Splenomegaly

There is a patient on the antepartum ward who has been here a long time.

She is now 43 weeks and 1 day today. She has 1 prior cesarean section, resulting in a living child, followed by three VBACs, all of which died. The first died at 1 month of life, the second two were fresh stillbirths (FSBs). She desperately wants a living child.

She was admitted with severe anemia three weeks ago. At that time, her hemoglobin was 5, and her platelets were 68. In addition, the fundus seems small and intrauterine growth restriction is suspected (although biometry cannot be done). Adding to her dilemma, her spleen was enormous. Absolutely massive. It is bigger than her uterus. It was measured to be 26cm. It is so big that it hangs down her abdomen, creates a pannus, and pushes the uterus downward.

On admission she received 2 units of blood, and has basically been waiting since then. On the day I saw her, it was Ugandan Independence Day (Oct 9), a holiday, so no consultants were around, only the interns and postgraduates. Plus, the lab was closed.

I felt she needed to be delivered, but how? She has one prior scar; she cannot be induced here (there is no fetal monitoring). But with the levels of hemoglobin and platelets that she arrived with, a cesarean could kill her. Only packed cells are available from the blood bank; platelets have to be ordered 1 day in advance from Kampala, and not on a holiday. Plus, she would have to undergo general anesthesia because a spinal with platelets that low is too dangerous. Furthermore, the last time she had labs was 3 weeks ago – the hemoglobin went to 7 the day after the transfusion. But what were they now? Whatever had caused her anemia could be getting worse.

Her blood pressure had been measured twice over her stay (seriously). Both times, it was 140/80. We took it again – 145/88. Did she have HELLP syndrome? It would go along with the labs and the fetal growth restriction. Or did she have severe hepatosplenomegaly syndrome from chronic repetitive malaria, causing hemolysis and platelet sequestration?

We reviewed her differential diagnoses; no matter what, she needed to be delivered. If it was pregnancy related (eg. preeclampsia), then she would improve after delivery. If it was unrelated, then it would still be there after she delivered, and she had plenty of indication for delivery, given her postdates and growth restriction. The medicine service had been consulted, and they agreed. But how can we do a cesarean when we don’t know her hematologic status? She can’t pay for labs, and the lab refused to do it for free. The medicine consult offered to contribute some of their Poor Patient Fund toward drawing labs for her. (The Obstetric Service needs to establish a Poor Patient Fund.)

The labs did not get drawn that night. They waited until the next day, and then took her blood to the MSF Epicentre, where the labs were tested free. Her hemoglobin is 6.6, and the platelets 87.

She is still pregnant. She was seen by the anesthesiologist, who recommended transfusion and delivery tomorrow under general anesthesia. That is the current plan.