Serena Williams holds many wonderful statistical records in tennis, but recently she nearly became a tragic maternal mortality statistic. Her experience further illuminates the shape of the maternal mortality problem.

Maternal mortality is disproportionately a problem of black women with pre-existing health conditions. All too often it involves poor medical care, specifically assuming pregnancy complications are rare when they are common. In Williams case, she literally had to save her own life.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Serena Williams literally had to save her own life.[/pullquote]

According to Vogue Magazine:

Though she had an enviably easy pregnancy, what followed was the greatest medical ordeal of a life that has been punctuated by them. Olympia was born by emergency C-section after her heart rate dove dangerously low during contractions… The next day, while recovering in the hospital, Serena suddenly felt short of breath. Because of her history of blood clots, and because she was off her daily anticoagulant regimen due to the recent surgery, she immediately assumed she was having another pulmonary embolism.

Williams had a history of a near fatal pulmonary embolism. A blood clot that developed in her leg traveled to her lungs and almost killed her. The problem was so serious and the risk of recurrence (and death) was so high that Williams needed to take anticoagulants daily. This is a major isue in and of itself but is further exacerbated by pregnancy which always increases the risk of blood clots above a woman’s pre-pregnancy risk.

A history of pulmonary embolus requires specialized management in pregnancy. The best daily anti-coagulant, coumadin (warfarin) is teratogenetic. Pregnant women must be switch to an anti-coagulant compatible with pregnancy, typically injectible heparin. The anti-coagulant must be carefully dosed during the last weeks of pregnancy and suspended altogether during labor in order to prevent excessive bleeding at the time of birth; the risk of excessive bleeding is even higher if a C-section is needed.

In the immediate aftermath of birth, the risk of blood clots remains very high so anticoagulants must be restarted within 6-12 hours after vaginal birth and between 12-24 hours after a C-section. While anticoagulants are suspended, the mother is extremely vulnerable and should be monitored closely.

Instead, Williams had to diagnose her own life threatening complication and then convince the nurse of its seriousness.

She walked out of the hospital room so her mother wouldn’t worry and told the nearest nurse, between gasps, that she needed a CT scan with contrast and IV heparin (a blood thinner) right away. The nurse thought her pain medicine might be making her confused.

The nurse thought the pain medication might be making her confused? Did the nurse have any idea of the risks to this particular patient? Apparently not. Instead, like all too many people who care for pregnant and postpartum women she assumed that everything was fine.

But Serena insisted, and soon enough a doctor was performing an ultrasound of her legs. “I was like, a Doppler? I told you, I need a CT scan and a heparin drip,” she remembers telling the team. The ultrasound revealed nothing, so they sent her for the CT, and sure enough, several small blood clots had settled in her lungs. Minutes later she was on the drip. “I was like, listen to Dr. Williams!”

Williams was absolutely correct. She needed an immediate CT scan (the appropriate diagnostic test for a pulmonary embolus) and IV heparin. Instead she was subjected to a useless screening test that wasted precious time. There is no excuse for the delay in her treatment.

But this was just the first chapter of a six-day drama. Her fresh C-section wound popped open from the intense coughing spells caused by the pulmonary embolism, and when she returned to surgery, they found that a large hematoma had flooded her abdomen, the result of a medical catch-22 in which the potentially lifesaving blood thinner caused hemorrhaging at the site of her C-section. She returned yet again to the OR to have a filter inserted into a major vein, in order to prevent more clots from dislodging and traveling into her lungs.

These were unfortunate complications that could have been predicted, but almost certainly could not have been prevented. Preventing a pulmonary embolus took priority over everything including bleeding into her incision. You can replace blood loss, but it is almost impossible to save someone from a massive pulmonary embolus. The decision to place a filter into her inferior vena cava was the appropriate response. It’s an invasive procedure but it prevents blood clots from traveling to the lungs and eliminates the need for any anti-coagulation.

Williams’ near death experience highlights the failure of our healthcare system in preventing maternal mortality. We know who is at risk and we know how to minimize that risk, yet in practice we ignore those risks, fail to employ the interventions that are needed, and falsely reassure women when they tell us they are ill.

The true scandal here is not that Williams nearly died; that was foreseeable. The scandal is that Williams had to save her own life; that’s inexcusable!