If she gets pregnant, she might die. Do I help?

When I started out in practice, I worked at one of the few hospitals in the area that accepted Jehovah Witness patients. Their beliefs prohibit them from accepting blood transfusions or blood products. Many hospitals are concerned about the liability of allowing a patient who refuses necessary blood products to die. For this reason, these institutions are not welcoming to Jehovah Witnesses. This is of special concern in surgical specialties such as mine, where blood transfusions are always a possibility. Because my first job was at the hospital where I trained, I didn’t think of seeing Jehovah Witness patients as an “issue.” I had become accustomed to and had come to value a patient’s religious beliefs. It was their body after all and it harmed no one but possibly themselves … except, in pregnancy. When a second life was involved, the issue became more complex.

Despite this concern, I continued to see Jehovah’s Witnesses patients in my obstetrics practice. In fact, I heard through one of my patients that my reputation preceded me, as I was mentioned in their publication The Watchtower as a Jehovah Witness-friendly physician. One patient, in particular, I remember because all her pregnancies required c-sections and I earned a few gray hairs keeping those surgeries as bloodless as possible. Fortunately (knock on wood, salt over my shoulder), the issue of transfusion never became an issue, and I was never forced to watch a patient lose their life because they refused a blood transfusion. However, many years later, a patient’s willingness to die presented itself to me not as a religious issue, but in a surprisingly different way. I had to decide whether to honor her wishes or pass her on to another physician.

She was one TOUGH lady, as in biker-chick tough. Dark mascara and eyeliner shaped her eyes, tight fitting clothes fleshed out her curvy body, and tattoos adorned her skin. Underneath all her “armor,” she had the sweetest heart. The first time I met her, she wanted her IUD removed because she was interested in having another child. Her only child, a son, was a teenager, born prematurely. He had many physical and mental disabilities which required him to use a wheelchair as well as needing constant care. The responsibility was a heavy burden, but when I asked her about how she managed, she would smile, shrug her shoulders and say, “Oh, it’s not so bad,” with love.

She now wanted, with her current boyfriend, a chance at a “normal” pregnancy and child. The procedure, in this case, would not be simple because her IUD string wasn’t visible. Normally in this situation, I would take the patient to the operating room to fish out the IUD so they could be sedated and feel comfortable. No, not this patient. She begged me to take it out in the office and avoid the OR to save time and money, reassuring me she could handle the discomfort. And so I did and learned quickly how tough she was.

She returned within the year pregnant. She glowed with excitement although I saw concern in her eyes, afraid repeating the past preterm delivery, the only memory she had of pregnancy. Her first pregnancy was so many years ago, it was impossible to get her records and determine the cause of her early labor. I promised I would watch her closely though, and so we went forward. Her first trimester cruised along without any issues. She finally reached her second trimester, the time for the anatomy ultrasound, and she was anxious to find out the sex of the baby. Much to her delight, it was a girl and she shed tears of happiness upon hearing the news. Her next appointment was in four weeks, but she didn’t make it to that appointment. Instead, she showed up in the emergency room, and as she put it, “I died, and they revived me.”

She indeed had a cardiac arrest upon arriving at the hospital. After stabilizing her in the emergency room, she was transferred to the ICU. When I arrived the next day, I found her hooked up to several monitors and IVs, receiving various medications to keep her alive. Although every day someone listened for the baby’s heartbeat, our immediate need was to keep mom alive. By her bedside was a post mortem c-section kit — if she were to die, we would have the ability to perform an emergency c-section at the bedside because we would only have minutes to save the baby. Thinking about that possibility sent shivers down my spine. The situation was heartbreaking, and unfortunately, at that moment, we were not clear about why her heart stopped.

Each day that I visited, she would smile as I walked in. But sometimes, I could see her through the window before she saw me, and I could see the strain on her face, occasionally tears on her cheeks. She didn’t have her usual makeup on, so her age and fatigue couldn’t be masked. We talked about how reaching the end of each day was a victory for her and the baby; one step closer to a full-term pregnancy. I found her courage and continued optimism inspiring.

Sadly one night, her body responded to all the stress and needing to care for only itself, by going into labor and the premature baby did not survive. The cardiologist had determined that an irregular heartbeat was the cause of her cardiac arrest. Eventually, she had a device placed in her chest to help control her irregular heartbeat. She was told to never attempt pregnancy again as her risk of death was too high. She left the hospital empty handed and defeated, her dream of having a “normal” child dashed. And then she disappeared.

It was about a year before I saw her again. She had spent the year seeing various doctors, trying to find clues about her heart issues. Overshadowing every step was the overwhelming desire to be pregnant. The words fell out of her mouth in rapid fire as she recounted her journey, emphasizing her relentless struggle to find answers. In the end, her thyroid was the culprit. It had gone into overdrive, thus causing her heart to become erratic and fire signals haphazardly. Once she discovered this, she honed in on treating the thyroid. And now, as she sat on the edge of her seat in the exam room, her eyes wild with desire, she finished with “I want to have a baby now.” In a flash, the memories surfaced and I’m back in the ICU, standing over her bed, hearing the beeping of monitors, praying she will survive. So now she wanted me to not only support her decision, but also care for her despite the risks.

I saw her desperation, her dreams, her recklessness and her hope all clouding the facts of her medical history. But I also saw her determination to beat the odds. In myself, I saw fear, hesitancy, concern and, biggest of all, having lived through a patient dying, I didn’t know if I could do it again. Could I really be a co-conspirator in her fantasy? What was my obligation to her, especially after all we had been through? And if I said no, would she find another doctor willing to take on the risk, especially after seeing her records and the words “DON’T GET PREGNANT AGAIN” boldly written? And if not, would she just go ahead alone, navigating the stormy waters on her own?

So many questions to wrestle with as I sat there, her eyes imploring me to take the risk and walk her through this journey fraught with danger. I told her I needed time, that this was not a small request and deserved a thoughtful response. I also wanted to review her records to make sure I understood her health issues clearly. In the end, I couldn’t say no. Her diligence in knowing her health issues made it clear that her heart was an innocent bystander to the hyperactive thyroid. Once the thyroid was in control, her heart followed suit. Once I agreed to continue caring for her, she quickly became pregnant. Glaringly different than her first 2 pregnancies, this one went smooth as silk. She birthed a full term, healthy girl and had no health issues during the pregnancy. I will never forget my tough, resilient, never-give-up patient.

Andrea Eisenberg is a obstetrician-gynecologist who blogs at Secret Life of an OB/GYN.

Image credit: Shutterstock.com

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