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“I have a 20-year-old with what I can only describe as a poorly repaired heart defect and, uh, suboptimal follow-up,” the cardiologist’s voice was rushed.

“That’s no good,” I said.

“Yeah, well, it gets worse. She had baby two years ago. Went into heart failure around 36 weeks. I’ve got the records. I have no idea how she made it home.” And then he added, “She had a c-section, but no one tied her goddamn tubes.”

“That happens,” was all I could say.

Actually, failing to do a tubal for a young woman with a very serious medical condition happens a lot. Patient refusal, Medicaid issues, or an OB dissuaded by her young age and the hope that advances in medicine might make it safe for her to be pregnant sometime in the next ten years. However, it was also possible that this young woman was so critically ill during her c-section that the doctors were just desperate to close her belly and get her off the table as soon as possible. Sometimes you just don’t have the five minutes.

“She came in short of breath. Eight weeks the radiologist says.” He added.

“So, uh, we have a problem …” I started, but he interrupted.

“Yeah, the pregnancy needs to be over. Today. Before she goes into heart failure,” he pressed.

I was fully aware of the medical urgency. That the amount of extra fluid the body accumulates in the early 2nd trimester can easily cause a damaged heart to decompensate. She’d already proven her heart wasn’t up to the challenge of the third trimester.

“I have to tell you something,” I said. I’m sure I closed my eyes, because even though I had nothing to do with it, I hated myself for what I was about to say. “There’s a new law. Maybe you don’t know about it? When the hospital’s budget was submitted this year to the state there was an additional clause. No abortions in this facility unless it’s life or death. Doesn’t matter if we can get insurance to pay or even if everyone is willing to waive their fees. The hospital is owned by the state.”

The Dean and the Chief of OB said they objected vigorously, but I don’t remember it being more than a minor blip in the news at the time.

“But it is a matter of life and death.” he said. “It’s not if it’s when. Her ejection fraction sucks. Her heart is crapping out already. Oh, and she had postpartum cardiomyopathy last time.” He was yelling by this point.

No wonder he was amazed that she survived her first pregnancy. Postpartum cardiomyopathy, devastating failure of the heart after delivery, has a 50% mortality rate. Women with underlying heart disease are at increased risk of getting this condition and the lucky survivors are more likely to get it again should they chance another pregnancy.

“Look, I’m not the bad guy here. But unless you can tell me she’s going to die in the next 30 minutes, we can’t do anything. Legal was very explicit. The next step is for you to call the concerned politician who wrote the law, explain her medical condition, and then find out if she meets his criteria for life and death. Basically, you need his permission” I paused, knowing what was coming next.

“You are kidding me. You are just kidding me,” he shouted. Not at me. It was abject disbelief.

Her odds of dying in the pregnancy or postpartum were high, but her chance of dying that day or tomorrow were not. When the balance would tip was difficult to know. Of course, the closer she was to a politician’s definition of certain death, the more dangerous any intervention would be.

“You could also arrange to transfer her to a private hospital, but I’m guessing she somehow hasn’t qualified for Medicaid.” His silence was reply enough.

“How is this a law?” He asked.

“It’s not about medical care, that’s all I know. Anyway, get your thoughts in order. Here’s the number for the hospital lawyer. He’ll arrange a conference call between you and the politician and then he’ll contact me if you’ve made her case.”

By the end of the day I still hadn’t heard, so I went home and waited for the phone to ring.

Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.