Snapshot: Handling Complications of High-Risk Pregnancy

Wednesday, 11:15 a.m.*

We are on 6 South; I’m hunched over a computer at the nursing station.

I spent the early morning coordinating care for our postpartum patient in the intensive care unit (ICU), so now I’m desperately trying to catch up on the rest of my inpatient notes from the morning. The fellow gets a call for an immediate maternal fetal medicine consult.

I hear her murmur, “29 weeks, spotting. How bad does the tracing look?” Without turning around, I open up the central fetal heart-rate monitor on the computer and look in triage. I don’t have to be told who it is; Bed A has a fetal heart-rate tracing that is too fast at 180 beats per minute, flat and with two ominous-looking drops in the rate, although it looks as though the patient has been in the bed less than ten minutes.

“Tell them to get steroids now. Grab the ultrasound, and I’ll meet you there.” We run over.

We hustle into the room, and I start talking. I say “I don’t want to scare you, but we’re going to swarm you a bit because your baby doesn’t look that great. A lot of people here, and it might feel frightening, but we’re here trying to take care of you and your baby.”

I’m talking while an IV gets placed, labs are sent off, oxygen is put on her face to help the baby; she’s rolled on her side to help the fetal blood supply. The patient is scared but a trooper; she speaks English with a bit of a Jamaican lilt.

She’s able to tell us that she started spotting yesterday, and now has more bleeding, although it seems to have slowed down since she called the ambulance. No trauma, no car accidents, she denies drugs—no real reason that explains what’s going on. All her care was at a different hospital, so we have no records, but she’s able to tell us that she was never told she has a placenta previa or any other condition that could cause bleeding.

This is her third baby; the first two were full term and had no issues. She has no medical problems, no surgeries, no medications, no allergies. Her blood pressure today is normal. We look below, quickly, with a speculum: for now, no active bleeding.

While we talk, we move her to labor and delivery. We make the neonatal ICU aware. There’s an anesthesiologist in the room, evaluating her airway. I take her off the monitor to scan her. There’s a fetus, there’s normal amniotic fluid, the measurements indicate a reasonable size for the gestational age. There’s a placenta. It’s not a previa, it’s on her left side and fundal—at the top of the uterus—but with a black area behind it. Is that a clot? It looks like a clot behind the placenta, an abruption—a premature separation of the placenta from the wall of the uterus. You usually don’t see these on ultrasound unless they’re really big.

I put the monitor back on. The fetus looks . . . okay. Still too fast a heart rate, still not great, but okay. I talk to the patient. I say: “I don’t want to have to deliver you, but I may have to.” I take this moment that we have to talk about an abruption, to talk about delivery. I talk about the prematurity of the baby, and say we will try to get a full course of steroids on board to help the baby’s lungs and brain and other parts, but that we need 24 to 48 hours to be able to do that.

I talk about C-section and its risks and benefits. I am very clear that I will do this only if there’s no other way, because of the prematurity, but that we are very close to having no other way. She asks her questions, nods and signs a consent form held by a waiting resident.

While doing the ultrasound, I get paged about a postpartum patient in the ICU. They need someone to evaluate her incision urgently, and I tell them I’ll be right down. While I’m returning the call, the resident manages to get some information from the other hospital, confirming the patient’s history and pregnancy dates.

I talk to the generalist OB/GYN attendings who are staffing the labor floor: “Here’s the plan. Let’s get labs back to make sure she’s safe to deliver, that this is not severe pre-eclampsia, and that she has enough clotting factor to make surgery safe. While we do, give her IV fluids and oxygen, to try to get the baby looking better. I will come back in twenty minutes. If it looks better, we’ll reassess. It would be nice if we could hold off for a few days, given her prematurity. If it looks worse, then you know what to do. Be ready for large-volume blood loss because of the abruption.”

I run downstairs to the ICU. Nine minutes later, I get paged. “Fetal heart tracing not good. Platelets back, normal.” I call them back: “If you gotta go, go.”

By the time I get back upstairs, they are in the operating room, operating. There is blood in the uterus, consistent with a large abruption. The baby is handed to pediatricians and is intubated, but looks pretty good. The placenta goes to pathology. The surgery is otherwise uncomplicated.

Eventually the patient comes out of the operating room and goes to the post-anesthesia care unit. I talk to her briefly about what happened, but she is still overwhelmed and not able to talk yet; I’ll come back in an hour or so. I hope her family will be here by then.

I head back to 6 South, to try to catch up on my notes from the morning.

 *All identifying details have been changed.