Thursday, November 12, 2009


Today was all about misdiagnosis, overuse and misuse of antibiotics and delays in care. Of course all of these happen at home, but not to the same degree. Sometimes you can only sigh, roll with it, and do what you can do.

I saw a woman on labor ward yesterday who had been diagnosed with "pelvic infection" at 15 weeks gestation. This didn't make sense, because pelvic infections (like PID) are extremely rare in pregnancy. When I spoke to her (using a nurse who spoke Japadhola), I found that she was tender only over her bladder (but not her uterus) and had pain with urination and urinary frequency - so it was more likely a urinary tract infection. (At home, I would get a urinalysis and a urine culture. Here, no such luck.) She had been prescribed Ampicillin, Metronidazole, and Ceftriaxone (they tend to throw loads of antibiotics at everyone here, regardless of diagnosis). Nothing had yet been given (also typical), so I told them to give only the Ampicillin. Today, she was feeling much better.

There was another 15-week pregnant woman on the ward, who was diagnosed with a urinary tract infection. When I spoke to her, though, this sounded incorrect. She had been having pain and bleeding for almost a month, had been seen multiple times and been given antibiotics multiple times (see antibiotic overuse, above) but hadn't gotten better. She was understandably frustrated. An ultrasound 3 weeks ago had been normal. Concerned about the source of the bleeding, I wondered about vaginal or cervical lesions, or potentially spontaneous abortion in progress. I asked the nurse for a speculum to be prepared (this usually takes at least an hour). I never got one yesterday, so I came back today.

The same woman was still there, and still having bleeding. I had brought two of the study's medical officers to practice ultrasound (she needed one anyway), and we started to scan. Immediately I noticed that the entire fetus was collected in the lower uterine segment, and there was no fluid whatsoever. On interviewing her further, the "blood" that she had been seeing come out was very watery. Her membranes had ruptured over a week ago, probably, and the pain she was feeling was slow cramping, preparing to abort, most likely. I explained the situation to her. She was upset, of course, but wanted resolution. I had the husband go and buy some misoprostol at the pharmacy. (Later he told me that 2 pills cost him USh 20,000 - about $10. That means that a medicine that costs pennies at home costs $5 here.) She started the first dose, and almost immediately the cramping increased. I think she will deliver after 1 or 2 doses. I hope so, because I'm not sure the family can afford any more.

Another woman we did an ultrasound on said she was 3 months pregnant, but when we did the ultrasound, we found nothing in her uterus, just some small blood collected near the lower uterine segment. Discussion with the nurse revealed that the patient had had heavy bleeding the night before, and had likely miscarried.

During that ultrasound, the nurse asked me to see another patient who had just come in with pre-eclampsia. Her blood pressure was 180/120, her urine protein was 4+ (very high), she was having a severe frontal headache, scotomata (seeing spots), and epigastric pain. She looked ill uncomofortable, and glassy-eyed, although was conscious and responsive. The nurse had already given her some sublingual nifedipine, and when we repeated the blood pressure it was 110/70, but she still had all of the symptoms. I asked the nurses to bring some magnesium, which 2 hours later, she still hasn't received. I also asked for gloves to do a pelvic exam, which took 15 minutes to find. Her cervix is unfavorable.
No labs have yet been done, and the nurses don't think that the hospital lab can do liver function tests. (They have never heard of creatinine, so don't know if it can be done).
Our ultrasound reveals a 31-week fetus with oligohydramnios.
Clearly, this woman needs to be delivered, but there are several problems
1. There is no anesthetist in the hospital
2. She has no labs done, and her clinical picture is highly concerning for HELLP syndrome. If we do a cesarean and she is coagulopathic, she could die. Then again, if we don't deliver her, she could die.
3. We could induce her labor (she has had 5 previous vaginal deliveries), but with no fluid and severe pre-eclampsia, who knows if the baby would tolerate it and if she would survive the long induction process? There is no ability whatsoever to do an emergent cesarean - it takes hours to get a patient to theatre.
4. She is preterm. In the US, we wouldn't worry much about a 31-week fetus in this situation, but here, survival is more limited. The absolute minimum survival here is 28 weeks, but even then it's precarious, and 31 weeks certainly is not guaranteed. But the mother could easily die of her preeclampsia - and soon - so she must be delivered.

I stop by the lab to see if they can, in fact, do liver function tests, but the lab is empty and locked (for lunch?). There is a young man in a wheelchair looking very ill, grunting and gasping. His family is waiting with him outside the lab. Who knows if he will get seen in time.

We find out that there is one anesthetist around (how? why? I don't know.) and willing to do the cesar. But first he wants the ward doctor to see the patient and make his recommendation. This could take hours. The midwives and hospital staff don't know me yet, so it's understandable that they want the ward doctor to see the patient. But I don't know how long this will take, and I can only wait and hope that he comes soon and that the woman and her fetus remain stable until then. I also hope that as time goes by, and the hospital staff get to know me, this will happen less. Until then, I can only sigh.

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