207: No One Is to Blame

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It wasn’t your fault, Claire.
Nor was it Jamie’s.
It wasn’t even Randall’s fault.

It wasn’t anyone’s fault.

All too often in medicine, as in life, simply horrific things happen to good people through no fault of their own.

claire in bed

We come to learn that Claire suffered a placental abruption.  The placenta has prematurely separated from the wall of the uterus, causing massive bleeding, contraction of the uterus and inadequate blood flow to her growing baby, ultimately resulting in the death of her daughter.

The raindrops beat on my face, on my throat and shoulders. Each heavy drop struck cold, then dissolved into a tiny warm stream, coursing across my chilled skin. The sensation was quite distinct, apart from the wrenching agony that advanced and retreated, lower down. I tried to focus my mind on that, to force my attention from the small, detached voice in the center of my brain, the one saying, as though making notes on a clinical record: “You’re having a hemorrhage, of course. Probably a ruptured placenta, judging from the amount of blood. Generally fatal. The loss of blood accounts for the numbness of hands and feet, and the darkened vision. They say that the sense of hearing is the last to go; that seems to be true,”

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

 

Blausen_0737_PlacentalAbruption
source

Risk factors for placental abruption include history of a prior abruption, trauma to the abdomen in pregnancy, high blood pressure, cocaine use, smoking, abnormalities of the uterus, and prior cesarean section.  Sometimes it will occur in the absence of any risk factors.

Placental abruption occurs in about 1% of pregnancies, and even now carries a risk of stillbirth or death within 1 week of life of up to 60%.[1]   When an abruption occurs and the mother’s blood pressure is found to be low, indicating substantial blood loss, a significant abruption has likely occurred.  As described in Dragonfly in Amber, Claire’s placental abruption was a catastrophic event.  She describes symptoms of hemorrhagic shock from massive blood loss, with numbness in the hands and feet and loss of vision.  Even now in the 21st century, she would have a very high risk of losing her daughter.

There was nothing that could have been done to change the natural course of this pregnancy.  Placental abruption is not caused by emotional stress. The emotional anguish involved in Claire’s learning of the duel and subsequently witnessing it was not responsible. Bed rest would not have prevented the placental abruption.  A change in Claire’s activities, less exposure to stress and highly emotionally charged events, less whisky and wine – none of this would have prevented this placental abruption.  She does not have any identifiable risk factors for abruption that we are aware of. This was a tragic and unavoidable event, despite our desire to discover a way we could have saved Faith.

Somewhere deep down, Claire knows this.  Overcome with grief now, she will blame herself and those she deems responsible for the circumstances surrounding the tragic loss of their daughter.  In the end, though, with time and healing, she hopefully will come to accept that this could not have been prevented.

holding hands at grave

Questions, comments, concerns, or suggestions for future Outlander medicine topics? I’d love to hear from you! Leave a comment here or find me on twitter @SassenachDoctor.

References:

  1. Am. J. Epidemiol. (2001) 153 (4): 332-337.
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