Monday, April 19, 2010

A Bad Kind of Itch

For better or worse, I get very attached to my clinic patients.

Maybe it is because patient continuity is so hard to come by as a resident. Every five weeks, you are shuttled off to a different rotation. Unless you happen to be on the labor floor when your clinic patient shows up in labor, the chances are that someone else will deliver them.

Y.S. is one of my dearest clinic patients to date. She is a lovely young woman from Guatemala expecting her first baby. It’s a boy. She’s going to name him Jack after her equally lovely husband. Y.S. was an unusual clinic patient. First off, her pregnancy was actually planned. She was healthy. She had a supportive family. She had no substance abuse or psychiatric issues. (Gives you an idea of what our resident clinic is usually like, no?)

One day, Y.S. came to me for her usual prenatal visit. Her only complaint was some relentless itching that had developed around her 34th week of pregnancy. She had no rash. The itching was worse at night. For my non-OB readers, this presentation is concerning for a disease known as Cholestasis of Pregnancy. It’s a rare disease which, for reasons that are not clearly understood, can result in an IUFD, or fetal demise. It is so rare that I doubted my patient had this. But being a responsible resident means ruling out “badness”, so I sent her to the lab to have her bile acids (a liver product) checked.

Normal bile acids are less than 40. Hers came back at 82. Dammit. We sent her to Gastroenterology and started her on a medication called Ursodiol. Despite our best efforts, by her 36th week, her bile acids were >180 (read: beyond what our lab could calculate).

My last day at work before vacation, Y.S. was brought in for an amniocentesis, a test for fetal lung maturity. The plan was to confirm that her baby’s lungs were developed and start an early induction of labor. We wanted to bring this baby into the world before Cholestasis had a chance to take him out of it. Unfortunately, things rarely go as planned. Little Jack’s lungs were NOT yet developed. Now what were we to do? Deliver a baby with the risk of breathing problems due to immature lungs? Or let him cook a little longer and risk his life to do it?

* UPDATE: As I returned to the hospital today, I made a beeline straight for Y.S.'s room. I found her - glowing, smiling, as happy a new mother as they come. Little Jack is fantastic. He is a healthy, bouncing, 6lbs 7oz bundle of joy. After a 2 day induction of labor, Jack was welcomed into the world around noon yesterday. Successful vaginal delivery - check. Healthy mom - check. Healthy baby - check. Now this folks, is a happy ending.

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