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Naomi was the pregnant patient in Babies & Bathwater.

Medical History[]

When she was 18 she had a baby girl named Grace who died of infantile Alexander's disease. She has also miscarried 3 times before. However, she was currently in the 28th week of an uneventful pregnancy.

Case History[]

Naomi, who was 28 weeks pregnant, was driving her drunk husband home. While talking about what things would be like when the baby came, Naomi momentarily passed out and they narrowly avoided a car crash. They were pulled over by a police officer who thought that Naomi was intoxicated. He made her perform a sobriety test as she seemed confused and continued to get more confused. Suddenly, she collapsed. An ambulance was called to the scene and she was taken to the emergency room at Princeton-Plainsboro Teaching Hospital.

The emergency room ruled out a stroke. There were no bleeds or clotting. However, her liver and kidney functions were impaired. Naomi thought it was preeclampsia and there was a possibility of miscarriage. Dr. Foreman was called in for a consult and told her that preeclampsia was a possibility. Naomi wanted to make sure that the baby was okay. Dr. Foreman told the patient and her husband that a nurse would be in soon to run some more tests.

Dr. Foreman and Dr. Chase brought the case to Dr. House. Dr. House asked for the results of the tox screen, but it was negative for drugs and alcohol. She was on oxybutynin for incontinence, however, when they took her off it there was no change. The patient's BUN and creatinine levels were up. Dr. Chase thought that it was preeclampsia. However her blood pressure was normal which ruled out preeclampsia. Foreman thought that there was an underlying physiology because of the patient's history of miscarriages. Dr. House suggested a pregnancy related autoimmune disease. He told them to check the blood. He also told them to do an MRA for vasculitis and an ultrasound. He also ordered magnesium in the event it was preeclampsia.

There was no sign of fetal distress on the ultrasound. Dr. Chase ordered bed rest and fetal monitoring, and put her on potassium and magnesium, and more fluids. Naomi was eating a pear when suddenly she started to choke on it. Dr. Foreman and Dr. Chase helped her by removing the pear. The patient realized she couldn't swallow.

They couldn't find any signs of vasculitis on the MRA. Dr. Foreman thought it might be a different autoimmune disease. Suddenly Naomi started getting cramps indicating premature labor. She told them that it felt like her miscarriage. They gave her medicine to stop the contractions. They started becoming less frequent.

Dr. Chase thought that the stress from the MRA combined with preeclampsia caused her to go into labor. Dr. Foreman was wondering about the myasthenia, which isn't a symptom of preeclampsia, however Chase argued that she didn't seem that weak. Dr. House asked what kind of food, and Dr. Foreman told him that it was a bit of cooked pear. House told them that that was way past muscle weakness. Dr. House told them to do an upper endoscopy. Dr. Chase suspected that there was something in her esophagus. He also tells them to check her eyelids.

Foreman asked Naomi's husband Sean if Naomi's eyes looked different to him. He told them that one was drooping a bit but that was probably because she was tired. Dr. Chase performed the endoscopy, and he found swelling indenting the esophagus. They needed to do an X-ray despite the risk to the developing fetus.

The x-ray revealed a three centimeter mass in her upper right lobe of the lungs that had to be a granuloma, had no calcification and indicated small cell lung cancer. The tumor was pressing against her esophagus. Although it hadn't metastasized, it had spread through her lungs, so they couldn't operate. The other symptoms were from paraneoplastic syndrome and Lambert-Eaton myasthenic syndrome. Naomi asked how bad it was, and Dr. Wilson told her that small-cell was the most aggressive kind of lung cancer with a 5-year survival rate of only 10-15%. They needed to give her chemotherapy and radiation therapy immediately. This would clearly require a Cesarean section to deliver the baby as it could not survive the treatment. Naomi asked what the chances were that her baby would survive. Wilson told her that it was about 80%. Naomi didn't like the odds. However, Dr. Wilson and her husband tried to convince her do it. When Naomi asked if waiting would improve the baby's chances, he told her that another two weeks would raise the chances to 90%, but postponing the treatment even for a week would reduce her chances to living no more than two to four months. Naomi refused to do the C-section or take radiation therapy despite her husband's urging.

Dr. Chase told Dr. House about the patient's decision. Dr. Foreman thought that she was trying to save her child. Dr. House wanted to "raise her odds", he went to find Dr. Wilson.

Dr. House found Dr. Wilson packing as he had just resigned after being dismissed from the board of directors. He told him that Vogler loves clinical trials so the hospital must be full of them, he thought that there would be one to help Naomi raise her odds. Dr. Wilson agreed to make some calls.

Dr. Wilson found a doctor that was doing a clinical trial and Dr. House spoke to him. The doctor asked him if Naomi was otherwise in good health, and Dr. House told him that she was. The doctor agreed to enter her into the clinical trial. The doctor told him that starting her the following week would be a waste of time because the disease would have progressed too far, so Dr. House assured him that she could start in two days.

When Dr. Foreman and Dr. Chase found out about the clinical trial they objected. Dr. Chase pointed out patients having surgery should wait at least a month before starting a clinical trial. Dr. House told Naomi that the clinical trial was for angiogenesis inhibitors which prevented new blood vessels from growing in the tumor. Dr. House told her the treatment would be fatal to the baby and that he had scheduled the C-section for that afternoon. The trial drug was successful in 30% of cases and Dr. House assured her the hospital has the best neo-natal facility in New Jersey. However, she was still reluctant. She thought that her baby's heart and lungs were still underdeveloped and told her husband that he doesn't know what it's like raising a sick child. Sean told House to talk to her, but Dr. House asked him to leave the room. When he did, Dr. House asked Naomi how long she had been taking oxybutynin, she told him that she had been taking it since she was twenty. Dr. House wondered why she had developed it at such a young age. He had deduced that at that age she had a sick child. Naomi told House the story of Grace, her first, child who was diagnosed with infantile Alexander's disease and died when she was two. She had not told her husband. Dr. House got her consent to have the C-section and to do the clinical trial.

Dr. Lim prepared to give Naomi the surgery. They gave her anesthetic, but Dr. Lim got off the phone with Vogler, who had canceled the surgery. They revived the patient. House confronted Vogler, saying that he had informed the patient of the risks. Vogler was worried about the effect of the patient's surgery on the trial data, which could keep the drug off the market. Dr. House accused him of killing the patient. Vogler said it wasn't worth one death to keep a drug off the market that could save thousands of people.

Sean thought that they could do the C-section and then the experimental treatment in a few weeks. However, Dr. Chase pointed out they would still need the permission of the doctor running the clinical trial. Suddenly the patient went into respiratory distress due to a pulmonary embolysm due to a blood clot. They needed to get her to an operating room for emergency surgery. Foreman informed Sean that enough blood was trickling past the embolysm to keep her alive and that these were not unusual in lung cancer cases, but they needed to do surgery immediately. However, he also informed him that the fetus was most likely dying from lack of oxygen and needed to be delivered by C-section immediately if it were to survive. However, it was also likely that if they did the C-section, Naomi would die given her current condition. Foreman told Sean that it was his decision as Naomi was unconscious. Sean told him that he just wanted Naomi to live and that they were not to do the C-Section if it would endanger her life.

Dr. Foreman and Dr. Chase started the surgery. Dr. Foreman wanted to use an anti-clotting drug, but Dr. Chase thought it would be too dangerous as she could bleed to death from the surgery. Dr. Foreman pointed out she was already hemodynamically compromised. When Dr. Chase pointed out the drug would also be bad for the baby, Dr. Foreman informed him that the husband didn't care about the baby. Dr. Chase administered the drug. Her blood pressure started dropping and the anesthesiolosist called for pressors. However, Dr. Chase didn't believe they had the time and started a procedure to suck out the clot. He succeeded and the patient's blood pressure stabilized and her oxygen stats improved. However, her blood pressure started dropping again. She had been given dopamine, but Dr. House noted was bleeding into her abdomen and there was no way to repair the damage. Dr. House ordered them to try to keep the patient stable and went to talk to Sean. Dr. House informed him that she suffered trauma during the surgery which resulted in irreversible bleeding. He asked for permission to the C-section, even though it would kill Naomi. Although the husband resisted, Dr. House pointed out that the only issue was whether she would die during the C-Section or in a few hours from the bleeding. Dr. House told him that Naomi would want the baby to live and that the baby would live if they did the C-section. The husband consented. The team the C-section, clamped the umbilical cord. The patient went into defibrillation. Dr. Chase intubated the baby as it was not breathing. Although Naomi could not be resuscitate, the baby started breathing on its own and was sent for pre-natal care.

Cause of death: Cardiac arrest from internal bleeding during surgery to remove pulmonary embolism.

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