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Friday, November 16, 2012

Cynical me

The Anchoress has a sympathetic nuanced take on a recent maternal death in Ireland that is cynically being used to push legalized abortion.

FYI: The treatment of premature ruptured membranes is usually watchful waiting.

But my question: Why so much back pain? Was she in labor? If so, you don't remove the child, you let her deliver it.

Renal infection? Then why no antibiotics?

And why did the family start insisting early in the case to abort the child? Because she had "back pain"? Nonsense. the treatment of back pain is pain medicine.

My cynical take: She did a self abortion but the docs missed it...wonder if they found the catheter at the autopsy. We saw many cases similar to this before Roe V Wade.

Alternative scenerio: her husband beat her, causing abruptio placenta (which unlike ordinary premature ruptured membranes is painful). And that might also have caused her back pain.

Or maybe the husband's story is indeed true, but as a doc it doesn't make sense for her to have so much back pain and insist that the child be aborted ...several days BEFORE the infection began.



related link: AAFP article on how to care for premature rupture of the membranes:
BEFORE 24 WEEKS
The majority of patients will deliver within one week when preterm PROM occurs before 24 weeks’ gestation, with an average latency period of six days.15 Many infants who are delivered after previable rupture of the fetal membranes suffer from numerous long-term problems including chronic lung disease, developmental and neurologic abnormalities, hydrocephalus, and cerebral palsy. Previable rupture of membranes also can lead to Potter’s syndrome, which results in pressure deformities of the limbs and face and pulmonary hypoplasia. The incidence of this syndrome is related to the gestational age at which rupture occurs and to the level of oligohydramnios. Fifty percent of infants with rupture at 19 weeks’ gestation or earlier are affected by Potter’s syndrome, whereas 25 percent born at 22 weeks’ and 10 percent after 26 weeks’ gestation are affected.32 Patients should be counseled about the outcomes and benefits and risks of expectant management, which may not continue long enough to deliver a baby that will survive normally.
Physicians caring for patients with preterm PROM before viability may wish to obtain consultation with a perinatologist or neonatologist. Such patients, if they are stable, may benefit from transport to a tertiary facility. Home management of patients with preterm PROM is controversial. A study33 of patients with preterm PROM randomized to home versus hospital management revealed that only 18 percent of patients met criteria for safe home management. Bed rest at home before viability (i.e., approximately 24 weeks’ gestation) may be acceptable for patients without evidence of infection or active labor, although they must receive precise education about symptoms of infection and preterm labor, and physicians should consider consultation with experts familiar with home management of preterm PROM. Consider readmission to the hospital for these patients after 24 weeks’ gestation to allow for close fetal and maternal monitoring.

summary:


so why the back pain?????

and why, if this was a "wanted pregnancy", did both she and her husband (at least that is the husband's story) insist the doctors remove/abort their wanted child? Most mothers would have been more desperate to save their baby, not to kill it, if it had a chance for life. Which is why I am cynical that there is probably a lot more to the story than is being reported.

But here, according to the husband's story, they both wanted the child to be aborted, even though it was not medically indicated.

Why? Because mom was having "back pain"? That is not a medical indication for inducing labor...and why was their first impulse to insist the doctors abort the child, not try to save it?

I should add that to remove the child by a hysterotomy (Caesarian section) is risky to the mom: If there is an infection, it spread the infection to her if you do a caesarian section. But removing it from below often means dismembering the child, since the bones are formed by 17 weeks. And complications of this include perforation of the uterus (either by instruments or by stiff fetal parts punching a hole in the uterus), and cervical trauma (resulting in all later pregnancies miscarrying from incompetent cervix.)

Even with a dead fetus, we prefer to let it deliver spontaneously for these reasons.

Indeed, one could argue that the reason for the death was the Caesarian section of a now infected uterus spreading the infection through her body. Why didn't they induce labor instead? Presumably they tried, but it failed.

In other words, there is a lot more to the story than is being reported...

-------------------------
I'm still thinking about what was causing the severe back pain in this woman, (the story insists the family wanted a second trimester abortion not because they wanted to kill  their child, but because of her severe pain).
so what causes severe back pain in the second trimester?

Contractions? But Premature rupture of the membranes is usually painless.

Kidney infection? Then she should have been on antibiotics and treated for this (a common cause of premature labor). Kidney stones? severe pain, but on and off suggests the problem.

An ovarian cyst, maybe one that ruptured or was bleeding? I've seen these missed quite a bit, and another problem could have been a twisted ovarian cyst. If so, it would have been found at exploratory surgery, and maybe the docs were hesitant to operate (again malpractice).

Another cause could have been a ruptured appendix, missed because the appendix moves upward with the growing uterus. Again, malpractice for missing it.

One problem is not that docs refused to do an abortion but that they refused to do exploratory surgery. I've seen all of these problems, so they can't be that rare.

Doing an abortion was not medically indicated (maybe socially desired, but that's another problem)

All I can figure out is that the doctors missed what was causing the pain, the cause of the pain caused the threatened miscarriage, and the sepsis was either from the cause of the pain or from the prolonged ruptured membranes.


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