Patient 1 was a 28-year-old Caucasian Irish woman in her first pregnancy. She presented to our Emergency Room (ER) in July 2012 with vaginal bleeding. Her last menstrual period (LMP) was 5 weeks and 3 days previously. An ultrasound scan showed an empty uterus and she was referred to our Early Pregnancy Unit for further assessment. A subsequent transvaginal ultrasound showed a left-sided adnexal mass with a background of serial serum beta subunit of human chorionic gonadotropin (beta-HCG) levels that were plateauing (94 to 108IU/L).

She initially refused any intervention and discharged herself against medical advice. She stated that she did not want any medical treatment and was advised fully of the risks of declining same, including death or severe maternal morbidity, by senior staff members. Our unit takes the issue of very ill patients self-discharging very seriously, given the obvious potential risks to their lives or well-being. On this occasion, we followed every protocol within the hospital, including having the most senior staff available to meet with her to advise her fully on the gravity of the situation. She was, however, found to be of sound mind and thus we could not force her to stay against her will. She left in the care of her partner and signed a form advising that she was taking her discharge against medical advice. Her general practitioner was also contacted advising them of the situation; her general practitioner assured our team that they would contact her directly themselves to attempt to persuade her to return.

Subsequently she presented to the ER 6 hours later in a state of collapse with hypotension and tachycardia. Urgent bloods were procured and her haemoglobin level was found to be 90g/L. She was reviewed by senior obstetric and anaesthetic consultants and consented to theatre. She was advised that this could be a life-threatening situation but she refused to accept red blood cell transfusion intraoperatively based on her religious beliefs. She consented to platelets and plasma transfusions. She underwent laparoscopic right-sided salpingectomy. Intraoperatively, a haemoperitoneum of 2 to 3 litres was noted. The use of cell salvage was also implemented to minimise blood loss.

Postoperatively, her partner advised hospital staff that she was not in a position to consent to platelets or plasma given her religious beliefs. He furthermore produced written directives, which he stated had previously been signed by the patient declining any blood products. The hospital legal team were contacted and advised as follows: “Physicians are not bound by written directives which they have not seen themselves. The initial verbal consent is valid and supercedes the written directive signed even if same is produced by the partner”. She was stable postoperatively and warranted no further intervention.

Patient 2 was a 35-year-old Nigerian woman in her second pregnancy. She had a previous normal delivery. She presented to the ER in January 2013 with PV spotting. Her serum beta-HCG was elevated (3900IU/L). Her LMP was 5 weeks previously. No intrauterine pregnancy was diagnosed and she was referred to our Early Pregnancy Unit for evaluation of pregnancy of unknown location. An ultrasound scan showed an empty uterus with free fluid and right adnexal mass. Haemoglobin sent at this time was processed as 57g/L and she was contacted to attend the ER for urgent assessment. Her vital signs were stable initially but she later became hypotensive and tachycardic.

She declined all blood products. She was again counselled by senior hospital obstetric and anaesthetic consultants about the gravity of the situation. She spoke at length with her pastor before finally consenting to surgery. Intraoperatively, she was given 1g tranexamic acid intravenously. The ectopic was of significant size (65×65×21mm) and 1.5 litres haemoperitoneum was noted. Cell salvage was again used to minimise blood loss. Ischaemic electrocardiogram changes were noted postoperatively including ST depression consistent with hypoxic damage. Her postoperative haemoglobin was 5.2 and she was discharged 48 hours later with advice to take Galfer (ferrous fumarate) twice daily.