You’re Pregnant; What do you do if you think something is wrong?

This was a very exciting time in Beth's*[1], life. She had gotten married a year earlier and was now in the third trimester of her first pregnancy. As a health professional, she knew she was at a slightly higher risk since she was over the age of 35, but she felt she had a trustworthy OB/Gyn and that she was in good hands.

Then something strange happened. It was Friday evening, and the covering doctor notified her that her blood hemoglobin was 5. She noted that the on-call doctor seemed somewhat concerned but told her that her regular OB/Gyn would call her. The weekend passed, and when she didn’t hear anything, she reached out to me.

I had known Beth for many years; our parents’ friendship led to our relationship. While we did not talk often, our interactions were always warm.

She texted me and informed me of the situation. She had struggled with anemia since she was sixteen years old, and at 29 weeks of pregnancy, she was worried about the effect it could have on her baby.

I did not want to alarm her, but she had every reason to be concerned. Per multiple studies [2], anemia is associated with complications including preterm birth (giving birth to a baby before 37 weeks of pregnancy), placental abruption (where the placenta separates from the uterus), severe postpartum hemorrhage (excessive bleeding after the birth of the baby), intensive care unit admission, eclampsia (seizures associated with elevated blood pressures in the perinatal period), and even maternal death. The risk increases with the level of anemia. Per ACOG, severe anemia as defined by maternal hemoglobin levels less than 6 g/dL has “been associated with abnormal fetal oxygenation, resulting in nonreassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilatation, and fetal death. Thus, maternal transfusion should be considered for fetal indications in cases of severe anemia.” [3]

I was hopeful due to her lack of symptoms that it was a testing error, but I told her to address it “very, very soon" I advised her that they should repeat the test right away to double-check. We followed up the following day; her doctor’s response was that she should triple up on her iron and that she should see the hematologist in a week. That did not sit well with me. I didn’t agree.

I spoke with her and gave the best advice I could, including warning signs of when to seek emergency help. I shared recommendations on doctors and hospitals that I had obtained from other contacts I had in the area. Still, I was limited since I did not have access to all her information, and she lived in a state thousands of miles away, so I could not offer any more direct assistance.

She was not given any other appointments by her doctor’s office to get evaluated sooner.

A few days later, when she noticed some symptoms of shortness of breath, she visited a local ER (emergency room) with a good reputation and got appropriate testing and evaluation. Thankfully, on repeat testing, her blood count was in an acceptable range, and her evaluation for shortness of breath did not reveal any concerning findings. She progressed well for the remainder of her pregnancy. It appeared it was a “false alarm,” but...

She gave birth to a healthy baby and was about to be sent home. She noticed that her blood pressure was in the 140s or 90s. She was surprised because they were usually normal. She commented that they kept repeating it because they seemed to be focused on “getting her out of the hospital" She was discharged the same day as soon as they obtained one normal value.

She went home, and the next few days were a blur. She was constantly tired and stressed by the demands of motherhood. However, independently (possibly influenced by her career as a health professional), she intermittently checked her blood pressure. She noticed that it was elevated with values in the 160s and 90s. This time, she did not call the doctor’s office. Neither did she need me. She went immediately to the ER, which she trusted. She was admitted, diagnosed with postpartum preeclampsia, and remained in the hospital for five days until her blood pressures were in a safe range for her to return home. She noted that a relative had a similar story, but that relative, unaware of the early signs, went to the hospital when she had severe symptoms, was hospitalized for 2 weeks, and almost had failure of all her organs (but she lived).

I hear far too many of these stories, and the evidence is overwhelming that it disproportionately affects some women more than others. Beth is black.

I can’t help but think of the tragic death of Olympian Tori Bowie and the intersections with Beth’s story. Both had conditions related to elevated blood pressure in the perinatal (pregnancy and postpartum) period. Both are, by many standards, successful black women. For Tori, I have so many questions. Did she have a clinician to call or one that she felt safe calling? Was she ever educated on the warning signs of pregnancy? Did she try to reach out, only to be ignored? We may never get any answers for Tori. However, too many black women in America do not have a trusted clinician, are not properly educated about possible complications, and even when they call for help, they are ignored.

However, Beth’s story gives me reason for hope. Reasons that I would like to share with you if you are a black woman in the US, either pregnant or considering pregnancy, or if that identifies someone you care about.

Beth’s instinct and knowledge guided her to seek additional information even when her care team left her wanting more.

She called a friend. Even though I am well aware that many of us don’t have Ob/Gyn friends, if we explore our network, sometimes there is someone we know who can help.

Do you know the best maternal health facilities in your area? Do you know if they treat black mothers well?

Thankfully, there are more and more resources to help you answer that question.

Take advantage of the abundance of resources to improve your knowledge of maternal health so that even if they don’t tell you what to do, you still know what to do.

I believe Beth’s false alarm prepared her to take the appropriate steps when she actually did develop a life-threatening condition.

While she still had to be treated for several days in the hospital, her quick action likely reduced her risk of major complications and death.

It definitely should not have to be the responsibility of black pregnant mothers to always advocate for their health. I know that sometimes when women or their families advocate for themselves, the system still fails them. I know that the maternal health system in America needs to improve. Change is slow. Fortunately, many are working to make it happen, and we stand ready with you to help protect you and all our mothers.

[1] * name changed

[2] Auerbach, M., Landy, H. Anemia in Pregnancy Up-to-Date

[3] https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2021/08/anemia-in-pregnancy