Voluntary termination of pregnancy. Voluntary interruption of pregnancy. These are the medical terms for what the layperson thinks of as an abortion.
Missed abortion. Threatened abortion. Incomplete abortion. Spontaneous abortion. Septic abortion. Inevitable abortion. These are medical terms for the failure of a pregnancy.
All these medical terms are just that: medical terms. Nomenclature to differentiate biological processes, so as doctors, we can clearly communicate what is happening with our patients. However, in the mainstream, these terms are laced with judgment, bias, morals, ethics, and misinterpretation. I find it interesting that in medicine, the word abortion is not the term used when someone decides to end a pregnancy voluntarily.
As an obstetrician, I have to take care of two patients at once. Sometimes, their needs are very different, so different that one may need to sacrifice the other to survive. These choices are never black and white, but generally carry layers of possibilities and outcomes. And the choices are not between good and bad, but worse and less worse, leaving the patient having to live with the consequences of either decision being devastating. Let me walk you through one of those stories.
She is fairly young, early 20s, newly pregnant and excited about her family growing. At her first appointment, I talk with her and her husband and do an ultrasound. We see the baby, all one centimeter of it, and began the journey of a “normal” pregnancy. A bright woman, she comes to her appointments with few complaints, few questions, really just enjoying the ride. At about 16 weeks, we do a genetic screening test (a blood test) that includes something called AFP, which can be elevated with several fetal abnormalities. Unfortunately, her test is elevated; so after calling her, I have her set up an ultrasound appointment at the hospital. She does not seem particularly alarmed; I think she can’t entertain the idea something could be wrong with her baby.
Never a good sign, the specialist at the hospital calls me the day of the ultrasound. “This baby has a large cystic hygroma, already nearly as big as the baby’s head.” A cystic hygroma is basically a cystic growth, generally arising at the neck, that can also be associated with abnormal chromosomes. The next step would be to get an amniocentesis to determine the chromosomes. Unfortunately, cystic hygromas can continue to grow during the pregnancy and cause many complications to both the baby and the mother.
Obviously, my patient is heartbroken. Her usually cheery, easygoing demeanor is now in a state of shock. How do you process this, especially when there is still so much unknown? By this time, she is nearly 18 weeks, and the results of the amino would take two weeks. She is starting to feel fluttering, maybe a slight kick, a reminder of the love she is growing inside of her except it is not the perfect baby she had expected. It is a long two weeks for her, and when the results come back, the hospital calls her before me …. the chromosomes are abnormal. They recommend she come in for a multidisciplinary meeting, a meeting that consists of several specialists to assist in understanding the consequences of her diagnosis. They would discuss what would happen if she continued the pregnancy and if she didn’t. I, unfortunately, cannot attend the meeting, but am informed of the details afterwards.
I call my patient later that day and we arrange an appointment the next day. She comes by herself, eyes puffy with lack of sleep and crying. She sits down, looking straight at me and says, “I need someone to tell me what to do.” I could feel my own tears forming; I know the prognosis of this baby surviving is nearly zero. How can I tell her this, the baby is very much alive in her now?
Unfortunately, she is running out of time to make a decision if she desires a termination, both because she is near the legal gestational age for a termination and because the size of the cystic hygroma is getting larger, making the delivery all that more laced with possible complications for her. We talk for quite a while about what it means for her to terminate the pregnancy versus letting nature take its course as well as the consequences to her either way.
In my heart, I want to protect her; she is my patient, and I don’t want her harmed in any way. I don’t know the baby; I don’t have a relationship with the baby: My relationship is with mom. All I can see is that this pregnancy, if continued, could only harm her more, possibly harm her so she can’t have any more children or even take her life. I know this baby can’t survive, but there is no telling when it would die. And so, heavy hearted, I told her what I thought: “You need to terminate this pregnancy.”
She begins sobbing. Once she is able to settle herself, she looks at me again and with a calm voice says,”Thank you. No one at that other meeting was straight with me. I just needed an honest answer, and I appreciate you giving me that.”
That week she schedules the termination. Because it is such a high-risk situation, she has to be referred to a specialist downtown, the only person capable of doing the procedure. I hoped they would treat her with kindness and caring, and not just as another procedure. It is the week of Christmas, and it pains me to think the memory of this will be linked to the holiday for my patient.
Now years later, she has two healthy children. Although unspoken, we will always share the memory of her third child. At the time, she was accepting of the decision she needed to make, although I know it has haunted her.
The loss of a pregnancy, at any stage, whether a voluntary decision or one that Mother Nature makes, is never easy, is never clear, is never taken lightly.
Andrea Eisenberg is a obstetrician-gynecologist.
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