Resident Portfolio: A Tale of Two Women

A Tale of Two Women S ome shifts in the emergency department (ED) appear to have themes.The theme on this particular August night was ''Misfortunes in First-Trimester Pregnancy.''I picked up the first two patients from the tracking system, both of whom were young women with complaints of pelvic pain.Anticipating that a couple of pelvic exams were in my near future, I went to examine the first patient.TK was an 18-year-old who had been to a local clinic earlier in the day, where she learned she was pregnant.She reported that she awoke with vaginal spotting and crampy low abdominal pain and now was concerned that she was going to ''lose the baby.''I completed all the customary tests, including TK's first pelvic exam, which was performed in the attendance of her two cousins, whom she requested to be present.TK's os was closed, she had no blood in the vaginal vault, and her exam was otherwise unremarkable.I sent her off to ultrasound and proceeded to examine the next patient.SL was a 26-year-old woman who reported she had heavy vaginal bleeding for two hours before her arrival to the ED.She had a history of irregular periods, the last of which had been in May, and had noted increased fatigue, nausea, and breast tenderness over the last few weeks.She appeared shocked after I informed her of her positive pregnancy test.''I thought it was just a heavy period,'' she said.As I performed her pelvic exam, I noted that her os was open.There was a gush of blood, and I could see the products of conception bulging from her os.I gently removed the sac and tissue and placed it in a urine container.I explained what had just transpired, and SL expressed an instant relief from her pain and anxiety.As she began to mull things over, she burst into tears.''I feel so guilty,'' she cried.''I have been trying to get pregnant for so long and didn't think I ever could.''As I tried to legitimize SL's feelings of loss, I also tried to assure her that miscarriages do occur despite all that we do and do not do to have healthy pregnancies.It was clear that she truly wanted this baby, even if she had not known of the pregnancy before that night.Upon completion of TK's studies, I went back into her room to discharge her.''I've got good news for you.The baby looks fine now.''I proceeded to tell TK that we could not guarantee she would not have a miscarriage, but things were stable for now and I gave her a referral to the Obstetrics clinic.Then, she dropped the bombshell.''Well, I was thinking that I might want an abortion.Can you give me a referral?''I had to step back for a moment before I responded.TK was young and unsure.Was it my instincts telling me that TK had not truly thought out this decision, or was it my moral compass telling me abortion is fundamentally wrong?