She entered my outpatient clinic rather abruptly and plonked in the chair in front of me. I gazed at her. She was grossly obese and obviously pregnant; what also caught my attention was her expression of bitter anger, rather poorly concealed.
A BMI of above 30 and a complicated pregnancy, my senses whispered to me. A few seconds later the door opened again and her case file appeared, wheeled in a trolley by the porter. It was in three huge volumes bound separately, akin to some tome... Clearly the porter couldn't carry it in her arms. It’s going to take some time assimilating it.
“You can have a cup of coffee from the eatery in the corridor while I finish reading it,” I suggested to her.
She left the room before I even completed my sentence. With trepidation I started studying the file and jotted down the summary.
She has had five Caesarian sections before, is diabetic, hypertensive, there is suspected cardiomyopathy and she is non-compliant. She is currently six months running with placenta previa increta (afterbirth covering the mouth of the womb), which was morbidly adherent to the musculature of the womb on account of her previous surgeries.
By the time she had returned I had completed the case summary and written down the admission slip.
“You will have to remain in hospital for the remainder of your pregnancy,” I told her after examining her and explaining her condition in detail to her. She listened to me with irritated impatience, occasionally yelling to her children playing outside.
“I will think of getting admitted after one week,” she snapped and got up.
“Your life is in danger,” I retorted.
“Will you look after my kids when I stay in hospital?” was her parting shot before slamming the door shut.
A good part of one hour was spent on her and the rest of my patients were waiting outside. I had no time to reflect on her intransigence.
Two weeks later, she got herself admitted in hospital. The next few days was a battle to get her to listen, comply with her treatment schedule and get her co-morbid medical conditions under reasonable control. Beyond that, her severe obstetric condition and its possible outcomes were a source of considerable worry and caused sleepless nights for our entire team. Her presence in the hospital was like a ticking time bomb, which had the propensity to explode any time.
“Your life is in danger. You will need a hysterectomy during the Caesarian to save your life. We need a consent for that,” we explained as gently as possible.
“I know that. But I’ll never give consent,” was her blunt answer. Endless discussions at clinical meetings ensued. Her husband was called in for a combined counselling session. At the end of the discussion he said: “All you eminent doctors, please do what you consider is best for her health. But a woman without a womb, ceases to be a woman!” His wife listened passively, resigned to her fate. I raged inwardly but chose to remain silent. Slowly and sadly I started gaining insights into the turmoil within her.
She never budged from her position. However the clinical decision was taken to proceed for hysterectomy as a life-saving measure if required even without consent during surgery.
A few weeks later I recall being called for her as she had started hemorrhaging. She was in the eighth month of pregnancy. By the time I reached hospital she was prepared and getting wheeled into the operating room.
I held her clammy hand, watching her increasing pallor and racing pulse, outward signs of the massive bleeding that had started.
“Doctor, can you leave me to die if you were to remove my womb?” she asked helplessly. I evaded a direct answer and replied: “Think of the happiness of having a new baby beside you tomorrow.” I could see the trickle of blood quickly becoming a pool and staining the white sheet beneath her.
On opening her we found the placenta covered with a bluish, engorged, tortuous network of blood vessels infiltrating and protruding through the entire thickness of her womb amidst torrential hemorrhage. The pathological process had already damaged the womb beyond repair. The baby came out wailing joyously but the womb, the source of life-threatening hemorrhage, had to be removed, and quickly too.
The next four to five hours was a frenzied, bloody war zone to retain her life where the entire perspiring team, including anesthesiologists, hematologists and the obstetric team, battled it out to save her as bottle after bottle of blood, plasma, platelets and cryoprecipitate poured into her system to combat the loss that had incurred. With her womb removed, the bleeding abated but she remained critical postoperatively, maintained on inotropic agents to sustain her blood pressure and other vital parameters.
Slowly but surely she started recovering in the ICU. On regaining consciousness, she knew the inevitable. She was without her most prized possession... the one she valued more than her life. During my constant vigil around her, I never once saw her husband visiting her until she was discharged... probably she had ceased to exist for him.
When she was leaving for home she whispered to me. “You have taken good care of me doctor, but I don’t know how I will live again.”
“You will surely live and you will learn to be happy and independent,” I responded rather optimistically.
More than six months later one fine day she barged into my room. Gone was the expression of hatred, anger and bitterness. She was in fact smiling profusely.
After exchanging pleasantries she said: “Doctor, I have learnt to live for myself and my children. My husband has left me, and I now realise that he does not deserve me. And I am so happy I don't have to be pregnant again. I have discovered myself.”
Somewhere in my mind I remembered a quote I had read before: “How wrong is it for a woman to expect the man to build the world she wants, rather than to create it herself?”
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