The dangers of ectopic pregnancy are long overlooked | Expert Opinion

At 3 a.m. my work phone rings: It’s the hospital; I am needed in the operating room in 30 minutes. A patient has arrived with a ruptured ectopic pregnancy — a critical emergency involving a pregnancy growing outside the uterus. She is stable, for now.

I race through my prep list: Cold shower, clogs, ID. I grab a banana and hit the road, calling ahead to make sure the OR has what I need. When I arrive, I hold her hand, already clammy due to blood loss. and I make the same promise I always do: My name is Dr. Abernathy, I am so glad you made it here. We got you. With that, she is off to sleep under anesthesia, and my work begins.

As an OB-GYN, I have performed this life-saving surgery countless times to remove the fallopian tube containing the ectopic pregnancy. Without care, this patient and others in her condition could massively bleed into the abdomen and die. The U.S. has the worst rate of maternal deaths among high-income countries. This type of bleeding in pregnancy is often overlooked, as most people worry about bleeding only at the time of delivery. Yet ruptured ectopic pregnancies caused 12% of pregnancy-related deaths in Philadelphia from 2019 and 2023.

The statistic tells a story of nefarious neglect, and should be a wake-up call. We have the medical tools to save women’s lives. Will we?

For decades, the medical community has built systems to make childbirth safer. But we have not created the same infrastructure for the beginning of pregnancy, where we desperately need it.

An ectopic pregnancy, sometimes called a tubal pregnancy, occurs when a fertilized egg implants outside the uterus, usually in the fallopian tube. Neither the developing pregnancy nor the pregnant person will survive without care due to the growing pregnancy causing catastrophic internal bleeding.

It’s especially frightening that often people with a ruptured ectopic pregnancy can look relatively well. Young, healthy people can compensate, even while losing enormous quantities of blood into their abdomen.

Worse, a pregnant person may not show symptoms until the condition has progressed to the point of rupture. Symptoms that may serve as warning signs include severe, one-sided abdominal pain with vaginal bleeding, lightheadedness or fainting, and sometimes sharp shoulder pain.

Designing our system to save their lives requires recognizing the uncertainty inherent in early pregnancy diagnosis.

This uncertainty has become even more challenging for doctors since the Supreme Court overturned Roe v. Wade and ended a national right to an abortion. In two national physicians’ surveys, nearly one quarter of emergency physicians and one third of obstetrician gynecologists in states with restrictive abortion laws reported delays in treating patients with known or suspected ectopic pregnancy. The most common reason: Care providers were navigating laws that required greater certainty that the pregnancy was ectopic before they could intervene.

But certainty is exactly what early pregnancy cannot provide. An ectopic pregnancy is not viable, and delaying treatment does not save a pregnancy. It can simply enable a treatable condition to become an emergency.

Even in states like Pennsylvania and New Jersey that have not passed restrictive abortion bans in recent years, we still need to build a different system that promotes evaluation and early diagnosis and treatment.

My team at Penn Medicine launched the first early pregnancy access clinic in the U.S. to better serve patients in early pregnancy. The model we developed nearly a decade ago at the Hospital of the University of Pennsylvania has since been replicated at clinics across the city and nationally. Next, we developed Conversational AI for eaRly pregnancy CAre (CIRCA), a conversational texting tool that offers patients early pregnancy education and helps them to triage symptoms around the clock. Our early data suggest we are catching complications sooner.

We still need a better early pregnancy care system at a larger scale. This would include digital triage resources that connect directly to clinicians, along with rapid laboratory testing and ultrasound access.

Citywide, Philadelphia’s Maternal Mortality Review Committee recommends better training for early pregnancy complications, stronger follow-up when women come to the ER during early pregnancy, and innovative approaches to earlier detection and intervention.

Pennsylvania now has an extraordinary opportunity to act. The Commonwealth’s Rural Health Transformation Plan will invest $1 billion in federal funding to redesign rural care. Maternal health is one of its priorities. Those investments should expand how we look at maternal health to include the beginning of pregnancy — particularly where maternity units have closed.

Philadelphia’s death statistics should be a warning: if patients can fall through the cracks in our city, where most patients have access to hospitals and healthcare providers, the consequences could be even graver in rural communities that can struggle to sustain maternity care. Timely care should not depend on your ZIP code.

Concerned citizens can ask state officials for a regional summit, demand early pregnancy care be more of a focus, and spread the word about early pregnancy resources.

The night that I received that emergency overnight call, I kept my promise to my patient. She was fine. But without better healthcare during the weeks before prenatal care begins, others may not be so lucky. No one should have to bleed to death during early pregnancy, before we recognize their need.

Alice Abernathy is an assistant professor of Obstetrics & Gynecology, Medical Ethics & Health Policy, and a senior fellow at the Leonard Davis Institute of Health Economics at Penn.