Pro Choice or Pro Life!

It was a cold December morning in Bangalore. A busy OPD. Little did I know that the first few years after residency would be almost as busy. Had been 3.5 years since getting my degree but was still clocking in 12 to 14 hours a day. And the new and old cases were my responsibility. No resident was around to help. Most days I’d wrap 50 to 70 cases by 2 pm and take unresolved cases to the senior consultants for discussion, wrap work up by 3:30 to 4:00 pm. This day was different. Patients were coming in with conditions that needed extra attention and time.

I had 11 patients left. Three people walked in to token number 44, a couple in in their late 50s and one who I assumed was their daughter in her twenties. I would generally have 2 chairs in my room, one for a patient and one attender, but since they were 3 I expected the parents to sit down. But the girl sat first on the chair closest to me. I said, “ let the patient sit here.” “ I’m the patient sir,” she said.

I opened her chart on my computer and quickly read the preliminary note typed out by the resident at the screening block. The patient had a seizure one month ago and imaging was reported as a meningioma. The seizure had not recurred after starting an antiepileptic. I reconfirmed the findings and reviewed the MRI scan in a glance. It showed a fairly large extraaxial lesion in the left frontal region. There were no contrast images so I ordered a contrast scan and sent her to the counter for further assistance.

The lady at the counter called me immediately informing me that the patient was apparently pregnant. I gulped an averted embarrassment. The radiologist would have given me a earful for not checking. They always do but it is no excuse for you to not. Sometimes you could ask the patient all relevant history and take time to examine them, but they forget to mention important history unless specifically asked for. I assume the stress of discussing about the ailment makes them forget. I had them back in my room to counsel them further.

Some patients get irritated with doctors. “Every department we’re asked the same question, it’s very annoying.” Rest assured, redundancy is strategically placed in every field to avoid plausible preventable mishaps. And alot of times it fails because people take redundancy for granted. Someone else must’ve already done it. Wrong side craniotomies, wrong level laminectomies, radiation exposure in pregnancy; the list of avoidable errors is never ending.

“ Meningiomas are known to increase in size during pregnancy due to the associated hormonal changes, and the tumor may further increase in size until delivery. Termination of pregnancy is not an option before surgery as fetal age is more than 20 weeks. But surgery is also a neccisity as the tumor is fairly large. However, with surgery there’s a risk of losing the fetus.”

The father a burly bearded gentleman with a strong deep voice and an intense gaze spoke first. “ Sir, she is my only daughter. Nothing is more important to me than her well being. She is the priority before the baby.”

I felt warm listening to his words, the clarity and love for his daughter was very reassuring. The patient then told me, “ I did not want to have the child. I was planning an abortion but couldn’t make the appointment due to the seizures. And once the MRI was taken this became a priority. So yes. we accept the risk to the fetus with surgery and want to proceed with surgery.”

I assured them that our efforts are going to be directed towards saving the patient and the fetus. There was a little haggling for an early date for surgery and I assured them surgery in less than a week. That was that. The patient was sent away for an obstetrics opinion and pre anesthetic evaluation.

The case was operated upon by a senior consultant and the chief resident at out hospital. During surgery, the lesion was found to be intraaxial and frozen section was suggestive of a high grade glioma. The tumor had multiple areas of necrosis and it was most likely a grade 4 glioma/ GBM. It was a heart breaking diagnosis with a very poor prognosis. Life expectancy was less than a year without adjuvant treatment and a little more than that with adjuvant treatment. A supramaximal resection was achieved.

When we study an intracranial mass, the first thing we want to know is whether the mass lies in or outside of the brain (intraaxial or extraaxial respectively). Pre operatively, 3 out of the 4 doctors who saw the scan assumed it to be an extraaxial lesion, ie a meningioma. Only the HOD had suggested it might be intra-axial. No contrast images were available. This immediately brought me back to my own days of residency when one of my consultants would always ask me to first say if the lesion was extraaxial or intraaxial. Usually A broad base towards the dura is one sign and most people stop at this while glancing casually. But there are a few other radiological cues to confirm and in my hurry in the OPD I hadn’t. Sticking to basics (and more importantly being trained to be vigilant of basics) is so important.

Extra-axial versus Intra-axial Locations for Intracranial Lesions. The presence of “white matter buckling” may provide a valuable clue in determining whether an intracranial mass is intra-axial or extra-axial in location. A. Diagrammatic representation of normal axial image at level of centrum semiovale. Fronds of white matter (black area) insinuate themselves into cortical gray matter (G). s, subarachnoid space; sl, sulcus. B. Extra-axial tumor (T) crowds fronds of white matter producing white matter buckling. g, gray matter. C. Intra-axial tumor (T) expands white matter, thickening white matter fronds. Tumor is bathed by white matter edema. Ref: https://radiologykey.com/central-nervous-system-neoplasms-and-tumor-like-masses/

Nevertheless, it was great that we operated on her and did not delay the surgery further. I was very sad thinking of the heartbroken parents. When conveyed the possible pathology and prognosis, the mother was visually confused and needed some time to process it. I did not see the father, as only one attender is allowed to stay with the patient. I could imagine his anguish.

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Once the diagnosis was confirmed I was curious to know what would be the next step. Would they go for radiotherapy with shields to protect the baby? Would they induce the baby pre-term delaying radiation by 8 weeks? Would they delay chemotherapy?

This got me into a train of thought. What would I want had I been in their shoes. I assumed the baby which they dint want would now be a ray of hope, a semblance of continuity of their daughter's existence experienced through the baby. It felt like divine respite to the parents. The daughter would pass away but a grandchild would unburden to whatever extent possible the weight of her loss off their shoulders. It felt like a permutation of moves on a chess board where the universe was several steps ahead. That this baby was destined to live. By inducing a seizure prior to MTP and delaying it, by surviving surgery and possibly being shielded through RT. I was wondering if god’s will would get him or her through a pre term delivery without hassle as well.

I asked the resident incharge of the case what the family had decided. “They want to terminate the pregnancy. The risk of radiation induced teratogenicity is unacceptable. And they don’t want any treatment delays on that account.”