Another night in the hospital last week has passed, and I again think about how weird and different practicing medicine is in Kenya, even in our great Kijabe Mission Hospital. The nigh of obstetric call started with handover. This is where the doctors who are leaving, but have covered the day, “hand over” the care of the patients in the hospital to the doctors covering the night. As I listened I felt my stomach drop a little as I realized the night would begin poorly. There was a young mother in the hospital whose baby had fetal hydrops which is a problem in which an en-utero infant for a multitude of reasons has swelling all over the body. These babies do not do well. She needed emergency delivery at 27 weeks of pregnancy, and we knew the baby would likely not be able to survive after delivery. Even more problematic was that she had a scar from a previous cesarean section which meant that we were going to do a preterm surgery. These usually go well, but they have their own increased risks. We took her back to the OR, and as I delivered the baby’s head through the uterine incision it looked so perfect, and I thought nervously that maybe we had the diagnosis wrong. But as the rest of the baby delivered the terrible swelling over the rest of the body was very obvious. He lived just 10 minutes before dying.
I came out of surgery to hear that a twin pregnancy that had arrived just a bit earlier had been evaluated and only one heart beat could be found. I placed the ultrasound on her abdomen and confirmed that one of the twins had passed. The mother cried as I told her, and her husband looked angry wondering what had changed in the last 10 days when her last appointment had shown two healthy babies. What could we say? She went quickly for an emergency surgery, and on delivery the first twin showed signs of having died several days prior. Its hard for a pregnant woman with twins to sort out the movements of her babies. She could not have known that all she was feeling were the movements of one of them.
Obstetrics can be a great joy when it goes well. But when it is bad, it is so sad. God help us all to show compassion!
I am back on the obstetrics service. Family doctors are good at floating in and out of different areas. Within the last year we have had family doctors working in pediatrics, internal medicine, obstetrics, the outpatient department and emergency room. For most of us it is a pleasure to move around the hospital. It keeps life interesting. The reason I am back on obstetrics is one of the volunteer obstetricians is leaving, and so the consultant staffing is a little bit low. So I am back to fill the needs of the hospital. We are starting this call right with a woman with severe pre-eclampsia, pulmonary embolism, and treatment with warfarin and one previous cesarean section scar needing an emergency surgery. She also has a large anterior uterine fibroid. Without explaining everything, let me say that is a tough case. Below is the team that will take care of it.
All my obstetric calls seem to take me on to places I do not want to go. My last call started with a older woman with severe high blood pressure at about 26 weeks pregnancy. These pressures were so high she was at risk of seizing, and her baby was not getting the blood flow through the placenta that it needed to live. So off to the operating room we went to deliver this too young baby. To complicate the matter there were big benign tumors all over her uterus. God is good and we were able to deliver her baby without too much difficulty. Unfortunately 2 days later her baby passed. 26 weeks is a threshold age for premature babies at our hospital where the chance of survival decreases. This same mother did end up seizing 2 days later from her pre-eclampsia, and is still in the ICU being treated for very high blood pressure. As this was going on we had a call that a patient was coming in with a molar pregnancy, which is a non-viable pregnancy that can transform to a cancer. She had been bleeding, although she was stable on arrival. Then another call came with a possible ectopic pregnancy arriving (an ectopic pregnancy is a non-viable pregnancy outside the uterus which can cause massive bleeding killing the mother). We started evaluating her, and a another call came in letting us know that a woman with a cancer of her hand (she was going for amputation of her entire arm the following day) who happened to be pregnant had unfortunately lost her baby. It is called an IUFD or intrauterine fetal demise. Did we need to induce now or wait until after surgery. We decided to wait and get the arm taken care of first. Another older woman rolled into the casualty (ER) with severe pelvic pain. We admitted her and it turned out that she had bilateral tubo-ovarian abcesses that were causing her to become septic. This are major infections of the female reproductive organs. Somewhere amidst all of this another woman arrived. She was 38 weeks pregnant, and she had a huge vulvar abcess due to an infected Bartholin’s gland. We admitted her to prepare her for surgery the following day. It was a busy night, and not all of it is exactly the bread and butter of family medicine. Oh yeah. I have just been switched off of medicine to do a month of full time obstetrics. The needs of the hospital must be met. 🙂 What have I got myself into?
This is what it looks like in the middle of the night right before doing surgery on a woman with an ectopic pregnancy. This mother of three came to our hospital with severe lower abdominal pain, a very fast heart beat, and low blood pressure. When we examined her abdomen it was very tender in the lower pelvic region. We did a quick ultrasound confirming our suspicion that she had a ruptured ectopic pregnancy. This is a surgical emergency. I walked quickly to the operating rooms and woke up the surgical staff, but I could not find the anesthetist. It turns out he was trying to help revive a 28 week baby who had been born two days earlier. I found him because the pediatrician called as I was sitting the in the OR and asked me how a different, critical patient in the ICU was doing. This other patient was admitted for severe HELLP syndrome. This is basically a multi-organ failure during pregnancy resulting in anemia, liver failure, clotting failure, and in this patient’s case she had developed blood clots in her lungs. I said she was stable, asking why she would want to know. It turned out this unfortunate woman’s baby had died. My on call anesthesia tech had been helping try to resuscitate the baby. Ari (the pediatrician) wanted to assess how the mother was doing in the ICU before she let her know her baby had died. I ran up to ICU to check on her, and I watched as Ari in the most gentle manner shared the bad news of our sick patient’s baby’s death. I walked quickly back to the OR, scrubbed in and opened up the abdomen of our ectopic pregnancy patient. The pelvis overflowed with blood and clots, but with suction the uterus was seen and the large ectopic pregnancy (this is a pregnancy outside of the uterus) was seen in the area where the fallopian tube enters the uterus. We took care of the dead ectopically positioned pregnancy, started a transfusion for the mother, and then closed up. I went home only to be woken to the news that another patient had a severe perineal tear from her early morning delivery. Back to the hospital I rushed to sew up this bleeding tear in the operating room. Today I have a lighter load, doing lectures in the ICU. I am so glad, because it was a tiring night. Oh, and its my birthday! A great start to year number 49. Yes that means I am 48 years old today. I cannot believe it.