Issue link: https://maltatoday.uberflip.com/i/1315450
6 maltatoday | SUNDAY • 6 DECEMBER 2020 NEWS Ectopic pregnancy treatment highlights health risks of abortion ban LAURA CALLEJA MALTA'S ban on abortion could be leading some doctors to treat ectopic pregnancies by surgical- ly removing a woman's fallopian tube, as a legal way out to termi- nate a pregnancy 'indirectly'. But pro-choice doctors claim that in certain specific cases, the use of methotrexate medi- cation to target the embryo can terminate the pregnancy while preserving the fallopian tube, al- lowing the possibility of future pregnancies. The choice that faces doctors in Malta in the way they treat ectop- ic pregnancies is now part of the abortion debate that has been on- going for the main part of 2020. Last week, the treatment for ec- topic pregnancy in Malta was the subject to criticism after this newspaper found that doctors required government approv- al 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 com- monly 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 approxi- mately 11 out of 1,000 pregnan- cies. "Gynaecologists in Malta generally use the ethical 'prin- ciple of double-effect' as a legal loophole to treat these cases by removing the fallopian tube sur- gically," the pro-choice organisa- tion said. "This is considered to be an 'in- direct termination of pregnancy' because it is done to save the life of the mother. But in select cases, for example in unruptured ectop- ic pregnancy, low pregnancy hor- mone (HCG) levels, no significant pain and so on, evidence-based guidelines in the rest of the civ- ilised world recommend the use of methotrexate." Doctors for Choice say meth- otrexate 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 pos- sibility of future pregnancies," the NGO said. "Randomised controlled trials comparing methotrexate with laparoscopic surgery have shown that, in selected cases, metho- trexate is equally successful to surgery and leads to better repro- ductive outcomes." The NGO wants the law to change so that access to this med- ication, 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 us- ing a drug to terminate the preg- nancy, albeit ectopic ones. What needs to follow is a revision of the law to clearly specify the defini- tion 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 ar- rived 48 hours after diagnosis. Yet despite a government claim that the "board" does not ex- ist, information sourced by this newspaper confirms that doctors must send an exceptional treat- ment form to the Directorate for Pharmaceutical Affairs by email, where a person responsible then gives the green light to a pharma- cist 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 doc- tors might feel uncomfortable prescribing methotrexate. "Un- like surgical removal of the tube which indirectly ends the preg- nancy, this medication directly destroys the pregnancy, wheth- er 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 miscar- riage, which would be an abor- tion, 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 ec- topic pregnancy is illegal, because it is used to directly terminate the pregnancy?" The Doctors for Choice spokes- person said it believed that the healthcare system could not be guided by vague, unclear or ques- tionable legal frameworks. "It hinders the work of doctors and puts patients' lives at risk... doc- tors 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 fi- nally following evidence-based guidelines in the treatment of ec- topic pregnancy, there should be no reason for the delay in decid- ing 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 wors- ened 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 wom- en being given short shrift in medico-legal situations. The pro-life medical organisa- tion Doctors for Life criticised the pro choice medical organisa- tion, saying they had spread mis- information 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 present- ing with an ectopic pregnancy. "This very same organization that claims that life should be protect- ed from the moment of concep- tion, 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 preg- nancy'." 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 recur- rent ectopic." Doctors for Choice claim this is a misrepresentation of facts, in- sisting that medical management by methotrexate offers several benefits over surgical treatment. "It is less invasive, less expensive, can be given on an outpatient ba- sis and does not need expertise like laparoscopy. Future repro- ductive expectations are better with methotrexate with higher intrauterine pregnancy rates and lower ectopic rates subsequent- ly." 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 de- fects identified after methotrex- ate treatment of an ectopic preg- nancy, are a consequence of the treatment or were already pres- ent before the pregnancy, and were thus the cause of the ectopic pregnancy." Pro-choice doctors say Maltese doctors surgically remove fallopian tube to avoid criminal liability of abortion in ectopic pregnancies