Nocturnale

I encountered this scenario in Station 4 of the Penang MRCP PACES Course.

The patient, Mrs Lee has a history a pulmonary embolus currently on warfarin. She was recently found to be pregnant. You are here to see her in regards to her anticoagulation therapy. Before you could do this, you received a call from the nurses to say that the patient is very angry and wants to see a doctor immediately.

There are two issues which a candidate must address. The angry patient and the counseling for anticoagulation therapy in pregnancy.

This is how I would have approached the case. A fellow participant who was unluckily picked for this ordeal, had a tough time dealing with this belligerent bitch patient. 

N: Good morning, my name is Dr. N, the registrar in charged of running the clinic. You are Mrs. Lee?

P: Yes! Doctor, doctor! Please tell me if my baby will be okay?

N: You seem to be upset, tell me what happened?

P: No, doctor! You don’t understand! I am pregnant and your nurse at the reception was shock to hear that I am on Warfarin! Is my baby going to be alright? She told me I should not have been on warfarin since I am pregnant! What is going on, doctor!?

N: You are obviously dissatisfied about not being well-informed of your previous treatment. I agree this must be distressing to you. But first it would help me a great deal if you could shed some light of what actually transpired during your last consultation here at our hospital, for example when and why you were first given the warfarin drug.

P: They told me I have this blood clot on my legs which have travelled to my lungs and that I should be taking a blood thinning drug. But doctor! Nobody told me that this warfarin drug is harmful to my baby! That doctor, what his name, just advised me that I must take this drug but make no mention at all if it affects the pregnancy. The least he could do is warn me about the risk but he didn’t!

N: Yes. I think it is understandable that you should feel the way you felt. Is that your only concern, about the detrimental effects of warfarin on pregnancy?

P: No, doctor, you don’t understand. Do you know how difficult it is to conceive? My husband and I have been trying for a baby for years! We were almost going to give up until a week ago when we found out I am pregnant for the very first time! This baby is very precious, doctor!

N: You feel the treatment has been a mess and you were kept in the dark all this time about the potential risks posed to your pregnancy. Given these circumstances, I can imagine how angry I would feel myself if that happened to me.

P: I want to know the name of the doctor who treated me with warfarin! I want to file a complain. Please tell me who did this to me!

N: Mrs. Lee, I agree we must sort this problem out as soon as possible. As of this moment, our priority would be to ensure that you continue to receive appropriate treatment for your blood clot problems and at the same time making certain that your pregnancy go unharmed. I can comprehend the degree of anxiety and concern on your part about this unexpected but important conception… [interrupted]

P: No, doctor! I want to find out who the doctor is!

N: I am not in a position to make an informed statement about what happened during your previous consultation with the said doctor. However, I promise you that I will investigate this matter further and try and bring this issue to the attention of the appropriate personnel. This is obviously unsettling to you, but please understand that I am equally concerned about this. I will speak to the relevant departments and establish what had happened and then give you a clearer feedback. How do you feel about this?

P: So doctor, what will happen to me and my baby now?

N: Right now, our first step is to stop the warfarin medication. Your apprehension about the potential harmful effects of warfarin is reasonable. No doubt about that. However, blood clots in the lungs or what doctors call pulmonary embolism remains a significant risk to the mother during pregnancy. We need to put you on alternative blood thinner that will not cause harm to your baby. What have you been told about warfarin and its danger to pregnant ladies?

P: Nothing except that it will make my baby die?

N: The fear that doctors have about the use of warfarin in pregnant patients is mainly attributable to two main complications, namely bodily defects and bleeding from the baby. The precise risk of warfarin induced complications in the fetus is however not known but the actual risk of carrying a deformed, mentally retarded infant and development of other major complications is believed to be relatively low. Furthermore, there is a relationship between the warfarin dosage and fetal complications, in other words, women taking less than 5 mg of warfarin daily were at much lower risk of fetal complications than those taking a higher dose. Do you understand what I am saying?

P: Okay. So now what?

N: This is what I have in plan for you. I will refer you at the earliest opportunity to see the obstetrician so that an early antenatal scan can be performed. On the other hand, you will be commenced on heparin therapy, the alternative blood thinner we spoke about earlier for the rest of your pregnancy. Rest assured that heparin is both safe and effective to prevent or treat blood clots in pregnancy.

This medicine is given as a shot into the fatty part of the skin.

You have to make sure you tell your dentists that you use this medicine as you may bleed more easily. Try and avoid injury, falls and accidents. Use soft toothbrush, electric razor. Inform us if you are taking aspirin, aspirin-containing products, other medicines as these medications may interact and cause more problems.

Possible side effects of the drug are bleeding problems, irritation where the shot is given and weakened bones with long-term use.

Don’t worry; we will closely liaise with the obstetrician, with close follow-up and assessment of your treatment and wellbeing of your baby.

I believe we have covered quite some grounds here. Are there any further questions?

P: Yes, I want to file a complaint against the doctor who first prescribed the warfarin to me!

N: I can understand your ongoing resentment. I will speak to the nurse in charged who will assist you in your complaint matters and determine the best way to channel the concerns to our complaint and patient service department. Would that be alright with you?

P: Ok.

N: In that case, I hope I have been of help in alleviating some of your apprehensions. I am sorry to hear your predicament over what had happened.

Thank you for your patience and we will be arranging to see you again soon. This is the clinic’s contact information should you need to reach me for further queries. And before you go, keep this handy pamphlet with all the information about use of heparin in the treatment of your condition in pregnancy. It explains everything we have discussed before.

So, thank you and goodbye.