http://www.medscape.com/viewarticle/410628
Secondary Abdominal Pregnancy in a Jehovah's Witness
Howard A. Shaw, MD, Emeka Ezenwa, MD, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center-Tulsa.
South Med J 93(9):898-900, 2000. © 2000 Southern Medical Association
Abstract and Introduction
Abstract
A 35-year-old woman, gravida 2, para 1, aborta 0, arrived at our emergency department with abdominal pain of more than 2 weeks' duration. Diagnostic pelvic ultrasonography confirmed a 16-week intra-abdominal pregnancy. Hemoglobin level was 6.9 mg/dL, and hematocrit value was 20.1%. The patient refused blood transfusion on religious grounds. Laparotomy revealed 2,000 mL of blood in the abdomen and a live fetus, with the placenta attached to the omentum and the serosal surface of the right fallopian tube. Postoperative hemoglobin level was 2.8 mg/dL. The patient was transferred to another facility for hyperbaric oxygen therapy, where she subsequently died. Abdominal pregnancy is rare, but has high fetal and maternal mortality rates. Our patient's case was complicated, since she was a Jehovah's Witness and refused lifesaving treatment on religious grounds. Serious medical decisions were made, while respecting the autonomy of the patient.
Introduction
Abdominal pregnancy is rare but is associated with high fetal and maternal mortality rates. In the United States, there are 10.8 abdominal pregnancies per 100,000 births and 9.2 abdominal pregnancies per 1,000 ectopic gestations. The risk of dying of abdominal pregnancy is 90 times greater than with an intrauterine pregnancy. [1] The overall maternal mortality rate associated with abdominal pregnancy is estimated at 0.5% to 8%. [2,3] Our case was further complicated by the patient's right to refuse lifesaving treatment on religious grounds. It also reinforces the importance of early diagnosis and treatment of ectopic pregnancy and early prenatal care. [4,5]Case Report
A 35-year-old woman, gravida 2, para 1, aborta 0, came to the emergency department with a last menstrual period having occurred 14 weeks previously. She complained of abdominal pain for more than 2 weeks that was acutely worse on the day of hospital admission. She had become acutely ill hours before, with dizziness and cold sweats. No vaginal bleeding, fever, chills, or urinary tract infection symptoms were present. Physical examination revealed an ill-appearing woman in severe distress. She was alert and oriented. She was pale, with cold, clammy extremities. Blood pressure was 89/51 mm Hg; pulse rate was 114/min. Orthostatic hypotension was observed. The abdomen was distended, with rebound tenderness and guarding.
The quantitative b-human chorionic gonadotropin level was 33,264 mIU. The hemoglobin and hematocrit levels were 6.9 mg/dL and 20.1%, respectively. Urine specific gravity was 1.030 with large ketones and moderate leukocytes. Vaginal probe ultrasonography was done because of the patient's severe pain. It revealed an intra-abdominal, live fetus at 16 weeks' gestation and a large amount of free fluid in the peritoneal cavity. Fetal cardiac activity was noted by ultrasonography. No intrauterine gestational sac was seen, and the placenta appeared to be attached to the pelvic cul de sac.
Rapid fluid resuscitation and face-mask oxygen therapy were administered. The patient and her husband (both Jehovah's Witnesses) declined blood transfusion on religious grounds. Operative reinfusion was considered, but both the patient and her husband refused this modality. Perfluorocarbons were also considered but were unavailable in our city. Exploratory laparotomy revealed more than 2,000 mL of blood with clots, a live fetus, and disrupted right tube and placenta attached to the omentum. Partial omentectomy and right salpingo-oophorectomy were done. Adequate hemostasis was observed with minimal intraoperative blood loss. Hetastarch colloid fluid replacement and epoetin alfa recombinant therapy were administered during surgery. The patient remained relatively hemodynamically stable throughout the procedure. The postoperative hemoglobin level was 2.8 mg/dL.
Four hours after surgery, the patient's sensorium began to decline. A diagnosis of early hypoxic encephalopathy was made. This diagnosis was explained to the patient's husband. He was asked to authorize blood transfusion in view of an advanced directive obtained earlier. The husband adamantly declined to authorize blood transfusion. Obtaining a court order for a blood transfusion was considered; however, after discussion with the hospital ethics committee, this was believed to be unethical.
The patient was then transferred to another facility for hyperbaric oxygen therapy. She was declared brain-dead on the third postoperative day, and life support was discontinued.
Discussion
There are many case reports of exsanguination in Jehovah's Witnesses after ectopic pregnancies, vaginal delivery, and other surgical procedures. [6-8] Blood transfusion has been doctrinally forbidden for Jehovah's Witnesses since 1945. [9] This prohibition against transfusion is derived from the Bible's Old Testament:
And whatsoever man there be among you, that eateth any manner of blood: I will even set my face against that soul that eateth blood, and will cut him off from among his people. (Leviticus 17:10-14).
A Jehovah's Witness who accepts blood transfusion risks "disfellowshipping" (excommunication) from the community, loss of eternal life in God's new world, and shunning by family and friends. A Witness who has had a transfusion by court order may be mitigated by the degree transfusion was resisted. [10]
With the increasing number of Jehovah's Witnesses in the United States (more than a half million), provision of quality health care is a growing challenge to physicians. Most Jehovah's Witnesses care deeply about their health but decline blood transfusion solely on religious grounds. They accept and are usually compliant with other forms of medical therapy that do not include blood products or transfusion. [11] Elective major surgical procedures have increasingly been done on patients declining the use of blood products without significant disadvantage, including cardiovascular and orthopedic procedures. [8,12]
Under planned conditions, surgical skill becomes the most significant factor in the success of any major surgery since blood loss is kept to a minimum. In an emergency with massive, acute blood loss, the Jehovah's Witness has a poor chance of survival in the absence of autotransfusion unless timely hemostasis is secured. Presently, there is no accepted lower limit of hematocrit considered life-threatening. However, when our patient refused blood transfusion, her chances of survival decreased significantly.
Jehovah's Witnesses believe that blood removed from the body should be disposed of; therefore, they do not generally accept autotransfusion of previously deposited blood. They have strong religious convictions against accepting homologous or autologous whole blood, packed red blood cells, white blood cells, or platelets. Techniques for intraoperative collection or hemodilution that involve blood storage may also be objectionable to them. Many will allow the use of (non-blood-primed) heart-lung, dialysis, or similar equipment if the extracorporeal circulation is uninterrupted. However, Jehovah's Witnesses' religious understanding does not absolutely prohibit the use of albumin, immune globulins, and hemophiliac preparations; each Witness must decide individually whether to accept these. Other non-blood replacement fluids are acceptable. The Witnesses do not believe that the Bible comments directly on organ transplantation; hence, decisions regarding cornea, kidney, or other tissue transplants must be made by the individual. Physicians should consult with such patients to ascertain what each individual's conscience dictates. [13]
Most Jehovah's Witnesses are willing to sign the "Against Medical Advice" form. This form may relieve hospitals and physicians of liability resulting from Jehovah's Witnesses' refusal to accept blood products. This does not release the physician from respecting a patient's autonomy. Intraoperative transfusion was considered in our patient's case but was rejected by the attending physician as unethical. The courts (with exception of some cases involving minor children) have consistently upheld the right of competent adults to refuse lifesaving medical treatment. [14] The principles of management of hemorrhagic shock demand an attempt to stop further blood loss while replacing volume. The treatment then becomes an ethical dilemma for a physician, in which he disagrees with another's value system. This then prevents the physician from doing what he thinks is right and possibly saving life.
The patient's bill of rights places emphasis on informed consent. Our patient was considered to be competent to give informed consent until she became incapacitated. She had signed an advanced directive giving her husband the right to speak for her if and when she became incapacitated. When she refused transfusion, her physicians were faced with an ethical dilemma, based on the ethical principles of the Hippocratic Oath and autonomy. Do we do what we believe is in the best interest of the patient (transfuse), or do we abide by the patient's wishes (autonomy)? Her physicians, as well as the hospital ethics committee, believed that autonomy was the overriding ethical principle.
Most abdominal pregnancies arise due to a partial rupture of a tubal pregnancy. [1,4] The occurrence of a primary peritoneal implantation has been reported but remains controversial. [15] In 1942, Studdiford [16] set the criteria for diagnosis of a primary abdominal pregnancy. These include: (1) normal tubes and ovaries bilaterally, with no evidence of recent or remote injury; (2) absence of any evidence of a uteroperitoneal fistula; and (3) presence of a pregnancy related exclusively to the peritoneal surface and early enough to eliminate the possibility of implantation after a primary nidation in the tube. Our patient had a disrupted right tube consistent with secondary abdominal pregnancy. Therefore, opportunity for earlier diagnosis and treatment was missed due to lack of prenatal care and more than 2 weeks' delay in reporting the initial symptom of abdominal pain.
Abdominal pregnancy is a rare but life-threatening emergency. Timely treatment of ectopic pregnancies will reduce the incidence of secondary abdominal pregnancies and life-threatening anemia. This is even more important in the Jehovah's Witness. Management of our patient's case was complicated by refusal of lifesaving treatment on religious grounds. As physicians, we should be aware of the ethical dilemma that treating Jehovah's Witnesses presents. By using our hospital ethics committees, forethought, and planning, the conflict may not end in a decision made by the courts, but may be resolved as it should be, between patient and physician. [17]
Read before the Section on Obstetrics and Gynecology, 93rd Annual Scientific Assembly, Southern Medical Association, Dallas, Tex, November 10-14, 1999.
References
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- Immovable for the right worship. The Watchtower 1945; 66:195
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- Questions from readers. "What, however, about accepting serum injections to fight against disease, such as are employed for diphtheria, tetanus, viral hepatitis, rabies, hemophilia and Rh incompatibility"? The Watchtower 1978; 99:29-31
- Bouria v Superior Court. 179 Cal App 3d 1127, 225 Cal Report 297, 1986
- Dover RW, Powell MC: Management of a primary abdominal pregnancy. Am J Obstet Gynecol 1995; 172:1603-1604
- Studdiford WE: Primary peritoneal pregnancy. Am J Obstet Gynecol 1942; 44:487-491
- Sacks DA, Koppes JD: Caring for the female Jehovah's Witness: balancing medicine, ethics, and the first amendment. Am J Obstet Gynecol 1994; 170:452-455