Rare case of injustice in obstetric medicine

Pregnancy complicated by Acute Intermittent Porphyria (AIP) poses a multitude of ethical conflicts for the patient, family, and physician alike. In pregnancy, fluctuating hormones precipitate exacerbation of attacks that predominate as life-threatening seizures and acute abdominal pain [1]. The rarity of this high-risk obstetric complication emphasizes the under-representation of this concomitant etiology in scientific literature and therefore limited treatment and management options in obstetric practice. This reality presents conflicting views for both the equally susceptible patient and physician. In general, AIP studies provide evidence for avoidance of precipitating factors (hormones, drugs, starvation or dieting, and infections) in treatment of the disorder. However, naturally occurring hormone increases are inevitable in the pregnant patient predisposing her to neurotoxic effects that manifest as neuropsychiatric and neurovisceral symptoms [1]. The deficiency of porphobilinogen deaminase coupled with precipitating factors (such as hormone fluctuation in pregnancy) causes increased Haem biosynthesis and subsequent accumulation of porphyrin precursors [1].

The primary treatment for the AIP patient is limited to avoidance of the otherwise precipitating factors and has shown minuscule improvement in pregnancy outcomes [1]. In addition, this diagnosis in pregnancy complicates routine management of the otherwise healthy obstetrics patient as general and local anaesthetic and intravenous induction agents are contraindicated [1]. The limitation of resources for the physician to treat the patient’s condition has yielded poor fetal and maternal prognosis overall. This unfortunate reality has led the physician to review medical termination of pregnancy as an option in the management of the patient’s condition during initial obstetrics education and counseling with the patient [1]. This is one implication of how underrepresented patient populations face injustice in medicine. What do you feel should be done to improve the maternal prognosis for the AIP patient?

[1] Sahu, M. T., Rajaram, S., Saxena, A. K., Goel, N., & Ghumman, S. (2006). Medical Termination

of Pregnancy in Acute Intermittent Porphyria. Gynecologic and Obstetric Investigation, 62(1), 38–40. https://doi.org/10.1159/000091835