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Medical History Edit
Emma is in the 21st week of an uneventful pregnancy although she did suffer from morning sickness. The pregnancy was the result of artificial insemination. She had previously suffered two miscarriages and four failed attempts at in-vitro fertilization.
Case History Edit
Emma was brought to Princeton-Plainsboro Teaching Hospital emergency room after suffering a stroke during a photography session, which she self-diagnosed. Dr. Cuddy asked Dr. House to provide a consult and he performed a short physical examination. She told Dr. House that she learned the acronym FAST (Face - Arms - Speech - Time) from her child's biological father, a neurologist. Although Emma had quickly regained her equilibrium after treatment for the clot that caused the stroke and both she and the fetus appeared to be in good health, Dr. House noticed a pro-natur drift, inflammation of the blood vessels in her retina, she could not resist sudden pressure on her cheeks without exhaling, and blood in her urine. He felt that she had micro-aneurysms that would most likely lead to further strokes, rescinded her discharge order and admitted her. He told her he would be ordering more tests.
Urinalysis showed excessive levels of proteins and red blood cells. The chem panel showed a creatinine level over 2.5. This indicated that her kidneys were starting to fail. However, an ultrasound showed no tumor or kidney stones, there was no fetal distress or sign of urinary tract obstructions. Her blood pressure was normal, ruling out preeclampsia. Dr. Cameron suggested the kidney failure may be the cause of the stroke rather than the result of the stroke. The kidney could have thrown a clot that made its way to the brain. The early symptoms of kidney failure - nausea, vomitting and ankle swelling could have been mistaken for morning sickness. Dr. House felt a clot from the heart was far more likely, but Dr. Cameron pointed out that her echocardiogram was clear and she had no history of heart problems. However, Dr. House pointed out she had strep throat. If it had not been properly treated, it could have lead to rheumatic fever which leads to mitral valve stenosis.
Dr. Cameron and Dr. Chase performed an MRI and found calcification of the mitral valve as Dr. House predicted. They started a procedure to open up the valve to prevent further clots, which was successful. However, her kidneys continued to get worse. Dr. Chase reported this to Dr. House. Dr. House accused Dr. Chase of screwing up the procedure, but Dr. Cameron pointed out that although there was thickening, it was insignificant. It was possible the underlying diagnosis was wrong. Dr. Foreman suggested they try dialysis in the meantime. They started a new differential as very few conditions can cause these symptoms. Preeclampsia had been ruled out and Dr. House ordered tests for proteinuria and low platelet count. Dr. Cameron suggested that the fetus could be drawing necessary nutrients so Dr. House ordered telemetry. Dr. Foreman suggested infection, sepsis, HUS or TTP. Dr. Chase thought it might be a cholesterol embolism, so Dr. House ordered a smear and ultrasound to check the blood vessels for plaque. This seemed to exhaust the possibilities.
However, after all the tests turned out negative, despite the fact Emma's kidneys were still negative. When Dr. Chase suggested that someone screwed with the lab results, Dr. Foreman pointed out no-one else had access. However, Dr. House realized that there had to be something wrong with the fetus that was adversely affecting Emma - Maternal mirror syndrome. Usually, when there is a problem with the fetus, there is either a miscarriage, the baby is stillborn or it is born very ill. However, on occasion, the baby can poison the mother's bloodstream. This meant they had to diagnose the fetus - if they solved its problem, the mother would get better as well. Luckily, only a few underlying causes lead to mirror syndrome: fetal Arrhythmia, fetal anemia and placental chorioangioma, which are treatable. However, other causes weren't treatable - Trisomy 13, Ebstein's anomaly or an aneurysm of Galen's vein. They decided to start with heart troubles, as those could be seen on a standard scan. However, in order to get the fetus to be still, it would have to be paralyzed.
Dr. Cameron and Dr. Chase went to Dr. Cuddy to tell her about Dr. House's plan to paralyze the fetus. Dr. House pointed out this was the only way to get a clean scan of the heart. He and Dr. Cuddy went to get Emma's consent. She agreed and Dr. House injected the umbilical cord with a paralytic.
The MRI showed the problem was with the fetus's bladder - it was four times its normal size. Dr. Cuddy found out the problem and noted that the fetus had a urinary tract obstruction. A shunt could be inserted. Dr. Cameron asked if Dr. Cuddy was taking over the case, and Dr. Cuddy said she was and that Dr. House wouldn't mind as the diagnosis was over. Dr. Cuddy informed Emma of the problem and how to correct it. However, they had to check the fetus's kidney function - if the kidneys were too damaged, the fetus would have to be terminated. However, Emma noted that she had trouble conceiving and this could be her last chance to have a child.
However, when Dr. House found out about the kidney function test, he had to remind Dr. Cuddy that if the urine had been blocked for too long, the test would be inconclusive as the urine would have been created weeks ago, and the second test would be stale too. She would have to test the third batch of urine to get conclusive results. He also asked why Dr. Cuddy was so interested in Emma's case. He feared that she was projecting her own fears of not having children onto Emma and losing her objectivity. However, he didn't want to take the file back as he wanted to go on vacation. However, Dr. Cuddy ordered him back onto the case until Emma was cured.
The kidney tap turned out to be normal and they planned to do the shunt. They would remove the shunt and correct the obstruction after he was born. The procedure was successful and the fetus's bladder started to shrink. However, Emma started complaining of abdominal pain. Dr. Cameron examined her eyes and found she was jaundiced, showing her liver was failing. She reported this to Dr. House. Her AST and ALT levels were high, and her bilirubin levels were extremely high. Dr. House figured that the urinary tract obstruction was a red herring and the real problem was elsewhere. Dr. Foreman suggested hypoplastic left heart syndrome, but the heart had already been checked and looked fine, but they hadn't looked at the fetus's lungs because they hadn't developed yet and wouldn't do so for two weeks. Dr. House felt that termination of the pregnancy was the only option.
Dr. House went to speak to Emma to tell her that she had to terminate the pregnancy. Delivering the fetus and putting it on a respirator was not an option - the fetus was at least two weeks away from being viable. Emma wanted to wait for two more weeks, but Dr. House pointed out that although the dialysis could replace her kidneys, nothing would replace her liver function and she would be dead within two days. However, even though Dr. House pointed out that the choice was not between her and the baby - they would both die if it wasn't aborted, Emma refused to terminate the pregnancy. Dr. House scheduled an abortion, but Emma refused to consent and told him he better figure it out in two days.
Dr. House went to Dr. Cuddy. He told her that Emma's kidneys were almost gone and she had already developed DIC. She asked if he had given Emma steroids to speed the fetus's lung development. Dr. House said it was pointless as Emma was dying too quickly. However, Dr. Cuddy understood Emma's dilemma and refused to side with Dr. House and approve the abortion.
Once again, Dr. Cuddy took over the case and went to the team. She asked them to assume the mirror syndrome diagnosis was in error, but the team agreed it couldn't be - the fetus was hydropic and Emma's kidneys and liver were both failing. She then asked the team to assume that the mirror syndrom was corrected when they inserted the bladder shunt and that this was a new problem. Dr. Cameron suggested acute fatty liver, which would have the same symptoms, and Dr. Chase suggested viral hepatitis and HELLP syndrome. Dr. Cuddy wanted to do a liver biopsy, but Dr. Foreman pointed out that with her low platelet count, she would probably bleed to death. She ordered them to do the biopsy by approaching it through the hepatic vein as the bleeding would merely return back into the bloodstream. She then removed Dr. House from the case.
Dr. Chase and Dr. Foreman started the procedure. However, as they completed the procedure, Emma's heart rate and blood pressure spiked and the fetal heart rate slowed to 50. Suddenly, Emma had contractions - she was in pre-term labor. Dr. Foreman started a terbutaline drip to stop the contractions.
The liver biopsy was negative and the early labor made it clear it was mirror syndrome - Emma's body was trying to terminate the pregnancy on its own. Dr. Cuddy wanted to know if the biopsy had caused the contractions, but Dr. Chase told her it was irrelevant. Dr. Cuddy thought the pre-term labor was a new symptom, but Dr. Foreman reminded her that it was simply confirmation of mirror syndrome. Emma's transaminase were 10 times normal level, meaning the liver had almost completely failed. Dr. Cuddy wanted to do a TORCH test, but Dr. Foreman told her there was no more time for tests - it was termination or death. Dr. Cuddy told them they had to work faster and suggested that the problem had to be in the lungs as it was the only option they hadn't ruled out. Dr. Cuddy wanted to increase the dose of steroids, but the team pointed out that this would suppressadrenal gland function and lead to long term adverse effects on the fetus's organ development. Dr. Cameron pointed out Emma was already on tocolytics and that more steroids would lead to pulmonary edema. When the team resisted giving Emma steroids, Dr. Cuddy said this was exactly what Dr. House would do in similar circumstances. However, Dr. Foreman pointed out that Dr. House had already recommended fetal termination six hours ago. Dr. Cuddy went to administer the steroids herself.
The team became concerned about Dr. Cuddy's behavior and approached Dr. Wilson. He went to see Dr. Cuddy, who was treating Emma for pulmonary edema just as Dr. Cameron predicted. He reminded her this is why steroids cannot be administered in multiple courses and recommended terminating the pregnancy. She told Dr. Wilson to either get her a laryngoscope or leave the patient's room. Dr. Wilson chose to leave. Dr. Cuddy and the nurses managed to stabilize Emma.
Later, Dr. Cuddy went to Dr. Wilson for advice. She told him that they were all right - Emma's lungs were failing faster than the fetus's lungs were developing. She had stopped the steroids. Dr. Wilson reminded her that Dr. House wanted to terminate the pregnancy, but Dr. Cuddy asked what Dr. House would do if he didn't want to terminate. He reminded her that House would be objective about the problem. Although he wanted to impress upon Dr. Cuddy the need for termination, Dr. Cuddy decided instead to give Emma more steroids because she was already on a respirator and didn't need her lungs.
The fetus's lungs finally started to expand and Dr. Cuddy went to Dr. House for a consult. He reminded her she wasn't being objective, but she wasn't an idiot. The scans were inconclusive an could show broncho-pulmonary sequestration, diaphragmatic eventration, bronchogenic cysts, bronchial atresia, or lung lesions CCAM. Dr. House agreed to return to the hospital. The team discussed using an MRI, but there was no way to get the detail they needed. Dr. House asked them to imagine it was a one pound adult - how would they diagnose the lung buds? Dr. Cameron suggested a transesophageal echo, but they can't access the esophagus. Dr. Foreman suggested a CT Scan, but that much radiation would kill the fetus. Dr. Chase suggested a ventilation/perfusion scan, but that required a breathing patient. With all other options ruled out, Dr. Chase suggested exploratory surgery. Surprisingly, Dr. House agreed.
Dr. House and Dr. Cuddy went to Emma to get her consent. They told her the procedure would be dangerous and would risk both her life and the fetus. However, there was no other choice. Emma nodded yes.
They immediately scheduled the surgery, with a full observation room watching on. The initial incision was made to expose the uterus and the amniotic fluid was drained. The fetus was exposed and felt Dr. House's finger. They attached a pulse monitor and found it's vital signs were stable. They started the operation on the fetus and exposed the lesions, confirming lung lesions CCAM. The surgeon felt he could reset them. However, Emma went into defibrilation. Dr. Cuddy grabbed the defibrilator. After two unsuccessful attempts at reviving Emma, Dr. House reached for a clamp to cut the umbilical cord, but Dr. Cuddy ordered him away so she could try again. After two more attempts, Emma's heart rate returned to normal and the surgeon continued with the lobectomy.
After the operation, Emma recovered quickly and was told the fetus would develop normally. Emma thanked Dr. House, but he reminded her that it was his idea to terminate the pregnancy.
Dr. House reminded Dr. Cuddy that although she was successful, 99 times out of 100, both the mother and the fetus die. She said it was worth it for both Emma and her son.