Doctors for Choice insist that law must change so access to Methotrexate in the case of an ectopic pregnancy can be provided in time.
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 these can still be fatal if left untreated. In the UK, the incidence is approximately 11/1000 pregnancies. Gynaecologists in Malta generally use the ethical ‘principal of double-effect’ as a legal loophole to treat these cases by removing the fallopian tube surgically. This is considered an “indirect termination of pregnancy” on the grounds that it is done to save the life of the woman.
However, in selected cases (e.g., unruptured ectopic pregnancy, low pregnancy hormone (HCG) levels, no significant pain), evidence-based guidelines in the rest of the civilised world recommend the use of Methotrexate. This medication is preferred 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. Indeed, 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.
One can understand why some doctors might feel uncomfortable prescribing methotrexate. Unlike surgical removal of 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, the law as it currently stands (Articles 241 and 243 of the Criminal Code) criminalises any/all ways of inducing miscarriage (i.e. 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? As Doctors for Choice we believe that healthcare systems cannot be guided by vague, unclear or questionable legal frameworks, as these hinder the work of doctors and put patients’ lives at risk. Moreover, 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 delay in deciding whether to use a medication that is in widespread use in the rest of the EU. 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.
The law must change so that access to this medication, which technically causes an abortion, can be provided in a timely fashion. Meanwhile we are pleased to see that the Maltese health service have finally admitted to using a drug to terminate pregnancies, albeit ectopic ones. What needs to follow is a revision of the law to clearly specify the definition of an induced abortion and the conditions under which it can performed legally.
Have you experienced a traumatic experience due to lack of support in dealing with an ectopic pregnancy? Do you agree with Doctors for Choice on this matter? Contact us or send us an email at [email protected] to share your experience with us.
Professor Stabile is a gynaecologist in private practice at St James Hospital, Malta. She is also currently Director of the International School for Foundation Studies and Medical Foundation Programme at the University of Malta. Currently her main research interests are in medical education.
