Читать книгу Medical Romance December 2016 Books 1-6 - Sue MacKay, Carol Marinelli - Страница 15

CHAPTER FIVE

‘GEORGIE, LEO...’ CHARLIE BEGAN as Juliet entered the room carrying some handwritten notes on a clipboard along with the printed obs. ‘This is Dr Juliet Turner. She is the in-utero surgeon who has travelled from Australia to consult on your pregnancy. She will be providing another option with regards to the condition the boys have developed. I must say upfront that I’m not supportive of this option for reasons I have already explained. However, Dr Turner has flown a long way to explain the procedure and answer your questions so I will hand over to her.’ He paused and turned his attention to a very stunned Juliet. ‘Dr Turner, let me introduce Leo and Georgina Abbiati.’

Juliet couldn’t believe that he had just put doubt in the Abbiatis’ minds before she opened her mouth. Despite his apology and consideration in ensuring she made it to the consult, he was not giving her any other professional courtesies. She stepped forward with her hand outstretched. ‘Very pleased to meet you.’

Juliet knew she was up against his bias. He was stubbornly conservative and not open to accepting proven progressive procedures just as her father had suggested. It was not what she would expect at face value from the motorcycle-riding doctor. The two seemed miles apart. She drew a deep breath hoping Charlie would leave any further opinions until they were alone in his office and show a mutual professional respect and, as he said, hand over to her. She was not about to back away from her belief that the in-utero surgery was the best and most logical option for the patient. In the limited time Charlie had given her, Juliet had read the last few days’ patient notes and it was exactly as she had first thought: an open and shut case in favour of laser surgery. The twin-to-twin transfusion needed to be halted immediately.

‘It’s a long way to come just for our babies,’ Leo said as he tenderly stroked his wife’s arm. ‘And we appreciate it. This is a huge decision for us to make. It’s our babies’ lives we’re talking about.’

‘Of course it is and I was more than happy to travel here so that you and your children have options to ensure for the best possible outcome,’ she replied empathetically. ‘The hospital board and the Assistant Head of Obstetrics believed it necessary for me to come and discuss the next management strategy that can be employed. Can you please tell me what you know about your babies’ condition, so that I don’t repeat anything that either Dr Warren or Mr Darrington have already covered?’

‘We know that the two girls are okay and the two boys are sharing an artery or something so one of our boys is getting lots of blood and the other one not enough. Georgie’s been having a special diet hoping to get all of them big enough in case they came early anyway. She’s twenty-nine weeks tomorrow.’

‘You certainly have an overall picture of what’s happening. Twin-to-twin transfusion syndrome, or TTTS for short, is a condition of the placenta that affects identical twin pregnancies. The placenta itself is shared unequally by the twins so that one of your sons is receiving too little blood to provide the necessary nutrients to grow normally and the other too much and so his heart is being overworked. Your TTTS was diagnosed at stage three, which is already advanced, and unfortunately has progressed to stage four.’ Juliet paused. She knew that she needed to be honest but what she had to say would be hard for the parents-to-be. ‘I am not telling you this to add to your concerns but I need to tell it how it truly is and, while the recipient baby is coping at the moment, if we do not surgically intervene that can change quickly and he can suffer heart failure. If that happened, it would immediately cross to stage five and we cannot save him and you will only have three babies. And even then their survival will be compromised.’

The expressions on Leo’s and Georgie’s faces fell further. ‘What do you think, Charlie?’

‘I agree with Dr Turner that the boys’ condition is serious but I feel the high-protein diet has assisted with the babies’ gaining weight and if we continue on that path we may be able to deliver within the next two weeks if necessary.’

Juliet felt as if she were playing a polite game of medical ping-pong but she had to keep serving. ‘I would like to commend Dr Warren for the exceptional care he has provided to you and your babies up to now, but unfortunately your boys’ condition has worsened. I’m not convinced that without surgical intervention you’ll be able to carry four healthy babies for long enough for a good outcome,’ Juliet countered.

‘But I don’t understand why it happened,’ Leo said, oblivious to the battle of medical opinion that was being waged very politely in his wife’s room. ‘We’ve asked everyone and everyone has told us we did nothing wrong, but you’re the specialist. Be honest, was it something we did?’

‘Not at all,’ Juliet answered. ‘It’s something that the medical experts can’t predict. The events in pregnancy that lead to TTTS are quite random events. The condition is not hereditary or genetic, nor is it caused by anything either of you did or didn’t do. TTTS can literally happen to anyone having multiple births at any stage up until about thirty weeks.’

‘So it’s definitely not our fault?’

‘Absolutely not,’ Juliet responded again honestly and without hesitation.

‘Charlie and Mr Darrington told us that but it’s nice to hear it from you.’

Georgina’s expression, on hearing confirmation about the cause of her babies’ condition, was subdued but Juliet was happy that at least unwarranted guilt would not be another struggle for the quads’ mother.

‘We know the boys are in trouble but are there any risks to Georgie from the TTTS?’ her husband asked as he looked at his wife with loving concern.

‘That is something we have to consider, and another reason your wife is in Teddy’s on bed rest,’ Juliet continued. ‘Carrying quads is in itself quite taxing on a woman’s body and that stress has been increased by the TTTS. Her uterus is being stretched past what is normal for pregnancy—’

‘Should you just wait then and take the babies in two weeks as Charlie says and not put Georgie at any risk?’ Leo cut in.

Without giving Charlie time to interrupt, Juliet answered quickly. ‘Actually no. That could’ve been a consideration if, since the diagnosis two days ago, the condition had not progressed, but it has and, for want of a better word, aggressively. I’m not convinced that the recipient baby would survive until thirty-one weeks. If the pregnancy was just twins, we could deliver at twenty-nine weeks. However, with quads the babies are still very small so if we can prolong the pregnancy another few weeks by having the laser surgery, the babies will be bigger when they’re born and that will make their lives easier. At the moment they are all less than three pounds and we no longer have time on our side to observe their growth.’

‘Like you said, Dr Turner,’ Georgina responded, ‘we agree that Charlie has taken such good care of me up until now we’re really struggling to think about ignoring his advice. Perhaps we should have the needle and stay with bed rest.’

Charlie drew in a deep breath, plumped out his chest, and in Juliet’s opinion looked like a pigeon about to mate. His polite interruptions made her believe their professional battle would lean towards a gentleman’s sword fight, but a fight nonetheless, and she was right. But for the good of the mother and her babies, she would not hold back. There would be a level of professional courtesy, but she would not cower to him. Juliet was prepared to argue on the evidence-based merit of surgery and then leave the decision where it should lie. With the well-informed parents.

‘While the needle you spoke of, an amniotic reduction, can work well in stage one patients, you have moved past this option very quickly. Teddy’s brought me here to discuss laser surgery and the benefits and they would not have flown me halfway around the world if there was any doubt that surgery was a viable and preferable choice for you.’ Juliet paused for a moment, then continued with a serious timbre in her voice. ‘But I won’t lie to you, there are risks in the surgical route as there are with any surgery, but the benefit far outweighs the risks. I also must let you know that if you choose to proceed with the laser surgery, then it would need to be this week. On Thursday or Friday at the latest as time is not on our side if we decide to help your sons surgically. If we leave it too long, your body will make the decision for us.’

Juliet watched Georgina’s and Leo’s expressions darken. It was a lot to process and, while she had not wanted to put additional pressure on either of them, she felt all the facts had to be stated. Time was unfortunately not on their side and that was the harsh realisation they all needed to accept. To deliver four living babies, something had to be done. She just prayed they chose surgery.

‘Can you give us more details, like what the surgery involves and how long it will take?’ Leo asked as he ceased stroking his wife’s arm and reached down to hold her hand tightly.

Juliet stepped away from the bed to give the couple a little more space. Hearing news and making potential life-and-death decisions, she knew, was overwhelming and they needed to feel safe together in their own space. ‘Of course,’ she began and then noticed that Charlie had brought her a chair. She wasn’t sure if he was being gallant and considerate or if he was trying to make her appear weary. She didn’t waste time deciding which it was, instead choosing to graciously accept the chair and continue.

‘The operation involves endoscopic surgery using a laser beam to cauterise the offending arteries and halt the exchange of blood between your boys. Each baby will remain connected to his primary source of blood and nutrition, the placenta, through the umbilical cord. The use of endoscopic instruments allows for short recovery time and no effect on the other babies and would be done only once during the pregnancy.’

‘Dear God, we pray if we go ahead it’s just one time,’ Leo interrupted as he looked into his wife’s tear-filled eyes. ‘Georgie’s been through so much over the last eighteen months with the three rounds of IVF, and that was unsuccessful, and then finding out we’re having four babies conceived naturally. And now this heartbreaking news about the transfusion while I was away.’

‘Leo, you’re suffering as much as me, and you had to make the trip to New York,’ she told him as she mopped the tears that threatened to escape. Her eyes were reddened from too many nights of crying. ‘We’ve both been through so much and we’re doing our best to stay strong together.’

‘And we will. No matter what, we’ll get through all of this. And we’ll take our babies home to where they belong. Their nonni, all four of them, are waiting to meet their grandchildren.’

Juliet nodded. ‘That’s my plan and I’m so pleased to hear your positive outlook. That’s exactly what your babies need.’

‘Ah, you know Italians, we’re a strong race and our children will be fighters too.’

‘Goodness, Leo,’ Georgina said. ‘You sound like my father!’

‘Well, it’s the truth,’ Charlie added. ‘You and Georgie have been strong and focused since the diagnosis and that’s why you should not completely rule out continuing on the current conservative path.’

Juliet swung around on her chair with a look of indignation. She could not believe what she was hearing. Charlie clearly had not handed over to her as he’d promised. Fuming but unable to tell Charlie how she felt, Juliet regained her composure, turned back to the couple and continued. She would let Charlie know in no uncertain terms how she felt about his interference, after the consultation. But for the moment she intended to calmly give Georgina and Leo all the information so they understood it was their choice, and theirs alone.

‘Minimally invasive fetoscopic surgery is the name of the procedure and it is aptly named because it’s minimally invasive. It involves small incisions and I will be guided by both an endoscope and sonography. Essentially it’s keyhole surgery so far lower risks than open foetal surgery, which is completely opening the uterus to operate on the foetus.’

‘But there’s still a chance it could go wrong?’ Leo asked anxiously, looking from Juliet to Charlie.

‘Yes, but not undertaking the surgery has equal if not greater risk,’ Juliet said honestly and, armed with further facts, she elaborated. ‘I do not want you to be under the misapprehension that the safer choice is doing nothing as that is quite incorrect. In the past the twin survival rate with severe TTTS was very low, around ten per cent before ultrasound made it possible for us to make an early diagnosis and the introduction of laser surgery. I think you should consider taking advantage of this medical advance. In years gone by women had no choice but to wait and pray they did not give birth to a stillborn baby. As I have mentioned excess amniotic fluid caused by the TTTS is causing your uterus to grow to an unsustainable size. It’s a condition called polyhydramnios, and it can cause premature labour.’

‘I have a fifty-four-inch waist now.’

‘Yes, that’s a combination of four babies and the fluid and it will continue to increase,’ Charlie added. ‘We’re monitoring that and can continue to do so, and perform the amniotic reduction procedure.’

Juliet bit her lip again. Charlie was not allowing her much space to move.

‘Georgina, you will be monitored in hospital until all four babies are born, no matter your decision. However, I’m suggesting surgery because there are four very tiny babies still growing inside you and they need optimum time to grow. The final decision rests with you.’

Georgina shifted on the bed and raised her feet again. Her rounded stomach was still covered by the sheet and lightweight blanket, but only just. Her pretty face was almost hidden by the mound that held her precious babies. Juliet knew the young woman’s ribs would be excruciatingly tender from the pressure of four babies.

‘So you can definitely separate the blood supply?’ Georgina finally asked.

‘The tiny telescope in your uterus will allow me to find and destroy all the connecting vessels. This is the only treatment that can disconnect the twins.’

‘How common is it for parents to choose laser surgery?’

‘Laser surgery is now performed all over the world as more and increasing numbers of progressively attuned doctors are convinced that this will lead to the best outcomes.’ Juliet’s words were directed at Charlie but she did not pause over the words or look in his direction. Two could play at the same game. ‘Most physicians worldwide agree that placental laser surgery results in the highest numbers of healthy survivors.’

‘Including those in the UK?’ Leo enquired.

‘Yes, particularly in a hospital like Teddy’s.’

Georgina and Leo gave each other a knowing look. ‘Would I be awake?’

‘Yes, Georgie, you’d be awake. You would be under conscious sedation and local anaesthetic for this procedure. We need you and the babies to be relaxed and pain free during the procedure but there’s no need for a general anaesthetic.’

Leo straightened his back, took a deep resonating breath and looked at Charlie. ‘Charlie, by what we’re hearing, and the urgency of everything, are we right in thinking we have to make the decision tonight? It’s a lot to take in and not a decision we want to make in a hurry.’

Charlie cleared his throat and stepped a little closer. ‘Not quite tonight but, yes, if you choose Dr Turner’s surgical option you would only have a day or two to make that decision. However, my plan would not see you making any changes other than looking at prescribing heart medication as pills given to Georgie, or injected directly into the twin if he is showing signs of heart failure. We can also look at another therapy using medication to decrease the urine output in the recipient and lessen the amount of amniotic fluid that is causing Georgie’s uterus to expand.’

Juliet bit her lip. She could counter but chose not to do so. She had said enough and if they chose the non-surgical option she would remain on staff at Teddy’s to help in any way she could, including the delivery. But she hoped they would choose her way forward and she would be able to use her surgical skills to increase the babies’ chances of survival and happy and healthy lives.

Georgina and Leo looked at each other with what Juliet knew would feel like the weight of the world on their shoulders but their love for each other still shone brightly in their eyes. Finally Leo spoke. ‘Is it all right if we sleep on it?’

‘Of course,’ Charlie and Juliet said in unison then they too looked at each other. But it was not lovingly; their look was more of an aloof stare.

Juliet had felt as if she were on a roller coaster since she’d touched down at Heathrow, and even before that with the last-minute packing. But now it was a different type of roller coaster. The emotional type. And for which she had not willingly purchased a ticket, nor even had any idea she would be experiencing. But in the few hours since Charlie had stepped into her life and lifted her tiny daughter into his arms, she had ridden highs and lows that she’d never imagined. He was opinionated and brash; considerate and caring; her old school colleague and stubborn opponent; and still, to her annoyance, attractive.

He was quite the package and she definitely didn’t want to peel back too many layers or get too close. Charlie was confusing her and, working together for the next few weeks, she wondered how successfully she could avoid getting to know more about him. A conservative, bad-boy biker with attitude who seemed to adore children, or at least her child. Could he be any more complex? She doubted it.

And she wasn’t convinced she wanted to understand Charlie Warren.