"Protecting adults or children", the most common problem in this hospital, has always been controversial.
If you can't have both, most people may choose "Bao Da". But in reality, there are always people who make helpless decisions for various reasons.
For example, in the 5th episode of the doctor's observation documentary "My White Coat", there is such a heart-wrenching scene.
A 35-year-old pregnant woman suffers from gallbladder stones and sudden severe pain in her stomach
At 6:00 p.m. on March 15, a couple in their 30s came to the emergency department of Shenzhen People's Hospital.
The wife was pale, her tone was very weak, and she leaned back slightly because of the severe pain in her stomach when she entered the door.
"Previous ultrasound examinations found sediment-like gallbladder stones, and I was going to come back for surgery this year. It turned out to be 5 weeks pregnant again..."
After careful questioning, jiang Xicheng, the attending physician of the emergency department, found that although the pregnant woman did not have a fever, she had a stomachache since the afternoon of the same day, and there were symptoms of nausea and vomiting. On palpation of the tummy, there is significant tenderness in the upper and right lower quadrant.
Based on these conditions, doctors judge that pregnant women may have "cholecystitis".
"You're in real trouble with this situation. If it is cholecystitis, every time you have to get anti-inflammatory injections, those drugs have no effect on the fetus within 3 months, it is not easy to say..."
Therefore, Dr. Jiang first arranged for her to draw blood and do a B ultrasound.
But things are far from as simple as they seem.
In China, "cholelithiasis" is often the main cause of pancreatitis [1]. Therefore, patients with cholecystitis caused by stones generally have to check for pancreatitis through blood draw and imaging tests. This is also the intention of the doctor's move.
At 7:30 p.m., the results came out, and Dr. Jiang said three words again: "Very troublesome."
Because, the situation is more serious than expected:
This pregnant woman's blood amylase reached more than 1400, more than 10 times more than normal!
Blood amylase in normal adults does not exceed 115 U/L. Pregnant women may have physiologically elevated, but generally do not exceed 2 times the normal value.
If the blood amylase exceeds the normal value by more than 3 times, accompanied by symptoms such as epigastric pain, nausea and vomiting, the diagnosis of "acute pancreatitis" can be diagnosed.
Coupled with ultrasound results, pregnant women have developed significant bile duct dilation.
All this suggests that she is likely to have severe acute pancreatitis.
If not treated in time, the fatality rate is as high as 50%!
Obviously it is a problem of the gallbladder, why is it related to the pancreas?
This also starts with the two "neighbors" of the gallbladder and pancreas.
Gallbladder stones, why do they cause pancreatitis?
The bile of our body is not secreted by the gallbladder, but by the liver.
The gallbladder grows under the liver, like a "small reservoir" responsible for storing and concentrating the bile secreted by the liver, which is eventually excreted from the common bile duct.
The pancreas, on the other hand, grows on the back of the stomach and secretes pancreatic juice containing a variety of digestive enzymes, which is eventually excreted from the pancreatic duct.
The common bile duct and the pancreatic duct are like two rivers, both converging at the "estuary" of the duodenal nipple head. Bile and pancreatic juice flow into the intestines together, digesting proteins, fats, and sugars in the gut.
However, the biliary tract will also encounter "mudslides" -
Once the bile composition is out of balance, stones can form. As the bile flows, some stones will flow into the intestines, and some will block the biliary tract somewhere, and cholecystitis will occur.
(Pregnancy with acute cholecystitis)
These small stones will also stimulate muscle congestion and edema in the "estuary", resulting in poor excretion of bile ducts and pancreatic ducts, increased "water pressure", and dilated bile ducts and pancreatic ducts.
What's even more frightening is that the accumulated bile will also drill through the pancreatic duct next door and flow back into the pancreas!
Bile is not harmless to humans and animals, and acidic bile activates digestive enzymes in the pancreas.
These guys begin to digest the "own people" inside the pancreas, causing an inflammatory response in the pancreas and even the surrounding tissues, and the pancreas slowly necrotic.
The amylase in the pancreatic juice runs into the blood vessels in large quantities, resulting in a sudden increase in blood amylase.
This is the origin of "biliary acute pancreatitis".
In addition to cholelithiasis patients, people with alcoholism, overeating, and hypertriglyceridemia are also at high risk of acute pancreatitis.
Should pregnant women do CT?
Doctor: Wait 3 months and you may be gone!
Although the pregnant woman has already done A ultrasound, Dr. Jiang knows in her heart that this is far from enough.
Due to the influence of enlarged uterus and intestinal gas during pregnancy, B ultrasound cannot see whether the pancreas has necrosis or whether other surrounding organs are implicated.
In particular, tenderness has developed in the right lower quadrant of pregnant women, and it is likely that pancreatitis exudate has penetrated into the pelvic cavity. If pelvic inflammation occurs, it will lead to violations of organs such as the uterus and ovaries!
For advanced pregnant women who have just been pregnant for 5 weeks and the fetus is still unstable, this is undoubtedly worse.
In this case, it is best to do a CT to make a comprehensive judgment. However, these tests have radiation and can easily cause fetal malformations.
The husband didn't seem to realize the urgency of the situation. For the sake of the child's health, he also asked the doctor: "Can ct be done after 3 months?" ”
Dr. Jiang's tone was very serious because he was anxious for the patient:
"You go and search for what pancreatitis is." 3 months is either better or the person is gone! ”
In fact, in today's network is so developed, it is not difficult to understand a disease and a medicine. For example, Lin Pingna, a doctor who is a regular pei, instructed a patient's family to open the Tencent Medical Code APP for inquiry:
But some people are always accustomed to using their inherent thinking to "judge the condition", and think that pancreatitis is the same as "gastritis and hepatitis", but an organ is inflamed.
They simply did not know that once pancreatitis was very dangerous, the outflow of bile and pancreatic juice would quickly damage the surrounding blood vessels and implicate the surrounding organs, resulting in systemic complications such as hypotension, shock, and pleural effusion.
If left untreated, it is highly likely to be life-threatening! [2]
Dilemma, child or adult?
Dr. Jiang solemnly told them, "This child may really not be able to keep..."
The two fell into a brief silence and began to complain:
This is the second child, and it is not easy to conceive for more than two years. And the wife is already 35 years old, this fetus do not worry about not getting pregnant...
Why can't treating adults save children, is there no way to have both?
As Dr. Jiang said:
It is a pity that acute pancreatitis is such a dangerous disease.
This pregnant woman has an acute and severe incidence, and if it cannot be relieved by timely use of pancreatin-lowering enzyme drugs, it is likely to cause irreparable consequences.
However, these drugs are likely to cause fetal malformations (especially within 1 to 3 months), congenital disease, or miscarriage.
In addition, she may have severe biliary obstruction that requires emergency surgery to remove the obstruction. Otherwise, even if pancreatitis is temporarily relieved, the recurrence rate is very high, and even more serious symptoms appear.
Finally, Dr. Jiang sighed:
"If you really don't take your life seriously (insisting on saving your child), we don't use the fulminant pancreatitis first, only the usual pancreatitis."
However, this treatment method cannot be completely guaranteed to be harmless to the child.
You think you can use your life to fight for a future for your child; but it is more likely that you have paid, sacrificed, and finally a void! [3]
"So I think it's only for the adults." Think about it and give me an answer. ”
There are some things that can only be decided by the patient himself
Faced with this difficult situation, only the mother can decide whether to save the child or herself.
The wife wandered the corridors of the hospital for a long time. Finally, the husband went into the consultation room and told Dr. Jiang:
"I asked just now, and they said that the recommendation is conservative treatment first."
The pregnant woman also walked in, silently bowing her head.
Dr. Jiang sighed darkly, but remained calm and rational.
He immediately contacted Xu Lizhuang, deputy chief physician of the emergency department, and doctors of hepatobiliary surgery for consultation to evaluate whether conservative treatment could be made.
Because of the special situation, Dr. Jiang deliberately wrote "urgent" on the consultation form!
At the same time, patients and families are constantly urged to:
Doctors are like that, they can't make decisions for any patient, and they can't evaluate who is right and who is wrong.
They can only do their job well - to cure the sick and save people, in any case, to give the most appropriate solution.
It seems a bit cold, but they can only keep their sanity and do their best to reduce regrets.
Prepare for pregnancy scientifically, don't wait until tragedy strikes to regret it
Until the show aired, there was no follow-up news on this case. But the choice of this pregnant woman and her family is undoubtedly lamentable.
What are the consequences of conservative treatment?
In 2014, a domestic study had already given the answer [4]:
Of the 15 pregnant women with severe acute pancreatitis, 7 chose non-surgical treatment.
One of the pregnant women was aggravated after conservative treatment, and was sent to the emergency room for rescue as soon as she arrived at the hospital, and after 12 hours, the rescue was ineffective, and the mother and baby died;
Another 2 pregnant women refused surgery due to conservative treatment, and the mother and baby died.
The other 4 pregnant women had a full-term vaginal birth after being cured. But they are likely to be in the third trimester, and the effect of medication and surgery on the fetus will not be so large.
In the case of this article, the woman is only 5 weeks pregnant, and the situation is obviously worse!
What about the other 8 pregnant women who chose surgery?
Five of them underwent a caesarean section followed by pancreatic surgery. Four of them were safe. The 1 who did not survive was because the operation was delayed, resulting in extensive necrosis of the pancreas, fetal distress, and finally maternal and infant death.
There are also 2 pregnant women who have just been admitted to the hospital and found that they have been fetally stillborn in the uterus, so there is no need to consider, direct caesarean section surgery to terminate the pregnancy, and then conservative treatment, and finally survived;
Another person only underwent a caesarean section, and then adopted conservative treatment, and the mother and child were safe.
This string of cruel numbers makes people chill. But overall, it is still a good chance to choose surgery first.
In order to keep the tragedy from happening, expectant parents must pay attention:
1. When preparing for pregnancy, be sure to do preconception examinations to screen out diseases and oral problems that may affect fetal development. Whether it is an emergency or not, it should be dealt with as soon as possible before pregnancy. Otherwise, after pregnancy, many diseases are more likely to occur or worsen, and it will be too late to deal with it!
2. If medication is needed before and after pregnancy, consult the doctor's advice first.
3. Various hormones in the pregnant woman's body will change suddenly, and complications such as gestational diabetes and hypertension may occur. If you are uncomfortable during pregnancy, you must go to the hospital in time to avoid delaying the condition.
4. Nausea and vomiting, persistent pain in the upper abdomen, be vigilant against pancreatitis, and quickly go to the doctor.
5. Gallstones must be found early and treated early, and small problems may also be dragged into big problems!
Finally, on the question of "keeping the big and keeping the small", I would like to tell the girls:
It's okay to love children and want children, but please don't turn yourself into a tool for procreation.
When you can't even save your life, leave a child born without a mother (or a future stepmother). You think "children are the continuation of your life", but is it really fair to him?
When you could have saved your life, but did not die in order to have a child, in the modern society where the medical level is more and more developed, this is not greatness, but ignorance.
Stay in the green mountains, not afraid of no firewood, without this child, at least you can find a way to reproduce, now there are not many ways to treat infertility, even if the cost is high, it is not as valuable as your life!
And for a man, you may love him very much, but you are gone, he can find another woman and have another child. For you, it is equivalent to losing everything, and you have to let your parents who have worked hard to raise you bear the pain of losing their daughter.
I also hope that more and more women realize that only you can control your destiny. Allowing yourself to live is your right to be human.
bibliography
Xu Xiaoou,Wang Yu,Li Yao. Treatment strategies of cholelithiasis in pregnancy[J/OL].Medical Review,2020(08):1568-1572[2020-04-23].
ZHOU Xidong. Clinical efficacy of surgical treatment of obstructive biliary acute pancreatitis[J]. Chinese Community Physicians, 2018.
WANG Xingpeng, LI Zhaoshen, YUAN Yaozong. Guidelines for the diagnosis and treatment of acute pancreatitis in China (2013, Shanghai)[J]. Chinese Journal of Pancreatic Disease, 2013(2):73-78.
Sun Yingdong, Wang Yong, Zhou Yong, et al. Systematic diagnosis and treatment of pregnancy complicated with severe acute pancreatitis: 15 case reports[J]. Chinese Journal of General Surgery, 2014, 23(3):376-378.
【Creative Team】
Editors: Wang Fengling, Ye Zhengxing
Typography: Wang Zhongqiang
Operation: Guo Qian
Coordinator: Zhang Ning