Op-Med is a collection of original articles contributed by Doximity members.
Missed abortion. Threatened abortion. Incomplete abortion. Spontaneous abortion. Septic abortion. Inevitable abortion. These are medical terms for the failure or potential failure of a pregnancy. Rather than the generic term “miscarriage,” these “abortion” terms also more accurately describe the physical process that is happening.
Voluntary termination of pregnancy. Voluntary interruption of pregnancy. These are the medical terms for what the layperson thinks of as an “abortion.”
Yet, 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 to each other. However, in the mainstream, these terms are laced with moral and ethical judgement, bias, and misinterpretation.
As an obstetrician, I have to take care of two patients at once: the mother and the baby. Sometimes their needs are very different, so different that one may need to sacrifice the other to survive. These choices, deciding to continue a pregnancy or not, are never black and white, but they generally carry layers of possibilities and outcomes. And the options are not between good and bad, but between worse and less worse, leaving the patient to live with the consequences of either decision.
Let me walk you through one of those stories.
She was fairly young, early 20s, newly pregnant and excited about her family growing. At her first appointment, I spoke with her and her husband and did an ultrasound. We saw the baby, all one centimeter of it, and began the journey of a “normal” pregnancy. A bright, well educated woman, she came to her appointments with few complaints, few questions, really just enjoying the ride. At about 16 weeks, we did a genetic screening test (a blood test) that includes something called AFP, which if elevated can indicate there is a fetal abnormality. Unfortunately, her test result was elevated; so after calling her, I had her set up an ultrasound at the hospital. She did not seem particularly alarmed; I thought she couldn’t entertain the idea that something could be wrong with her baby.
Never a good sign, the specialist at the hospital called 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 do an amniocentesis and obtain fluid from around the baby to determine its chromosomes. If there is also a chromosomal abnormality, there may be more significant issues with the baby than just the cystic growth. Unfortunately, cystic hygromas can continue to grow during the pregnancy and cause many complications to both the baby and the mother.
Obviously, my patient was heartbroken. Her usually cheery, easy going demeanor was now in a state of shock. How do you process this, especially when there is still so much unknown? By this time, she was nearly 18 weeks, and the results of the amnio would take 2 weeks. She was starting to feel fluttering, maybe a slight kick, a reminder of the love she was growing inside of her, except it was not the perfect baby she had expected. It was a long two weeks for her, awaiting the amnio results. When the results came back, the hospital called her before me….. the chromosomes are abnormal. They recommended that she come in for a group meeting with several specialists to help her understand the consequences of her diagnosis if the pregnancy was carried to term, and if it was terminated. I, unfortunately, could not attend the meeting but was informed of the details afterwards.
I called my patient a few hours after the meeting and we arranged an appointment the next day. She came by herself, eyes puffy with lack of sleep and crying. She sat down, looked straight at me, and said, “ I need someone to tell me what to do.” I could feel my own tears forming. I knew the prognosis of this baby surviving was essentially zero. How could I tell her this when the baby was very much alive in her now? Unfortunately, she was running out of time to make a decision. If she wanted a termination, there are the legal issues of how late in a pregnancy she can terminate, and this deadline was only about one week away. And she needed to address the growing danger for her… because the size of the cystic hygroma was getting larger, making the delivery all that more risky, including possible complications to her body and future ability to have children. We talked for quite a while about what it meant for her to terminate the pregnancy versus letting nature take its course, as well as the consequences to her body either way.
In my heart, I wanted to protect her. She was my patient and I didn’t want her harmed in any way. I didn’t know the baby, I didn’t have a relationship with the baby, my relationship was with mom. All I could see was that this pregnancy, if continued, could only harm her more, possibly to the point where she lost the ability to have more children or even her life. I knew this baby couldn’t survive, but there was no telling when it would die. And so, heavy hearted, I told her what I thought, “From all that we know, the abnormal chromosomes and the cystic hygroma, this baby will not survive. You need to consider the harm that may come to you continuing this pregnancy and seriously consider terminating this pregnancy.” She began sobbing. Once she was able to settle herself, she looked at me again and with a calm voice said, “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 scheduled the termination. Because it was such a high-risk situation, she had 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 was the week of Christmas, and it pained 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 for a woman, at any stage, whether a voluntary decision or one that Mother Nature makes, is never easy, is never clear, and never taken lightly.
Andrea Eisenberg, MD, has been an obstetrician/gynecologist in the Metro Detroit area for nearly 25 years. Through her years in women’s health, she’s shared in countless intimate moments of her patients, their joys, heartaches, losses and victories. On her blog, www.secretlifeofobgyn.wordpress.com, she captures the human side of medicine and what doctors think and feel in caring for patients. She has contributed to Intima, A Journal of Narrative Medicine and Pulse, Voices From the Heart of Medicine. Andrea is also a guest rotating blogger on KevinMD.