Sunday, January 24, 2010

The Lady with No Vagina

(Disclaimer: This story may be considered gross by many of you out there. But it's so interesting, I had to post. It talks about vagina a lot, as well as tearing caused at delivery.)

MIDWIFE: Doctor, we have this lady. She has this abnormality.

ME: What is the abnormality?

MIDWIFE: She has no vagina.

ME: Ok....

MIDWIFE: She is in labor.

ME: What? I don't understand. How did she get pregnant?

MIDWIFE: It happens. What do you call it? Vaginal atresia?

ME: What?? Is she full term? How could she be pregnant?

MIDWIFE: It happens. We have seen it before.

This makes no sense to me. I head to labor ward to see the woman. She is 16 years old, and this is her first pregnancy. At first, I wonder if she really just has an abdominal tumor that they are mistaking for pregnancy. She insists she feels the baby moving. I palpate the abdomen - it sure feels like a baby.

I do a vaginal exam. My fingers go in about 1-2 centimeters, then stop. I can feel the baby's head very low, but there is no palpable opening, and no cervix. In some places, it feels almost like very dense adhesion the way you would feel in an abdomen that had had previous surgery. I am so confused. I palpate and palpate, try to lyse some adhesions bluntly, but I can't do anything. She is already bleeding a little from several exams.

I get the ultrasound and take a look, and sure enough, there is a full-term pregnancy inside. The fluid looks low, but the baby is alive.

I consider the possibilities. First, when did this occur? If she has been like this from birth, how on earth did she get pregnant? To put it bluntly, how did the penis get in? And how did the sperm get up into her uterus if there is no cervix? Could this have happened after she got pregnant?

Second, what is the diagnosis? She is pregnant, so she must have a uterus and ovaries - so it can't be androgen insensitivity. It could be congenital vaginal atresia. It could also be an injury that occurred after pregnancy. She is only 16 - maybe she tried to abort, they injured the vagina, and the wound healed like that? Maybe she put inside something caustic. It could be a vaginal septum or imperforate hymen. The anatomy is distorted from the very low fetus, and impossible to examine with a speculum. And why would it feel so adhesed? Still I've never seen either one, so it's possible.

Third, what to do? If it is congenital vaginal atresia or some kind of injury, then attempting a vaginal delivery would hurt the fetus and likely the mother. If it is a septum or imperforate hymen, then I could just make an incision and the rest of the anatomy (including the cervix) would be normal. But if it isn't either of those, and I make an incision, I could hit bowel or bladder or do some serious damage.

I make a couple of panicked phone calls - the first is to a respected Obstetrician in Kampala. He has probably seen this before. He doesn't answer. The second is to a friend from residency working in Rwanda. She recalls that in Benin, women would put some sort of herb in their vagina that would cause a terrible burn injury and lead to a fistula.

I go back to the patient and grill her. Did you put something in there? To make the baby come? Any herbs, any instruments, anything? She denies anything.
(As an aside, all of this discussion is far from private - the labor ward consists of 6 uncomfortable delivery "beds" in one big room, separated only by chest-high walls. There are some curtains, but they are not great. Everyone can hear everything, and for the most part see everything. One of the midwives has to chastise the patient and family in the next bed who are peering over curiously at the goings on with this patient.)

I decide that cesarean is the only option, which is what the midwives have been pushing for. I tell them to organize the operating theatre. One of our highly motivated study doctors volunteers to do the cesarean with me - I will probably need an extra set of hands to examine the anatomy, so I agree. He had examined her as well, and he was a stumped as I was.

No surprise, there is a delay in theatre. They have called the anesthetist, but can't locate the theatre nurse. They will call us when theatre is ready. The Obstetrician in Kampala calls me back, and explains that there is probably a pinpoint cervix (which allowed her to get pregnant) but it is congenitally abnormal and will not dilate. He says there is no use of caustic herbs known in Uganda. He agrees with my decision to section.

We go back to the clinic and wait. We tell the other doctors about the case, and they are also dumbfounded. "But how did she get pregnant??" they all ask. I'm glad I'm not the only one.

A short while later, I realize I have left something on Labor Ward, and, I return briefly to retrieve it.

MIDWIFE: Doctor, the patient has delivered!

ME: Which patient?

MIDWIFE: The same one.

ME: The one with no vagina?? How did she deliver?

MIDWIFE: But she did!

I walk over to her, and lo and behold, there is a baby between her legs, and an umbilical cord still leading up into her body.

ME: What? How? What??

MIDWIVES: She is ok.

Two elderly women come up and hug me exuberantly three times each. They are her family members. They raise their hands up to the sky and embrace me.

MIDWIFE: They are thanking you for the miracle.

ME: Did you tell them I didn't do it? I was going to cesar her.

It doesn't matter. I get many sequential hugs. I ask the midwives to call me when the placenta is out so I can examine the damage. They do, and I go with the other study doctor to examine her.

There are two large tears on either side of her vagina, what we call "sulcal lacerations." At the anterior aspect, there is a thin film of epithelium hanging, which apparently used to be attached posteriorly as well. This is what was blocking entry into her vagina, which she did have. We also see a normal cervix beyond that. We try to identify whether it is a vaginal septum or an imperforate hymen, but we can't because of the distortion from the delivery.

I review the anatomy with the study doctor. We identify the entire hymenal ring, the normal tissue, the cervix and the rectum. There is no damage to the rectum at all. I show him how we are going to repair each side. The tear on the right side will require the tissue from the torn septum.

Suddenly, I am called to a phone meeting I can't miss. The study doctor says he is comfortable starting the repair without me. He injects Lidocaine and starts. I run to the meeting. By the time I am done, he is back in the clinic, having finished the repair. I return with him to examine her, and find that his repair is excellent. We caution her that she must stay until Monday to be sure that the vagina does not re-heal shut, but remains open. Not surprisingly, she insisted on leaving the next day, and went home. Let's hope she heals well.

And thus, the lady with no vagina had a vaginal delivery. Nature fooled us yet again.

Tuesday, January 12, 2010

The Story of J

One of the Theatre Nurses, J, has been pregnant for what seems like 5 years. This is her first pregnancy. Her due date passed about 6 days ago, and every time I run into her, I ask “So where is that baby?”

Finally, yesterday she came in complaining of contractions. I knew she wasn’t in active labor – you can tell by looking (although I've been surprised before). But she looked somewhat uncomfortable. She was 3 centimeters dilated, and the cervix was pretty thin. Latent labor – not bad! She was admitted to wait for active labor.

Today, I am in a meeting with various hospital staff when my co-worker calls me twice in a row. I call her back after the meeting. “They came to find you from Labor Ward. One of the staff is in labor and not progressing, and they want you to see her.”

I suspect it’s J. I go to the Labor Ward and I find I am right. I review her file, and it looks like she went into active labor sometime overnight, but since then has progressed slowly. I look at her – she looks too comfortable for active labor. She has 1 contraction while I am in the room, but she cringes only a little. I doubt her contractions are very strong. It is now 11am, and by my exam she is still 6cm – the same as 2 hours ago. I can feel a prominent bag of water, her amniotic membranes. I break her water, hoping to augment her labor.

I write a note, and the midwives (and J) that I expect her contractions to pick up soon.

I come out of the room, and the midwives have several more patients for me to see. Miscarriage, malaria, menopause – I see them all, do ultrasounds on some. After about an hour, J comes out of her private room, huffing and puffing, cringing visibly when contractions come - more like what I expect for active labor. She says to me “OK, what are we going to do? Pitocin?” She desperately wants her labor to be over – that’s a good sign. I encourage her and go back to the clinic to get some work done. I tell the midwives not to examine her for another 1-2 hours, unless she is delivering.

When I come back 1.5 hours later, she has been examined, and is now 8cm. Great news! She is huffing and puffing still. She is in such pain, so uncomfortable. “Please help me,” she says. I apologize that I can’t do anything except help her baby come. One of the head nurses is with me (the one who examined her) and I start telling her about the pain control options we have in the US for labor – epidural, narcotics, etc. She loves the idea of the epidural. “Doctor! When are you going to get us that one? Maybe with you here, we can get that one soon. We need it!” I try to explain that you need trained professionals to place the epidural. “Is it expensive?” she asks. “I don’t think the medications themselves are expensive, but you need someone who knows how,” I say. “You find out how and you bring it to us,” she commands.

I tell J she is doing really well, and I will come back to check on her. 2 hours later, she is still going, but she doesn’t look very uncomfortable anymore. The contractions have subsided somewhat. On my exam, the head is lower and there is a thick portion of cervix left anteriorly. The midwives and I both agree that this phase has slowed, partially because the baby is facing forward, not backward (occiput posterior).

Internally, I think “Oy.” At home, this would be easy. She needs gentle labor augmentation. You would set up a pitocin pump, and start a very slow infusion of pitocin at a controlled rate not to overstimulate. But – what pump? How can I induce? But I know she doesn’t need a c-section. The baby is small, her pelvis has plenty of room, and she just needs that extra push. It would be such a shame to do a c-section now.

The midwives tell me that J had bought some pitocin just in case (the hospital ran out last week – surprise). I tell them to inject 10 units into a bottle of IV fluid. We hang it and I set the IV catheter to run the fluid very, very slowly. Then I exhale deeply and cross my fingers.

Two hours later, I return to the Labor Ward. It’s 5pm, and I’m worried. What if she hasn’t progressed? Maybe the pitocin drip is too slow. Should I increase it? But then, what if it becomes too fast? It could overstimulate and hurt the baby. My kingdom for an IV pump! It’s getting late – maybe I should just do a c-section because if she needs one later and there’s no anesthetist, that could be really bad. What to do, what to do?

I arrive on Labor Ward and open the door to the private room – it’s empty and clean. “She has delivered!” says the midwife on duty. She has already been transferred to the postnatal ward. I race over there and see J lying on her bed smiling with her baby daughter next to her. We laugh together and I give her a Ugandan handshake and an American hug. She says the pain increased soon after I started the pitocin, and she delivered after about 30 minutes. Her whole family is there, and they thank me. I look at the baby – she has a squashed top of the head from the occiput posterior, but she looks great.

I find the midwife who cared for J the entire labor. “You are still here?” I say. “I worked last night, I was here the whole day with her, and I am coming back to work tonight. I am very tired,” she says. Then she lowers her voice and says, “Thank you. Your pitocin worked. I was very worried.” I say, “You know what? I was too.” We breathe a sigh of relief together.

I know I have written about tragedies, but there are happy stories here, too.

Wednesday, January 6, 2010

One More

A midwife pulls me aside to ask me to see a patient who has just arrived.

"She has come for a D&C. She took the family planning injection twice, but she was probably pregnant when she took it, because now she is bleeding and they have told her she is pregnant. I am looking at her and she may be too far along for a D&C."

I look at the woman too. She looks pregnant, which probably means she is in her second trimester. I bring the ultrasound to figure out what is going on.

She speaks only Lugazi, which none of the people in this area speak - it is more common in Mbale, which is an hour away. Her husband is hovering at the window looking worried, and the midwives tell him to come inside to be with her and help translate.

I scan the woman. She has had 9 prior children - this is her tenth. She is 17 weeks pregnant, with a normal, live fetus. She has what looks like a complete placenta previa. Her bleeding stopped last night, and it was never very heavy, just persistent for several days. They had thought (hoped) that the family planning injection had caused a miscarriage and that was causing the bleeding, but this was not the case.

When I explain to the husband that the baby is alive and well, he looks stricken. I try to explain it as good news, but it's obvious that it's not. I try to encourage him to translate for his wife and he tries, but the more he processes the information, the less he communicates to her. He looks like he is going to throw up or cry. He says some things that I don't follow. The midwife explains, "She has suffered a lot with this bleeding and they are worried about her." He seems genuinely concerned about her, and very upset.

A medical student from Mbarara is on rotation for 3 weeks, and he helps me. When I say something in English, he repeats what I said (in English) for the husband. Sometimes he rephrases. When I ask the husband questions about the woman - does she want more children, does she understand why she is bleeding - the medical student "rephrases" but asking the husband his preference/opinion/understanding. How many children do you want? The husband says that he wanted 6 or 7 children, but they kept coming more. That's helpful, but what does she want? I am all for male involvement, but not at the expense of the involvement of the woman.

Finally, I specify that I want to know HER preferences and HER understanding. A midwife who can speak a little Lugazi tries to ask her. How many children do you want? The woman starts listing all of her current children. No, how many children do you want? She lists her children again. The midwife can't get her to state her preference (which I have found to be remarkably common here). Finally, the husband says "We had agreed. That is why we went for family planning. We didn't want more."

Still, I can't do anything about this one. In the US I could, but here it's illegal, and with her gestational age and her complete placenta previa, it would be dangerous.
I start to explain the plan for her pregnancy - she will come to see me in my clinic every month, I will check the placenta to see if it improves, and if it doesn't she will need a cesarean at term. Either way, she MUST deliver in the hospital. The midwives and medical student help me to emphasize this point.

The husband only half hears us. He still looks devastated. "But can't you take out the bleeding?" I am confused, until the midwife says "He means take out the pregnancy, but he doesn't want to say it."

I am sympathetic. They are dirt poor, and they already have 9 children to take care of. But I know I can't do anything. The midwives and medical student chastise him, lecturing him that we can't "kill the pregnancy" when it is this far along. This is true (in Uganda), but I feel his pain and I don't want them to scold him more for hoping it. Those who proclaim their total opposition to elective abortion should live in this degree of poverty before they make their sanctimonious judgement.

I review the pregnancy plan again with him. I ask him if his wife has understood, because I realize that most of our conversation has now been conducted without translating for her. The husband says "I have understood." The medical student says "He has understood and that is enough because he is her husband." I say, "She is the patient and she needs to understand." What if she starts to bleed again and he isn't around? (Not to mention the ethics of patient autonomy.)

I have him translate word-for-word my explanation of the placenta previa and the plan for the pregnancy. It is obvious that she had not understood until now. She also doesn't seem to want the pregnancy, although she is less explicit and more stoic than her husband. She asks similar questions - about whether I can stop the bleeding, and what to do if it happens again. Finally, when I feel like they have both grasped everything, I sit to write my note.

Later, outside the Labor Ward, I run into the husband again. I take his hand and apologize that I can't help him more. He thanks me, and he asks again if I can't take away the pregnancy. "We have 9 already - it is so many mouths to feed, so many bodies need clothes, so many school fees to pay. It is too much." He looks so sad.

I apologize again, and explain that it would be unsafe. It occurs to me that in their desperation, they might try to go somewhere for an illegal abortion. If it is unsafe for me to do a D&E, it would be fatal to get one illegally. The placenta previa would bleed rapidly, the fetal size would require larger dilation, and she would be unlikely to be able to get a sterile procedure or a blood transfusion if she needed one.

I don't tell him what I suspect, but I explain to him what would happen if I tried. "She could bleed to death. What is important now is her life." He echoes me, "Her life." I continue, "If we tried to remove the pregnancy now, she could die, and she would leave your 9 children without a mother. She should come and see me in this clinic, and I will help her in the pregnancy and the delivery. She should be very careful." He asks me to point out the clinic building and I do, repeating the date I have scheduled her for follow up in 4 weeks. He still looks upset, but he takes my hand. "I will take your recommendation, doctor."

I hope so.