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"Am I miscarrying, do I have an ectopic, or is this just a bit of bleeding" is a patient scenario that plays out EVERY day in EVERY ER in the US.
I will diagnose almost EVERY patient with a medical term called abortion. Here's how it plays out:
Bleeding is very common in the 1st trimester. 20-30% of patients will have bleeding. Many patients go on to have a totally normal pregnancy. Many also go on to miscarry, called a "spontaneous abortion." Some will end up having an ectopic pregnancy, a pregnancy in the wrong spot.
Minor bleeding/cramping can be the only sign of an ectopic, and an ectopic can easily kill you if it's missed. So this is the diagnosis we focus on ruling out most in the ER. The treatment for an ectopic is an abortion, stopping the fetus before it ruptures and kills mom.
The evaluation in the first trimester typically entails an ultrasound, some blood tests to look at beta HCG hormone levels (which can give us some hints about the pregnancy's size/age) and a pelvic exam to evaluate bleeding. Sometimes it's straightforward:
All the tests are reassuring? This is called a threatened abortion; some patients will still go on to miscarry, but there's no evidence of this right now.
Others we give the devastating news that they're miscarrying. "Spontaneous abortion."
And others we diagnose with an ectopic.
And that's just if it's straightforward! OFTEN we can't really see much on ultrasound, but the pregnancy hormone levels are ⬆️, and there's minimal bleeding, and we say, "Yeah, we're not sure where the pregnancy is, or if it's healthy. Or it's too small to see." Come back.
In most healthy pregnancies, the bHCG hormone levels will roughly double every 48 hours. So when they come back, if the bHCG levels are doubling and there's no more bleeding, we say okay, maybe your pregnancy is just too small to see on ultrasound.
I cannot emphasize this enough: NOT UNCOMMONLY we still just don't know what's going on: maybe the levels are rising, but rising slowly. Or they're not rising. Or they're dropping (often a sign of a miscarriage). Or we still can't see anything on ultrasound.
Is it a miscarriage? Is it just an early pregnancy? Is it an ectopic? All of these options are still possible diagnoses, and sometimes the only way to know is time.
But if it's an ectopic, time is often of the essence.
Can you see why this is a conundrum?
These conundrums happen in EVERY field of medicine, ALL THE TIME. Medicine, biology, and humans are complex. Tests are not always perfect. Does the patient have appendicitis? The CAT scan couldn't tell. Is that small EKG squiggle a heart attack, or normal in a young person?
The conundrum in these pregnant patients is no different. So we—as experts with decades of training and experience—counsel patients, discuss things, and give our best recommendation possible. Sometimes it's "do more tests," or "come back if you get worse," or "let's do surgery."
And our OB-Gyn doctors do the same with "Pregnancy of Unknown Location." They counsel patients, talk about options, and give recommendations. Sometimes it's "Let's keep watching," and other times it's "I'm worried this is an ectopic but I can't say for sure."
Sometimes the decision is made to terminate the pregnancy. This is not a decision taken lightly by *anyone*, and is the exact scenario that almost every one of these laws would like to ban.
Which leaves these patients potentially walking around with deadly ectopics.
Or sometimes delayed miscarriages (missed, inevitable, or septic abortions), and at this point, pretty much never a pregnancy that would come to term and create an actual human baby.
As an ER doctor I have seen women near-death with ruptured ectopics with a gallon of blood in their abdomen (they have 1.3 gallons of blood total). I have seen women almost bleed to death from miscarriages, and removed the fetus stuck in the cervix to help stop the bleeding.
I don't understand why you would trust an ER doctor or OB-Gyn to manage every single medical scenario...except one.
These laws are intentionally meant to harm pregnant patients and make doctors' jobs harder, or they're so uninformed that they don't know basic human biology.
The real debate is what's worse:
Intentional malevolence or
Ignorant, fetid stupidity?