Not Only a River in Egypt

My patient was a thirty-something-year-old woman complaining of sudden onset of crampy abdominal pain—a condition for which the lengthy differential diagnosis runs from “nothing-burger” to life-threatening. Often a challenge, even for a seasoned ER doc.

On entering the cubicle, I found the patient supine with the head of the bed raised about 20 degrees; she felt most comfortable in that posture. Although not in severe distress, she appeared anxious; worse when a wave of pain traversed her lower abdomen. She looked otherwise healthy and well-groomed, neither obese nor thin, her affect neither hysterical nor stoic. Her speech was articulate but edged with worry. Her chart listed her occupation as “paralegal.” She was married, two children, no past miscarriages or abortions. No chronic diseases, non-obstetrical hospital admissions, or surgeries.

I zeroed in on her chief complaint. “When did the pain start?”

“Several hours ago.”

“Can you describe it?”

Her brow furrowed, lips pursed. “Crampy.” She looked away, embarrassed. “Like if I could just have a bowel movement . . .”

On further questioning, she noted no bowel irregularities or recent gastrointestinal issues. “But that’s how it feels. Like I need to make a BM.”

She denied nausea, vomiting, fever, or other symptoms. I noted her moderate abdominal distension and mentally clicked on “bowel obstruction or ileus” for possible diagnosis. Why would that occur in the absence of other symptoms, especially nausea or vomiting?

Time to consider possible gynecological causes. “When was your last period?”

She looked at the wall, shook her head. “I don’t remember.” A pause before she faced back toward me. “But they’re never regular.”

“Birth control?”

“My husband had a vasectomy.”

The required follow-up question: “Any other, uh, exposure?”

Her face flushed. Her voice clipped. “None. Ever.”

I believed her. Yet . . .?

She denied any other symptoms, including vaginal bleeding or discharge; and no urinary tract symptoms.

Throughout the history-taking, successive waves of abdominal cramps at regular intervals interrupted her. I needed to be blunt. “Is there any chance at all you could be pregnant?”

The same livid flush filled her face. Her angry retort, “Absolutely not.”

I examined her abdomen. As feared, I felt a mass consistent with a near-term pregnant uterus. When the next cramp hit, the wall of the uterus contracted—typical of active labor. With a stethoscope on her abdomen in between cramps, I heard undeniable fetal heart tones; normal in rate and quality.

I put the stethoscope back in the pocket of my white coat and moved closer to the head of the bed. “You are not only pregnant, ma’am. You are in active labor.”

Her face paled and her eyes widened. She rose in the bed and opened her mouth to speak, but could not form any words.

“You’re having a baby,” I said. As if I were talking to a child.

Another pain-wave hit, harder than the others, and she flopped back onto the bed. Her head shook side-to-side, tears welled in her eyes. “We can’t,” she said. “We decided . . . We can’t afford . . .”

I touched her hand in what I hoped was a reassuring gesture. “Where is your husband now?”

“In the waiting room.”

“Shall we call him in?”

She looked at me, her eyes frightened yet desperate. “Yes.”

The nurse went to summon the husband. “Another question,” I said. “When did your husband have the vasectomy?”

The woman grimaced. “Yeah. About nine months ago.”

“Maybe you were already pregnant.”

She let out a lengthy sigh. “Yep.” Her eyes reflected insight for the first time in our encounter. “I knew it soon afterwards. I just couldn’t accept it. So I . . .”

“Denied it. I’ve seen it before.”

“Really?”

“You’re not the first.”

Her husband entered the cubicle, a handsome man with both weariness and concern on his face. “Is she going to be okay?”

I spoke to the woman. “Do you want to tell him?”

She nodded. Tears filled her eyes when she looked at him. “You’re going to be a father. Again.”

The man’s jaw dropped. His face paled, then flushed. He looked at me. “A baby?”

“She’s in active labor. We’ll get her up to the OB floor.”

The man’s face and body language transitioned in phases from disbelief, to questioning, to stunned acceptance, to concern for his wife. He moved to the head of the bed, took her hand in both of his. His face bore not a shadow of doubt or distrust.

She looked at him, vulnerable and afraid. “What are we going to do?”

He smiled, squeezed her hand, and spoke in a robust voice. “We’re going to have a baby.” He leaned over and kissed her. “Together.”

As the couple was taken to the Labor and Delivery suite, I turned to the nurse. “Denial.”

“Not just a river in Egypt,” she said.

[Author’s note to my ER colleagues who may have questions: Back in the pioneering days of emergency medicine we didn’t have ultrasound in the ED, and few of us would know how to use it. We had to rely on clinical instinct. Despite the advances in diagnostic tools, that hasn’t changed, has it?]