Explaining the Awful Missouri Abortion Bill Involving Ectopic Pregnancies

Yes, it's a shit show

Missouri House Bill No. 2810 (link to the full shit show here) was recently introduced by Rep. Brian Seitz, and it is yet another perverse way an ignorant man is trying to control reproductive rights with zero regard for the consequences.

I want to draw your attention to Section A.3. The language here makes all abortion after 10 weeks illegal. Obviously, this is atrocious, but the next two lines are what drew even more outrage online as the language appears to conflate treating ectopic pregnancy with abortion, hence making treatment of ectopic pregnancy a class A felony. 

Medically speaking, this language about ectopic pregnancy makes no sense. 

Apparently Seitz doesn’t understand it either because when questioned if he understood how ectopic pregnancies are treated, he replied, “No, I do not.”

Piper for Missouri @piper4missouri

A hearing in which MO GOP Representative Seitz admits he doesn’t understand ectopic pregnancies though he authored a bill to criminalize ectopic pregnancies…

An ectopic pregnancy occurs when an embryo implants outside of the uterus. Ectopic pregnancies cannot go safely to viability. Without treatment, there are one of two outcomes. One, the ectopic pregnancy outgrows its blood supply, runs out of nutrients, and is reabsorbed. Basically, a miscarriage, but we never use this term for an ectopic pregnancy. The other scenario is the trophoblast manages to get enough nutrients and continues to invade tissue. But this invasion doesn’t happen in the uterus, which evolved for the specific high stakes challenge of managing trophoblast invasion. It happens in an oviduct (Fallopian tube) or ovary or even rarely, with an abdominal pregnancy, bowel or liver. This non uterine tissue can’t contain the invading tissue like the endometrium and myometrium (the uterus) can, and eventually the trophoblast drills its way into blood vessels. This is like opening a faucet, and it is only made worse by the fact that there is no muscle to contract and clamp down to slow blood loss, like the uterus does during menstruation or miscarriage. This bleeding can be a slow drip or it can be a catastrophic hemorrhage. This is how people die from an ectopic pregnancy, they bleed to death. Currently, ectopic pregnancies are the number one cause of death for a pregnant person in the first trimester. It is challenging to explain how medically catastrophic it can be when an ectopic pregnancy ruptures. The belly can be full of blood in minutes.  

One would think that lawmakers would leave a potential catastrophe, like ectopic pregnancies, alone. But no, not in Missouri. Rep. Seitz wants the Show Me state to show just how cruel it can be. It’s not enough to make abortion harder to obtain safely, the meddling is made worse by the fact that the language is medically unintelligible. What does preventing an abortion on someone with an ectopic pregnancy even mean? Does Seitz think we do abortions on ectopic pregnancies? We don’t use the word abortion when we treat an ectopic pregnancy because an abortion of a pregnancy in the uterus is very different from treating an ectopic pregnancy outside of the uterus. When we use medications, we use different ones. When we do surgery, we use different surgical procedures. Treating an ectopic pregnancy is never called an abortion. 

So what is the point of this language in the bill?

There is always the risk of missing an undiagnosed ectopic pregnancy with an abortion early in the first trimester. The rate of ectopic ranges from 6-14 per 1,000 depending on the population studied. Interestingly, the rate among those seeking abortion is typically lower. One study in the U.S. found that when a surgical abortion was performed at 6 weeks or less the rate of ectopic pregnancy was 5.9 per 1,000 pregnancies, and at the time the national rate was about three times higher. And, a large study of medication abortion at 7 weeks or less found the rate of ectopic pregnancy was 1.3 per 1,000 pregnancies.

After all the right questions have been asked and the appropriate tests performed, if there are no warning signs of an ectopic pregnancy, we proceed with the abortion. Patients are warned about the potential risk of an undiagnosed ectopic with early abortions and what do do should they have symptoms. This is part of their informed consent. 

The point of the bill seems to be to scare providers and patients away from abortion before 10 weeks, because if they happen to be the 1 in 1,000 who a week or so later turn out to actually have had an ectopic and not an intrauterine pregnancy as originally suspected (hence the abortion), based on the wording of the proposed law, a class A felony has now been committed. As we can’t tell who that 1 in 1,000 will be, and if you do enough abortions eventually you have a patient with an undiagnosed ectopic, the only way to avoid a class A felony would be to stop doing abortions.

Of course it is possible that Rep. Seitz is hoping to limit treatment of ectopic pregnancies as he literally knows nothing about them. Remember, Republican politicians in Ohio have actually thought ectopic pregnancies could be reimplanted and introduced a bill to require that doctors reimplant ectopic pregnancies into a uterus or be charged with “abortion murder”. Oh yeah, and they tried to do this twice. 

If this bill becomes law, providers will almost certainly require an ultrasound before an abortion to prove the pregnancy is not an ectopic. This will lead to delays and more cost, which is clearly the point. If they don’t do the ultrasound and the bill becomes law, it just takes one person to call the District Attorney, and unfortunately being “tough on abortion” is good for political aspirations in many states.  

And if this bill becomes law, more people will die as abortion is always safer than pregnancy and anything that restricts abortion will eventually have a negative pay off in the deaths of pregnant people. And no lives will be saved from an ectopic pregnancy standpoint. That person will have those same symptoms whether they have had an abortion or not. 

But there is even more potential badness. Because the bill is so poorly worded it is easy to interpret it to mean that treatment of ectopic pregnancy is now a class A felony. One of the downstream effects of medically illiterate language is it frees the police and the DA to interpret the law however they choose. Neither the police nor the DA will ever face any consequences for arresting someone over the appropriate treatment of an ectopic pregnancy.

And lest you think I am over reacting, state laws on feticide, which are usually introduced to enhance penalties for murdering someone who is pregnant, are currently being used to criminalize pregnancy loss and to grotesquely reimagine fetal loss as feticide. Since 2006, at least 1,200 pregnant people have been arrested for miscarrying. 

And currently in Texas, NPR reported that a woman named Anna ruptured her membranes at 19 weeks on her wedding day when she was in her dress getting ready. She was at high risk of an infection, but no one could offer her an abortion, an accepted part of medical care for this situation, because her fetus still had cardiac activity. Not only could the doctors not offer an abortion, they couldn’t even discuss it out of fear they might be reported by an eavesdropping colleague. She told NPR that she and the medical team were forced to communicate via text so as not to be overheard. Anna had to get on a commercial flight to Colorado to get care, sitting in the front row so she could go to the bathroom quickly should she go into labor on the flight.  

These laws are horrific. The bills are written in ways that can cause devastation even beyond their intent. Abortion is the safest pregnancy outcome and there is no data that they increase the rate of complications from ectopic pregnancy. If someone did have an early abortion, which later turned out to be unnecessary as they really had an ectopic, they would have received counseling about ectopic pregnancies and so the information they received from their abortion provider might actually save their life.

But Rep. Seitz doesn’t care. He doesn’t even care enough to learn about the treatment of ectopic pregnancies, and yet he wrote a bill that hopes to govern their care. It’s clear from Seitz’s words that bleeding to death in the bathroom by yourself or in an ambulance on the way to the hospital is part of the pro life agenda. 

References

Medication abortion up to 70 days of gestation. ACOG Practice Bulletin No. 225. American College of Obstetricians and Gynecologists. Obstet Gynecol 2020;136:e31–47.

Edwards J, Creinin MD. Surgical abortion for gestations of less than 6 weeks. Curr Probl Obstet Gynecol Fertil 1997;20:11–9. 

Ulmann A, Silvestre L, Chemama L, Rezvani Y, Renault M, Aguillaume CJ, et al. Medical termination of early pregnancy with mifepristone (RU 486) followed by a prostaglandin analogue. Study in 16,369 women. Acta Obstet Gynecol Scand 1992;71:278–83. 

Pregnancy-related mortality in the United States, 1998 to 2005. Berg CJ, Callaghan WM, Syverson C, Henderson Z. Obstet Gynecol. 2010;116(6):1302.