When Obstetrics becomes critical
The ethical fundamental rule in Medical Care is “First do no harm”. Second, is “DO good.” In the oldest human professional role, helping women to safely deliver their babies, we know that the first command is to save the mother, and then, IF POSSIBLE, save the baby.
Miscarriages occur in 20% of pregnancies, perhaps more. When they occur in the first 3 months, where there is a growing embryo, we understand that this is a life which cannot exist outside the womb. It cannot successfully be taken and planted elsewhere, like a good petunia! The development of the placenta is a complicated thing, and it carefully develops into an amazing life-support to the growing embryo, which then grows into a fetus, and at birth becomes a baby. In mid-pregnancy, the risk of miscarriages is often accompanied by life-threatening hemorrhage, because placental disruption is not complete, it remains partly attached and the blood vessels which were feeding it continue helplessly pouring blood into the open space in the womb. As the wall of the uterus continues to bleed, sometimes huge amounts of blood can be lost in a very little time. This is an obstetric emergency, and the uterus must be safely and completely evacuated so it can clamp down on the bleeding blood vessels. In centuries past, this was the most common reason for the death of a woman: an incomplete delivery of the placenta. Sometimes the bleeding slows, and it seems things will be ok. But if there is still placental tissue in the uterus, it still will intermittently bleed, and it also keeps the uterus from shrinking down to its normal size, with a tightly closed cervix. This puts the woman’s body at severe risk of life-threatening infection, (which used to be called Puerperal fever) and is now called Septic shock; and the mother must be given critical support of extra fluids, sometimes also transfusions of blood, and antibiotics to help control the infection. She may need to be in the ICU and need every kind of critical care support we can give. If she has lost a lot of blood before the antibiotics are given, it is harder for her body to muster the immune support to be able to overcome the infection, and she is at high-risk until the fever starts to subside and she begins to heal.
What has happened since the SCOTUS decision to reverse the national right to abortion and give the states power to enforce new draconian laws is very terrifying to those of us who are FIRST concerned with the life of the mother.
Reports are already coming out that in some places the hospital administration and sometimes medical staff are confused about our ancient mandate to take care FIRST of the mother, and then if possible, save the baby. If there is a heartbeat in an embryo or fetus, it still is not viable until it can live without the placenta, outside the mother. It is a miscarriage, and must be dealt with appropriately. God knows that this fetus is not salvageable. At some time in the future, we may have truly extracorporeal placentae, which will change the potential to save some fetuses, so we are not at the end of medical change and innovation which will help us have more choices. But right now, the baby’s heartbeat doesn’t matter, when this kind of miscarriage starts to occur.
We need to be prompt and clear about medical emergencies. An ectopic pregnancy is a pregnancy outside the womb, usually in the fallopian tube. The placenta cannot grow there, the wall is too thin. The mother is at risk of bleeding to death into the abdomen, if it bursts the tube and begins to bleed. It doesn’t matter if the embryo has a heartbeat, we cannot take this embryo like a little petunia, and put it safely into either a real uterus or an artificial one (yet) because of the delicacy and intricacy of how the placenta develops IN TANDEM with the wall of the uterus, which is going to work to pass food and oxygen to the developing embryo or fetus.
I am having nightmares about misguided protocols and delays in treatment of pregnant women having ectopic pregnancies or midtrimester (12-24 week) miscarriages. We need to make it crystal clear that the right thing to do before 24 weeks, is end the pregnancy by evacuating the uterus, so it can heal. There are some patients very close to 24 weeks with whom we can temporize and try to achieve enough time to strengthen the fetal lungs, to give it the chance that it may be able to live in the NICU for 3-4 months, and go home and grow up. BUT if the mother begins to have signs of infection she is at very high risk of Septic Shock, or Puerperal fever, and the answer is to empty the uterus regardless of the baby’s heartbeat. When this kind of tragic loss happens, we wrap the baby in swaddling blankets and let it be with the mother and father, until they are ready to say goodbye.
Thanks for listening to me on my soapbox!