I was at the clinic the other day, and I was finishing up the evening shift. A female patient showed up for a review with regards to lab test results. It isn't uncommon for us to end up reviewing a patient on behalf of one of our fellow doctors because their shift might have ended before investigations they'd ordered were complete. I honestly don't mind because it is usually a case that can be handled quickly.
In this case, it turns out that the lady was the one who had specifically asked for the tests. We get this from time to time too: some individual may have suffered from a specific malady in the past, thus they come in on a regular basis just to check on that specific parameter - Lipid profiles (cholesterol), Liver Function Tests, Blood pressure or sugars, Clotting profiles, etc. I pored through the lady's results and everything was essentially normal, which is the best kind of news - no management needed whatsoever.
At that point, the lady decided to let me know what had occasioned the testing. She had lost her last pregnancy in her 3rd trimester, and was considering getting pregnant again. I decided to question her further, and asked her if the baby had any identified malformations; she answered no. Next, I asked her if there were any problems with her blood pressure during the pregnancy; Yes, she answered.
So my mind pretty much knew what the diagnosis had been: Preeclampsia. So I continue to peel away the layers, finding out that she had very elevated blood pressures which had worsened towards the end; she had also developed generalized oedema. With blood pressures towering above the 170/100 mmHg mark at some point, she had generally crossed over into the realm of Severe Preeclampsia. She had been admitted for monitoring, but somewhere along the way foetal movements ceased and the baby passed away - an IUFD (IntraUterine Fetal Demise) at 32 weeks of gestation. To make matters worse, the lady ended up needing to undergo a Caesarean Section to deliver the recently deceased baby.
The hits had just kept on coming during that pregnancy, and almost 2 years down the line, this lady was still coming to me with questions. In some regards, as usual, she still felt that the doctors were at fault and didn't do enough to save her pregnancy; she was obviously hoping that the same thing wouldn't happen in this subsequent pregnancy attempt. In the course of the conversation, I also got the impression that she felt that things would have turned out better if it had been her life lost in the pregnancy and not that of the unborn child.
Being blunt
I had tried to be compassionate and offer up as much empathy as I could while we talked, but at some point it became necessary to give her the cold hard facts.
- She had experienced preeclampsia in her very first pregnancy; it had been a mild case that had developed in her 3rd trimester, but that was evidence enough that she'd be at risk of suffering preeclampsia in subsequent pregnancies. For this (fateful) pregnancy, the preeclampsia had started earlier (in the 2nd trimester) and progressed even faster. She definitely should have been booked into a High Risk Pregnancy Clinic for her 2nd pregnancy; but I let her know that it was imperative that she start any future new pregnancies with prior visits to her Ob-Gyn before conception.
- Preeclampsia/Eclampsia is no joke. It's one of those conditions that gives doctors nightmares because we don't fully understand its cause, but we have dealt with its ramifications many times. Any organ damage that happens during the pregnancy stands the chance of being irreversible! Let me mention a few of my fine examples
- Pre-internship (KNH)
- A mother shows up after a normal delivery in Kibera. She seems to be acting particularly aggressive and out of sorts, so we assume it is a case of puerperal (post-partum) psychosis. Only thing gleaned from her discharge notes was that she's had a BP of 160/100 mmHg at one point. 2 weeks into her stay we end up performing a Head CT scan which shows a massive bleed into her brain. A few days later, she's gone.
- A mother is 20 weeks pregnant, but her whole body is swollen like a grapefruit. We have a special term for this kind of oedema: Anasarca. I have never seen a case of preeclampsia progress this fast! Coming this early in the pregnancy, my consultants have no choice but to terminate the pregnancy to save the mother's life.
- Internship
- My introduction to the Obs/Gyne Department: a mortality debriefing. Mother had suffered kidney failure and basically had blood streaming into her urine bag instead of...well, urine. Patient succumbed soon after.
- A mother had developed seizures in the course of her delivery, and thus ended up being taken to ICU for further treatment.
- Typical night in the labour ward. Mother transferred in from Lord-knows-where in need of a Caesarean Section (CS). Mother hasn't really had any sort of antenatal clinic visits, so there isn't much for us to glean in terms of past medical history. Anaesthetist hopes to perform a rapid sequence induction using Ketamine, but, with the patient already on the operating table, finds out that the patient's blood pressure is at the 180/100 mmHg. Ends up having to switch to more traditional agents, which have a pressure lowering side effect, and as the surgeon I have to perform as quick a CS as I possibly can, and hope for no complications.
- Post-Internship - a relative comes down with a case of AntePartum Hemorrhage (APH) just 4 weeks prior to her official due date. Investigations prove that she's developed HELLP syndrome, and ends up needing a CS one week later to avoid any further complications.
- Most preeclampsia pregnancies - with regular doctor's visits and appropriate medication, we are able to ensure a smooth pregnancy. Delivery of the placenta usually results in normalization of blood pressures for the mother; an unlucky few go on to develop chronic hypertension.
- A doctor will NOT risk the life of the mother for the sake of the child. This is not some form of Roe v. Wade permissiveness - this is a real question of life and death where the pregnancy places the pregnant mother's life in immediate harm, possibly of imminent death. We don't particularly like sacrificing the life of an unborn child, but in terms of priorities, it is basically
Save the Mother first; if possible, save the Mother AND Child.
I do not hesitate in this matter in light of my experience losing Edna. I have been adequately prepared to answer this question by a Philosophy 101 class from my first semester of (Daystar) University. The justification for this is strangely Utilitarian: the mother is a microcosm - she has built up a wealth of relationships, and has very many people who actively depend on her; the foetus is wholly potential. Thus, as a doctor, in weighing the scales, it is more ideal for you to save the mother's life, preserving the already intricate web of relationships that she is a part of.
But then again, life is not so clear-cut and absolute. I remember hearing about the case of a mother who delayed chemotherapy treatment so that she could have a normal pregnancy, and give her unborn baby a fighting chance at a normal birth and life. This was wholly a mother's choice and sacrifice, and a reminder that mothers (and fathers) will on many an occasion make the ultimate sacrifice for their children. - Hindsight is 20/20. Doctors usually get asked to review situations where things have gone wrong, and asked to chime in our thoughts. This is why we typically have Morbidity and Mortality (M&M) meetings, which give us a chance to backtrack and see how things could have been done better. However, we are not always so quick to assign blame because there is the realization that every health situation evolves along a vast array of lines. In this case in particular, someone may argue that the baby should have been delivered earlier. Theoretically, I can think of 2 reasons why the doctor might have chosen not to.
- The mother's blood parameters might have been with normal ranges, and it was hoped that adjusting the set of medications that she was on should have allowed the doctors to prolong the pregnancy.
- It might also have been possible that the baby was considered "small for gestational age". Preeclampsia is one of a host of conditions that can cause Intrauterine Growth Restriction (IUGR), so prolonging the pregnancy would offer a better post-delivery outcome for the foetus.
Better is one day in your house...than thousands elsewhere
The songwriter was referring to being in God's presence...but he might as well have been talking about a foetus in the womb. Nothing we scientifically possess is capable of mimicking the fine-tuned conditions that exist in the womb; thus, as normal a progression of pregnancy is one of the main aims of any OB-Gyn. We usually find that it is ideal to let nature take its course as much as it possibly can.
I think it's worth noting that the patient described me as being "very blunt" at the end of our talk. I don't regard that as a worthy hallmark, nor is it representative of my typical bedside manner. However, she was thankful that I had taken the time to explain things to her in a manner she hadn't experienced before.
In hindsight, it is possible that we sometimes mentions these things to our patients, but they fly right over their heads if they're not yet ready to hear them. Sometimes, we really don't have that much time: I had the chance to go over the situation with her because it was a slow evening at the clinic; I can't guarantee I would've had the same outcome on a busy day. This is why it's probably a good reason to readily recommend some counseling for such patients. Allowing them to talk about the experience often provides more relief than merely doping them up for their depression.
I am thankful for opportunities to practice medicine, and chances like this to clarify things to my patients. I hope this patient gets the outcome that she desires, and can get the true healing that she needs from the events in her past.
God Bless.
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