possible vaginal bleeding); if they do become aware prior to rupture and get to medical attention in time, the current standard of treatment is salpingectomy which effectively terminates the pregnancy. Some centers will attempt salpingotomies in which the tube is opened, the gestational products removed and the tube repaired. Lots more work obviously.

I imagine that treatment approaches vary, but the approach that I have been taught is to always try to save the tube. If the patient is stable, the ectopic is small (ie no imminent risk of rupture), the patient is reliable for compliance/follow-up and there are no contraindications then you can treat medically with methotrexate. If they need surgical management, then a laparoscopic salpingostomy is the first-line. If the tube is not salvageable, then do a salpingectomy. If they are ruptured then they would need a laparotomy and salpingectomy.

Also, I think that by definition, a tubal ectopic is non-viable. I can't imagine a circumstance where it could be viable. (On a side note, I saw a patient last week with a likely ectopic. The couple had had 3 rounds of unsuccessful IVF and desperately wanted to get pregnant. They asked if it was possible to remove the pregnancy from the tube and put it in the uterus )

For the OP, if you really don't want to be involved, at a student level, I don't think anyone will force you. However, I think you should scratch ObGyn off your list if specialties!

 

[deleted87716]

For the OP, if you really don't want to be involved, at a student level, I don't think anyone will force you. However, I think you should scratch ObGyn off your list if specialties!

Second that.

 

[Doctor Bagel]

Second that.

Third! Although from what I've read on the on/gyn board, stuff like this unfortunately doesn't keep people away from that specialty.

 

[OncoCaP]

All pro-lifers I know (and I know many) accept that there are cases (ectopic pregnancies being a typical example) where abortion is "medically necessary." I haven't run across one that objected to abortion in the case of an ectopic (not saying that there aren't any, but perhaps they are rare?). I'm also not saying they were not bothered by it (many surgeries aren't exactly "for the fun of it" last time I checked) and the death of a child (pro-life view) is never a happy moment. Separating conjoined twins can also lead to injury or death of one sibling as well, but may also be necessary to save at least one.

I'm not sure why a medical student who is interested in OB/GYN but objects to elective abortions (but not ectopic ones) would necessarily need to scratch OB/GYN off the list. Now, OB/GYN isn't exactly the most loved specialty (I would rather not spend my days in court explaining child-birth complications), but I could see some pro-lifers wanting to do that and not wanting to do elective abortions.

 

[Doctor Bagel]

All pro-lifers I know (and I know many) accept that there are cases (ectopic pregnancies being a typical example) where abortion is "medically necessary." I haven't run across one that objected to abortion in the case of an ectopic (not saying that there aren't any, but perhaps they are rare?). I'm also not saying they were not bothered by it (many surgeries aren't exactly "for the fun of it" last time I checked) and the death of a child (pro-life view) is never a happy moment.

I'm not sure why a medical student who is interested in OB/GYN but objects to elective abortions (but not ectopic ones) would necessarily need to scratch OB/GYN off the list. Now, OB/GYN isn't exactly the most loved specialty (I would rather not spend my days in court explaining child-birth complications), but I could see some pro-lifers wanting to do that and not wanting to do elective abortions.

The op stated that he would have trouble treating a patient with an ectopic pregnancy if it meant terminating the life of the fetus. That to me implies that he's not merely unwilling to provide elective abortions. There's a big difference. No one is saying that people who are pro-life shouldn't go into ob/gyn. However, people who are unwilling to perform what is considered the standard of care for a medical condition probably shouldn't go into the specialty where that procedure would come up.

 

[Wanna_B_Scutty]

I'm not sure why a medical student who is interested in OB/GYN but objects to elective abortions (but not ectopic ones) would necessarily need to scratch OB/GYN off the list. Now, OB/GYN isn't exactly the most loved specialty (I would rather not spend my days in court explaining child-birth complications), but I could see some pro-lifers wanting to do that and not wanting to do elective abortions.

 

[OncoCaP]

The op stated that he would have trouble treating a patient with an ectopic pregnancy if it meant terminating the life of the fetus. That to me implies that he's not merely unwilling to provide elective abortions. There's a big difference. No one is saying that people who are pro-life shouldn't go into ob/gyn. However, people who are unwilling to perform what is considered the standard of care for a medical condition probably shouldn't go into the specialty where that procedure would come up.

Yes, that is part of the job (abortions for ectopics, etc.). Makes sense to me.

 

[Critical Mass]

thats why they should just take the whole uterus out. then fewer problems.

There is apparently an SDNer who might have some firsthand experience if he/she really was an ectopic fetus...

 

[QuantumMechanic]

However, my pro-life beliefs and goals stem from a desire to maximize life in all cases. In such a case as this one, where the death of the mother from medical complications is such a strong possibility, I believe that the right thing is to secure at least one of these two lives- even when that means sacrificing the other one.

first, do no harm

 

[OncoCaP]

first, do no harm

Could "second" be ... "If you can't save both of your patients, try saving at least one of them?"

 

[deleted109597]

first, do no harm

So, elective surgeries are out?

 

[ForbiddenComma]

I just gotta say, OB residents would get a chuckle out of this thread...

If you are so pro-"life" that you would kill the woman so that you wouldn't have to feel bad about removing an ectopic pregancy... well that says all that needs to be said about your morals, or lack thereof, right?

 

[MadameLULU]

I suggest that the OP read about the morbidity associated with ectopics before he declares he wants nothing to do with them.

 

[AmoryBlaine]

FYI the Catholic Church does not consider the removal of an ectopic pregnancy an abortion.

I have never heard of annecdotes of a fetus coming to term through an extra-uterine pregnancy. It would be a 1 in a million shot and for all the other 999,999 the ectopic would rupture and cause a surgical emergency for mama.

 

[Doctor Bagel]

I just gotta say, OB residents would get a chuckle out of this thread...

If you are so pro-"life" that you would kill the woman so that you wouldn't have to feel bad about removing an ectopic pregancy... well that says all that needs to be said about your morals, or lack thereof, right?

I just gotta say that you said what I was thinking. The op's viewpoints are actually very disturbing to me.

 

[lilnoelle]

Except I don't think the Op has made up his mind in this matter. (Initially said he believes terminating an ectopic pregnancy is different than abortion) He is entertaining these thoughts and asking for a response. I don't think there is anything wrong with that.
I'm finding that many of my previous beliefs about life have been challenged while in med school and am finding that I am having to reform my previous beliefs. I'm sure my thoughts and beliefs will change much more before I actually find myself in the position to make a decision about someone's healthcare.

 

[indo]

I'm vehemently pro-life (*sprays self with asbestos*

pro-life person covered in a cancer causing agent? wha?

 

[indo]

first, do no harm

do no harm by action or inaction. So, who dies? Mom or the fetus?

 

[indo]

How does the fetus get nutrition outside of the uterus anyway?

 

[trustwomen]

Third! Although from what I've read on the on/gyn board, stuff like this unfortunately doesn't keep people away from that specialty.

Fourth.

And don't worry, OP, the flames you get here will be nothing compared to the flames people get for DARING to be pro-choice on SDN.

 

[deleted77919]

How does the fetus get nutrition outside of the uterus anyway?

Newly fertilized eggs are like little vampires. They will attach and bore into whatever they can to find a blood supply. That's why ectopic implantations happen.

That said, carrying a tubal ectopic is not possible and carrying other ectopics to term is extrodinarily rare.

 

[deleted109597]

How does the fetus get nutrition outside of the uterus anyway?

See:

The answer to the nourishment is that the little parasite is able to leech on whatever it attaches to, and the fetal component will bore into anything. Same thing as accreta, those blasts can go straight into muscle, hollow viscous organs, you name it.
And yes, there is still risk to the mother, but often, abdominal ectopics aren't found early simply because they don't rupture like a tubal. Thus, they are much further along in there development when the US tech tries to find them. Sometimes, depending where they attach (abdominal muscles), there can be a viable outcome. Other times (colon, small bowel), they can't.
You better believe there is a whole host of people in the OR when they try to pump out an abdominal ectopic, because anything that can go wrong will go wrong.

And then

I have never heard of annecdotes of a fetus coming to term through an extra-uterine pregnancy. It would be a 1 in a million shot and for all the other 999,999 the ectopic would rupture and cause a surgical emergency for mama.

Well, it happens. Tubals, no, but abdominal, yes. So your n=1 fails.

 

[QuantumMechanic]

Could "second" be ... "If you can't save both of your patients, try saving at least one of them?"

the mother's life is the supreme concern, since everyone agrees about the sanctity of her life. do no harm to her, as we will never agree upon the sanctity of the fetus's life, especially in ectopic pregnancies where the mother is at extreme danger.

we complain about the loss of the family unit in America, don't we? How does bringing in a baby that will be motherless (given the choice bt mother and baby in our mental masturbation exercise) help this end?

 

[Doctor Bagel]

the mother's life is the supreme concern, since everyone agrees about the sanctity of her life. do no harm to her, as we will never agree upon the sanctity of the fetus's life, especially in ectopic pregnancies where the mother is at extreme danger.

we complain about the loss of the family unit in America, don't we? How does bringing in a baby that will be motherless (given the choice bt mother and baby in our mental masturbation exercise) help this end?

I agree. The op's concerns and what you mentioned just further confirm my belief that there are some anti-woman things going on in these thought processes. To me, it seems unbelievable that you would chose to favor a few week old fetus over a woman who's already here. IMO, the two lives aren't equal. Saving the mother takes top priority.

 

[chocolate-e]

To the OP,

I can sympathize with your dilemma. I'd look at it from the perspective of intent. The natural history of the condition is death for both parties, so you come into the situation trying to salvage what life you can. In this case, your only practical life-salvaging option is to save the life of the mother. The death of the embryo/fetus/baby is (to use a borrowed phrase) a foreseen but unintended consequence.

You might think of it as analogous to a massive disaster where there are not enough first responders/rescue resources for all of the victims. If you take time to save one person's life, a foreseen but unintended consequence is that you will not get to someone else in time, and they'll die. There's some inherent risk: what if, in spite of your best efforts at triage, the person you stabilize first could have actually waited till second, and the person who died waiting need not have died? (Analogous to the very small possibility of viable extrauterine gestation.) I'd argue that you've still acted morally, working to minimize risk based on the best information available.

 

[QuantumMechanic]

I agree. The op's concerns and what you mentioned just further confirm my belief that there are some anti-woman things going on in these thought processes. To me, it seems unbelievable that you would chose to favor a few week old fetus over a woman who's already here. IMO, the two lives aren't equal. Saving the mother takes top priority.

having grown up in a very conservative area of the south, I have come to realize that some people just don't get it. I'm not talking about those who feel that elective abortions are a bad thing. I grew up around many people who were vocal about how abortions were wrong in any situation, including ones where the mother could likely die if the pregnancy were carried to term. Most of these individuals are ignorant of the reality of the situation and how painful and devastating such a death could be.

How could these people live with themselves if they made abortion illegal in every situation? How would they feel if they were responsible for the deaths of countless women who they forced to carry dangerous pregnancies? What a quixotic quest for cosmic justice.

 

[da8s0859q]

pro-life person covered in a cancer causing agent? wha?

 

[tiredmom]

The abdominal pregnancy likely is implanted on the bowels, so they get all that CHO rich blood to diffuse with... that's why they can get huge!

 

[DrZeke]

I agree. The op's concerns and what you mentioned just further confirm my belief that there are some anti-woman things going on in these thought processes. To me, it seems unbelievable that you would chose to favor a few week old fetus over a woman who's already here. IMO, the two lives aren't equal. Saving the mother takes top priority.

Oh Doctor Bagel, I totally agree .

Also, does anyone else find it slightly irritating that the OP who is "vehemently anti-abortion" is a male... I'd love to hear this same opinion from someone who can actually get pregnant.

 

[OncoCaP]

I agree. The op's concerns and what you mentioned just further confirm my belief that there are some anti-woman things going on in these thought processes. To me, it seems unbelievable that you would chose to favor a few week old fetus over a woman who's already here. IMO, the two lives aren't equal. Saving the mother takes top priority.

This is one area where I could see it being the mother's choice without an ethical concern (for me anyway). If mom wants to carry a viable child to term and risk her own life (because she has diabetes, etc.), I could see that being her choice (or choice not to do that as well). There are many mothers who have willingly given up their own lives for their children. I agree that no one should force a mother to do something that would cause her to die for her unborn child. I know my mom would have done anything (and would still do anything) to save my life if it came to that.

Here is one example (of several):

(http://en.wikipedia.org/wiki/List_of_women_who_died_in_childbirth a larger list of moms who died in childbirth)
http://en.wikipedia.org/wiki/Gianna_Beretta_Molla
Saint Gianna Beretta Molla (October 4, 1922 - April 28, 1962) was an Italian pediatrician, wife and mother who is best known for refusing both an abortion and a hysterectomy when she was pregnant with her fourth child, despite warnings that continuing with the pregnancy could result in her death. The baby, Gianna Emanuela, was successfully delivered by Caesarian section on April 21, 1962.[1] Gianna Molla died of septic peritonitis a week after the birth. She was beatified by Pope John Paul II on April 24, 1994, and canonized on May 16, 2004. In his homily at her canonization Mass, Pope John Paul II called her "a simple, but more than ever, significant messenger of divine love."[2]

 

[AmoryBlaine]

See:


And then


Well, it happens. Tubals, no, but abdominal, yes. So your n=1 fails.

Thanks for the lesson. But would we ever reccomend someone try to carry an abdominal pregnancy to term?

 

[Doctor Bagel]

This is one area where I could see it being the mother's choice without an ethical concern (for me anyway). If mom wants to carry a viable child to term and risk her own life (because she has diabetes, etc.), I could see that being her choice (or choice not to do that as well). There are many mothers who have willingly given up their own lives for their children. I agree that no one should force a mother to do something that would cause her to die for her unborn child. I know my mom would have done anything (and would still do anything) to save my life if it came to that.

Here is one example (of several):

(http://en.wikipedia.org/wiki/List_of_women_who_died_in_childbirth a larger list of moms who died in childbirth)
http://en.wikipedia.org/wiki/Gianna_Beretta_Molla
Saint Gianna Beretta Molla (October 4, 1922 - April 28, 1962) was an Italian pediatrician, wife and mother who is best known for refusing both an abortion and a hysterectomy when she was pregnant with her fourth child, despite warnings that continuing with the pregnancy could result in her death. The baby, Gianna Emanuela, was successfully delivered by Caesarian section on April 21, 1962.[1] Gianna Molla died of septic peritonitis a week after the birth. She was beatified by Pope John Paul II on April 24, 1994, and canonized on May 16, 2004. In his homily at her canonization Mass, Pope John Paul II called her "a simple, but more than ever, significant messenger of divine love."[2]

I agree that if it's the mother's wish, it should be honored. However, I don't think any woman should be expected to sacrifice her own life for her unborn child. In fact, I'm a little offended that the Church made her a saint for that -- the implication is that choosing not to sacrifice your life here isn't a sin, but it's a little inferior on the moral scale, something that I strongly disagree with. Another reason why I'm an ex-catholic. BTW, a good portion of my notions about women-hating patriarchal pro-lifers comes from growing inside the catholic church.

 

[psipsina]

Ok so we've determined that a tubal pregnancy can't be brought to term (according to wiki 50% of tubal pregnancies result in spontaneous tubal abortions anyway) so I really don't see any ethical dilemma to even discuss. The ball of cells can't become a baby, the end.

Then I looked into the non tubal extrautarine pregnancies that seem to be causing all this hype. I found this on tha wiki:

2% of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal. Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. An ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria.[3]

While a fetus of ectopic pregnancy is typically not viable, very rarely, an abdominal pregnancy has been salvaged. In such a situation the placenta sits on the intraabdominal organs or the peritoneum and has found sufficient blood supply. In this author's experience this is invariably bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery or even aorta have been described. Support to near viability has occasionally been described, but even in third world countries, the diagnosis is most commonly made at 16 to 20 weeks gestation. Such a fetus would have to be delivered by laparotomy. Maternal morbidity and mortality from extrauterine pregnancy is high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. If the organ to which the placenta is attached is removable, such as a section of bowel, then the placenta should be removed together with that organ. This is such a rare occurrence that true data are unavailable and reliance must be made on anecdotal reports.[4][5] However, the vast majority of abdominal pregnancies require intervention well before fetal viability because the risk of hemorrhage.

So even if the fetus can make it to a viable stage the process of removing it has an incredibly high risk to the mother's life. I think the mother definitely has the right to choose to proceed but I believe it would be the physicians duty to make sure that she truely understood the massive risk she was taking when she made that choice. To not be willing to save the mother if that is her desire seems like it would be abandonment if you couldn't transfer her to another physician who would.

 

[AmoryBlaine]

Ok so we've determined that a tubal pregnancy can't be brought to term (according to wiki 50% of tubal pregnancies result in spontaneous tubal abortions anyway) so I really don't see any ethical dilemma to even discuss. The ball of cells can't become a baby, the end.

Then I looked into the non tubal extrautarine pregnancies that seem to be causing all this hype. I found this on tha wiki:


So even if the fetus can make it to a viable stage the process of removing it has an incredibly high risk to the mother's life. I think the mother definitely has the right to choose to proceed but I believe it would be the physicians duty to make sure that she truely understood the massive risk she was taking when she made that choice. To not be willing to save the mother if that is her desire seems like it would be abandonment if you couldn't transfer her to another physician who would.

Interesting. I think that would be a situation where the wise Ob/Gyn would say, "you can do this, but you'd need to find another doctor."

Obstetrics is fraught with litigation, I doubt you'd find very many Ob/Gyns who would be willing to take on a pt that would require such an operation. That said, I don't know that many Obs and I certainly am not familiar with this situation (as my first post indicated).

 

[psipsina]

Interesting. I think that would be a situation where the wise Ob/Gyn would say, "you can do this, but you'd need to find another doctor."

Obstetrics is fraught with litigation, I doubt you'd find very many Ob/Gyns who would be willing to take on a pt that would require such an operation. That said, I don't know that many Obs and I certainly am not familiar with this situation (as my first post indicated).

I think if you made a formal consent form and documented everything properly (i.e. multiple witnesses to the patient fully understanding and still wanting to go forward) you could cover your but well enough not to be successfully litigated. A patient can go AMA if they want to, and we need to respect their decisions even when we personally think they are insane. I'm sure you could try to find another doc for that patient, but if no one else stepped up to the plate its not like you could force them to terminate or just abandon them. Those actions would be far more likely to get you successfully litigated.

 

[AmoryBlaine]

I think if you made a formal consent form and documented everything properly (i.e. multiple witnesses to the patient fully understanding and still wanting to go forward) you could cover your but well enough not to be successfully litigated. A patient can go AMA if they want to, and we need to respect their decisions even when we personally think they are insane. I'm sure you could try to find another doc for that patient, but if no one else stepped up to the plate its not like you could force them to terminate or just abandon them. Those actions would be far more likely to get you successfully litigated.

Do you think so? I honestly don't know. It seems an Ob would be well w/in their right to say "I can't handle this in good conscience."

I also sincerely doubt that anything you could make a patient sign would keep the attorneys at bay. Is Law2Doc around to comment on that?

 

[deleted87716]

As a physician, you can never be "forced" to care for a patient that you aren't comfortable treating, especially if they're demanding treatment that is outside the standard of care.

Avoiding abandonment is as simple as providing notification in writing that you are terminating the doctor-patient relationship, with the provision of emergency care during a 30-day period of time to enable them to secure another physician. You are not obligated to treat them beyond that timeframe.

AmoryBlaine is correct that there is no waiver that will completely absolve a physician of liability.

 

[psipsina]

As a physician, you can never be "forced" to care for a patient that you aren't comfortable treating, especially if they're demanding treatment that is outside the standard of care.

Avoiding abandonment is as simple as providing notification in writing that you are terminating the doctor-patient relationship, with the provision of emergency care during a 30-day period of time to enable them to secure another physician. You are not obligated to treat them beyond that timeframe.

AmoryBlaine is correct that there is no waiver that will completely absolve a physician of liability.

Thanks for clearing that up KentW! I was under the impression that you had to help them find another physician. What if the neccisstated abortion vs delivery needed to happen within the 30 day time period you described? Could you still refuse to perform the delivery? Would you just wait until it became emergent and then try to save the mom?

We've talked about this stuff to some extent in ethics etc but I don't think I've heard a definitive answer regarding abandonment when there isn't anyone to turn the patient over to. We discussed a case where a patient is known to be HIV+ and the surgeon refuses to operate . . . the consensus that was that this is ok if the surgeon can turn the case over to someone else, but what if your in a rural situation where there is no other surgeon to turn to and the case is emergent? Can you just let them die because you aren't comfortable with the procedure? I know what I would do based on my own ethics but I'm not sure about legal obligations in these types of situations.