The telephone call was to Abigail – in her mid-twenties, six weeks pregnant and with vaginal bleeding that had started abruptly that night. I listened while Yasmin, the registrar I was training, took the details, ascertaining the degree of blood loss and making sure there was no faintness that might indicate Abigail had been losing more than she’d realised.
The likeliest diagnosis by far was a threatened miscarriage. Around 15 per cent of pregnancies end spontaneously, the vast majority in the first 12 weeks. Most are because of non-viable foetal chromosomal abnormalities. Pregnancy loss at Abigail’s stage rarely causes significant bleeding and can usually be managed at home without the need for a face-to-face assessment.
Before Yasmin could decide to deal with Abigail’s case over the phone, however, she needed to rule out an alternative diagnosis that affects around 1 per cent of pregnancies, an ectopic. This is where the fertilised egg implants outside the womb, most often in a Fallopian tube. As the embryo grows, it begins to erode the surrounding tissues, causing pain and bleeding. If it ruptures, an ectopic can be catastrophic, provoking sudden and life-threatening haemorrhage into the abdominal cavity. No one wants to misdiagnose one.
Pain from an ectopic is typically unilateral. Abigail said she had been getting cramps, but they were symmetrical and period-like, much more in keeping with threatened miscarriage. Other factors increase the chance of a pregnancy being ectopic: a history of pelvic inflammatory disease raises the risk, due to scarring in the Fallopian tubes; and a woman who has had a previous ectopic has around a 10 per cent risk of another.
One of the challenges of working out of hours is that you generally cannot access a patient’s medical records (different parts of the NHS use incompatible computer systems that are incapable of talking to each other, a lamentable state of affairs that illustrates how far Matt Hancock, our tech-obsessed Health Secretary, has to go before realising his vision of an NHS run by AI chatbots). In the absence of any background information, Yasmin set about obtaining the relevant details.
“Have you been pregnant before?”
There was a hesitation before Abigail answered. “Yes.”
“Can I ask what happened in that pregnancy?”
Another long pause. “I was too young. I was only 17. I had an abortion.”
Yasmin gently moved the consultation on; she had evidently stumbled across a painful memory. She explained that Abigail’s symptoms might represent miscarriage, and how to manage things in the days ahead. She also tried to find out how Abigail was emotionally. Just a few weeks into a pregnancy, an expectant parent can feel powerful love for their baby, and a miscarriage can precipitate intense grief. Equally, though, not every pregnancy is good news.
“I’ve not been with my boyfriend long,” Abigail said. “Only three months.”
A male voice in the background could just be heard saying, “Four!”
I debriefed Yasmin at the end of the call. She felt awful at having inadvertently caused Abigail to disclose personal information in front of a new partner. We decided that a prefacing remark like: “I’m going to need to ask you some very personal questions now, would that be OK?” would give future Abigails more control over the conversation.
Unrelenting pressure on services, coupled with demand for more convenient access to health care, is resulting in an increasing amount of contact with patients by phone, video call or even email. Remote consultations can be more efficient, but they come at a cost: the blunting of non-verbal cues that convey so much of our interpersonal communication.
As is often the case with out-of-hours work, I never found out how Abigail’s story ended. But her case illustrated that, when consulting with patients remotely, it is difficult to know who else is in the room.
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This article appears in the 03 Jul 2019 issue of the New Statesman, The Corbyn delusion