Chapter 10: Harsh Realities

Sunday afternoon, the three of them were again in Barry's office. To distract himself from the tension in the air, Wilson looked around and noted that the lists had been erased from the white board. Barry was shuffling papers, and House was staring intently at the floor.

Finally, Barry broke the silence. "I just wanted to make sure that we had really discussed the risks before we move forward. I've been spending the past day looking through the literature, looking at the case studies where abdominal ectopic pregnancies have been allowed to continue to term. The numbers don't look good." He picked up one of the papers on his desk. "According to Cohen, for an abdominal pregnancy, the maternal mortality rate is somewhere between 6-14%, and the fetal mortality rate is 90%." He picked up another paper. "One thing that seems to be a significant positive factor in most of the cases that have gone successfully to term is placential location on the uterus. Obviously, this is not a possibility here." He paused, before continuing, "I have no way of estimating the risks to you, but I can estimate that they would be higher than those tabulated by Cohen. I wouldn't even consider going through with this if you weren't both doctors."

Wilson could see that House was gripping his cane so tightly that his knuckles were turning white.

Barry looked up and then gave the bleak news. "I would say that there is less than a one percent chance of the fetus surviving to delivery." He waited until House looked up and met his eyes, and then he continued. "Unlike most pregnancies, where the biggest risk of losing the baby occurs in the first trimester, the risks will continue to increase as the fetus gets bigger. If there is insufficient blood supply to the baby as it grows, the fetus will die, and there may be no way of predicting when this could occur. The biggest risk is that the placenta could pull away from wherever it is attached, causing massive blood loss, and the baby could be lost and if there is no timely medical intervention, you could bleed out."

Barry grabbed another paper that was lying on his desk. "We can minimize these risks by delivering the baby at 34 weeks, but the odds are against sustaining this pregnancy even that long. If we do get to that point, the surgery itself will be dangerous, and there is a very real possibility that you could bleed out on the table."

He paused to let his words sink in. "The body is not designed to carry a fetus outside of the uterus. Your abdominal muscles will be taking up most of the work usually done by the uterus. You've probably read about all of the normal aches and pains associated with pregnancy. I can almost guarantee that for you, it will be worse. You are forty-six years old and clearly not in the best of shape. Pregnancy is hard on the body, even for someone who is young and perfectly healthy." He set the papers aside, and then looked up. His next words were kind. "Are you sure that you want to go through with this?"

House finally nodded, and then found his voice, "Yes."

"James?"

Wilson nodded as well.

"If I am going to be involved with this, I have two conditions, and they aren't up for negotiation. I know that both of you are doctors, and leaders in your respective fields, but pregnancy is my specialty. This is an extremely high-risk pregnancy, and there will be a time when bed rest will become necessary, if you manage to make it to that point. I need to know that you will not fight me when the time comes. The other condition is that you need to be completely honest with me. I need to know everything: every ache, pain, or funny feeling. I don't care how insignificant you think it is, you need to tell me. If I find that you have been hiding something from me, I will walk. Do we have a deal?"

When both nodded their agreement, he continued, "If you are sure, then we need to do everything to give this pregnancy the best chance for a good outcome. The most important thing is that I think we should have another OB on board, just for backup. I also think that we should have a couple of anesthesiologists briefed as well. If you start to hemorrhage and surgery is necessary, I don't want to spend precious time explaining the situation."

"Who do you suggest?" asked Wilson.

"Janet Larson. She's a great surgeon. She's a bit of a renegade; she frequently takes on cases that other doctors wouldn't touch because they consider them too risky. I think this is probably just up her alley. As for anesthesiologists, I'd suggest Richard Johnson and Jason Morgan. Both are top in their field, and both know how to be discrete."

House nodded. "Let's try and set up a meeting with them soon."

Finally they were down to the standard questions Barry would ask any patient, including family history of the standard diseases—cancer, diabetes, heart disease, high blood pressure, and stroke. It was when he reached blood clots, that another warning flag popped up. "Any family history of blood clots?"

"Six years ago." House answered, gesturing to his right thigh.

Barry listened in shock as House tersely explained the events that had lead to the removal of most of his thigh muscle. "You naturally have a higher risk of developing a clot, and pregnancy will increase that risk."

"Is there anything that can be done?" asked Wilson.

"Unfortunately, no. Blood thinners are too risky given the risk of hemorrhage in an abdominal pregnancy. You just need to be aware of the risk, and if there are any symptoms, to check them out immediately." Now that the family history portion was over, he moved on to the other questions. "How's your weight?"

"Lost nine pounds because I have been puking for 2 months straight."

Barry nodded. It wasn't a good sign, but not completely unheard of. He wrote out a prescription for Bendectin. "This won't completely eliminate the nausea, but hopefully will keep it so that you don't throw up. And hopefully the nausea will start to taper off in a few weeks. We'll need to monitor your weight pretty closely for a while. Pre-natal vitamins?" He looked up, and then answered his own question, "not exactly a planned pregnancy." He handed over another prescription. "Take these for the rest of the pregnancy, and try to eat as healthy as possible. I have several pamphlets that explain what you should and should not be eating." Now for the question he was dreading, given House's reputation. "Medications?"

"Vicodin for pain," House replied curtly.

Barry nodded. "Anything else?"

Surprisingly, it was Wilson that answered. "Nothing." At House's startled look, he elaborated, "I ran a tox screen because Cuddy was afraid you were doing cocaine or something because you had gotten so thin."

"Vicodin is a class C drug, so it is not considered safe for pregnancy, but there's no studies on how exactly Vicodin affects fetal development in humans. Some animal studies have shown adverse effects. Typically, the safest recommendation is to avoid this sort of medication, but on the other hand, massive pain has physiological effects on you, which in turn can adversely affect the baby. Withdrawal can also cause adverse effects. I would like you to cut down, as much as possible, and probably switch to other drugs that will have less of an effect on the baby. We need to talk with Richard about a new pain management regimen."

House nodded; Barry's request was reasonable.

"Do you have any questions?"

House shook his head, and Wilson was looking a little shell-shocked.

Barry smiled. "I know we have covered a lot today. Don't worry, that's par for the course. Here's my home number. Call me if you have any questions or if you think that something is wrong. I will let you know when I have arranged things with the other doctors. Because of the nature of this pregnancy, I would like to see you weekly. Seeing you up here in the OB/GYN clinic would eventually arouse some suspicion. Any thoughts of where we can meet?"

"I have a key to the downstairs clinic," Wilson suggested. "We could meet there as long as it is after the clinic is closed. We only have to worry if Dr. Cuddy is working late in her office."

"Wednesdays at 7 PM?" Barry suggested, and the other two men agreed.

TBC

Author's note: All of the numbers and information about standard abdominal ectopic pregnancies can be found in the following references. Of couse, Barry's estimates to the chance of House's baby surviving are my own invention, but plausible given the acutal info. Here are the references:

R. Beddock, P. Naepels, C. Gondry, P. Besserve, B. Camier, J.-C. Boulanger, J. Gondry,
"Diangosis and current concepts of management of advanced abdominal pregnancy," Gynécologie Obstétrique & Fertilité, 32 (2004) 55-61.

J.M. Cohen, J.C. Weinreb, T.W. Lowe, C. Brown, "MR Imaging of a Viable Full-Term Abdominal Pregnancy, American Journal of Roentgenology, 145 (1985) 407-408.

V. Malian, J.H.E. Lee, "MR Imaging and MR Angiography of an Abdominal Pregnancy with Placential Infarction, American Journal of Roentgenology, 177 (2001) 1305-1306.