Tuesday, March 23, 2010

Molar Pregnancy

“There is another woman you should see,” says the medical student, “It is another fascinating and horrible case.”

I chuckle a bit at his wording – how awkward it is, but also how true. Medicine is full of cases that are fascinating and horrible. Patients who are suffering don’t want to be fascinating; they want to be cured and go home. But we, as doctors, went into medicine because it is fascinating. I love medicine. I love to talk about it, think about it, hear about it. We doctors don’t wish ill on patients by being fascinated. We are just genuinely interested and passionate about the practice of medicine. It’s what makes us good doctors.

“What is the case?” I ask.

“It is a molar pregnancy. I have never seen one,” he tells me.

A molar pregnancy (or “mole”) is truly a pregnancy gone awry. It started out as a pregnancy, but the genetics are all wrong. It becomes something that looks like just a huge placenta, and grows much more rapidly than a normal pregnancy would. Usually, there is no fetus. Rarely, there can be a normal fetus with a mole, but this is a very uncommon situation. There is a significant risk that the mole can have a malignant transformation – a pregnancy that becomes cancer. Most moles are not cancer, but it is nearly impossible to tell before it is removed and the pathology evaluated.

Classically, a patient with a molar pregnancy presents in the first or early second trimester of pregnancy with a uterus that is much bigger than expected for her gestational age. Sometimes she has pain, and often she has bleeding. Immediately, her labs are checked, and the Beta-HCG (the pregnancy hormone in the blood) is astronomically high. She sometimes has symptoms similar to hyperthyroidism – her blood pressure and pulse might be elevated, she might even be breathing a little rapidly. Sometimes her ovaries are enlarged from overstimulation. An ultrasound is done, and the contents of the uterus contain not a fetus, but a “snowstorm” appearance – a homogenous hazy quality similar to the fuzz on a malfunctioning black-and-white television.

If that pregnancy were allowed to continue, the woman would either eventually begin to miscarry on her own – at which point she would hemorrhage, likely to death. A molar pregnancy is extremely, extremely bloody. Therefore, a D&C is required upon diagnosis. Or the mole could transform into cancer, and she would then develop metastases. The most common site of metastasis is the lung. So before the D&C, the patient would typically have a chest x-ray to verify a lack of lung lesions. If malignancy is suspected or confirmed through testing, the D&C might be avoided and a hysterectomy performed.

This particular patient started bleeding at home very heavily, and came to the hospital. She was sent to the hospital ultrasound unit, where her husband paid USh 5000 ($2.50) for an ultrasound, which revealed a molar pregnancy. One of the hospital doctors was notified, and I see his note ordering oxytocin and misoprostol for induction, and something about a D&C.

At this point, I am not sure whether to be confused, stunned or horrified. This patient should not, under any circumstances, undergo an induction. It will only cause her to hemorrhage further. She needs a D&C – NOW. I say this to the medical student, who then insists that the doctor had ordered this medication only as backup for the D&C, in case of hemorrhage. I am pretty sure the student is fabricating, because the note does say “induction,” but whatever.

First I decide to fully assess the patient before making any recommendations. I review the chart further. She is 45 years old, and has 10 living children. This is her 11th pregnancy. Her last delivery was 1 year ago, and that child is still nursing. Her last menstrual period was in November. She doesn’t speak English, but her husband does. Her husband looks extremely frightened, and has come out of the Gyn Ward to the hallway to hover around me and the medical student as we discuss.

I go in the ward to examine her. She looks every one of her 45 years, and she looks uncomfortable. I ask about the bleeding, and am told that she has been bleeding very heavily for 2 days. Right now, the bleeding is lighter. She is also having abdominal pain. I notice that she seems to be breathing just a little bit heavily. It could be from discomfort and pain, but immediately I become concerned about lung metastases. I review the ultrasound report, which is pretty convincing for molar pregnancy, and the labs. Her hemoglobin is 5.9, which is extremely low. In the US, a patient would be transfused at that level. Here, she would not, but since she is currently bleeding and will likely lose blood in surgery, it is concerning. She is very pale. I also notice that her Urine HCG is negative.

Urine HCG is another way of measuring the pregnancy hormone. It is less sensitive than the Beta-HCG, but since the Beta-HCG should be astronomical in a molar pregnancy, the UCG should be positive as well. This is strange. In addition, there is the matter of her age. A 45-year-old has a low chance of spontaneous pregnancy, although if pregnant, she has a higher chance of an anomaly (including mole).

I turn to a midwife and explain that we should absolutely not induce the patient. “We know, Doctor. We saw that note and we were suspicious, so we wanted you to see her. We waited for you. We have not done anything.”

I am relieved to hear that. Love these midwives. Unfortunately, it’s 4pm on Friday afternoon. How am I ever going to get a D&C now? And if not today, then how can she wait until Monday if she is bleeding? The patient arrived around 11am. I wish someone had called me earlier, because I could have gotten the D&C done.

In the meantime, I reevaluate the situation. How definite is the diagnosis of molar pregnancy? It is important not to get stuck in the first diagnosis made by someone else, but to consider all possibilities. A 45-year-old has a low chance of being pregnant at all. But she has a 1-year-old child, so obviously she is a very fertile person. Another possibility is endometrial (uterine) cancer. The incidence of endometrial cancer increases with age, and although 45 is still a bit young, it definitely happens with increasing frequency after age 40. She has no risk factors for endometrial cancer – she has many children, she is not obese, and has no exposure to exogenous unopposed estrogen. However, if a uterine cancer were very advanced, it could possibly grow into a large intrauterine mass that might look like a molar pregnancy. That would also explain why the UCG was negative. Endometrial cancer does also present with abnormal, sometimes heavy, uterine bleeding, which would be consistent here.

On the other hand, the woman did miss her period for several months before the bleeding, which is more indicative of pregnancy. And one would not expect an endometrial cancer to form such a huge mass within the uterus (making the uterus visible and palpable from the outside) before metastasizing. It would be more likely to bleed before reaching that point, unless it was some kind of more rare uterine cancer, like a leiomyosarcoma or a carcinosarcoma. But it is doubtful that those rare tumors would look so much like a molar pregnancy on ultrasound.

Regardless of whether this is a benign molar pregnancy, a choriocarcinoma (malignant molar pregnancy) or endometrial cancer, this woman will need a D&C for diagnosis. She may need a hysterectomy later, but she needs a D&C now.

I bring my ultrasound over to scan her myself. It often helps to see the images oneself, not just read the report – which is one reason I am glad I was so well-trained on ultrasound in my residency. When I do the scan, I see exactly what the ultrasound report said – it looks very much like a molar pregnancy. I can’t be 100% certain, but molar pregnancy is highest on my differential.

The next step is getting the D&C. The midwife has tried to call the anesthetist for me, but he is gone for the day and his phone is off. I know that the chances of getting an anesthetist over the weekend are not good, but I can only hope. If not, it will be Monday.

On Saturday, she looks a little worse. The breathing is a little more labored, and her husband tells me she had severe abdominal pain overnight, although the bleeding is still minimal. I am getting more nervous. The anesthetist is available, but he refuses to do the case unless there is blood available. But there is no blood available in her type – only in B+, which we can’t use for her. Aargh. I try to make arrangements for the hospital to get blood from Mbale (where they usually get their blood supply), hoping we can do the case tomorrow, if the anesthetist is around.

On Sunday, she is even worse. Her breathing is more uncomfortable. I am even more nervous. Is this breathing problem really caused by possible metastasis? If so, that’s really bad and scary. It’s still possible that it’s being caused by a combination of her pain and the pseudohyperthyroidism from the molar pregnancy, although it is now seeming a bit too severe for just that. I try to listen to her lungs to see if there are crackles or wheezes, but it is hard to get her to take a deep breath. That is not uncommon here – patients never understand what I want when I ask them to breathe deeply, even with a translator – but it might also be because she is breathing too fast to take a deep breath.

I hunt down the anesthetist, but he still refuses to do the case without blood. I am really frustrated that the hospital didn’t acquire any blood yesterday. But what did I expect? It’s the weekend, and there is no one who is accountable for this problem. And now it’s Sunday, and the blood bank in Mbale is closed. The first time we will be able to get blood is tomorrow, probably in the afternoon when our research car goes to transport lab tests. Which means I won’t be able to do the D&C until Tuesday.

At this point, I am really wondering if we need to wait for available blood. I know she is severely anemic, and that moles tend to bleed heavily during a D&C, but how long can she wait? I remember one particularly scary mole I operated on in residency – we all were prepared for massive hemorrhage, but the bleeding wasn’t so bad at all. Maybe this will be ok too. But then again, if I do the D&C, and she does hemorrhage, and I don’t have blood available, she could easily die, and I would never forgive myself.

The husband has become increasingly panicked, and often comes to find me in the clinic or as I am walking by the labor ward. It is touching to see how concerned he is for his wife; I can’t say that most of the women on the labor ward have a husband who is so involved and concerned. I wish I could help them immediately, because I know how awful this must be for them. I feel terribly that my hands are tied. I have discussed the option of going to Mbale for treatment with him, but he very clearly can’t afford it. There are the transport costs, the costs of testing and medication, and the possibility that they will have to bribe one or more people when they get there.

On Monday, the patient looks awful. She has decompensated into full respiratory distress. She has retractions – use of the voluntary chest wall muscles to breathe, not just the diaphragm. There are tears in her eyes from the pain and fatigue of trying to keep breathing. In my head, I let out a string of curses, mostly toward myself. In my hope that she would be ok, I let myself believe that her breathing wasn’t as bad as it really was. But she was obviously getting bad so fast. Why didn’t I see this coming?

The husband says something that catches my ear – the patient has been having fevers. No one had told me that before. Maybe Occam’s razor is wrong in this case. Maybe she has a different reason for the respiratory distress. Pneumonia? It could be. I listen to her lungs. It is still hard to get her to take a deep breath, but I think I hear crackles on the left. Nonetheless, I have to try something, because she isn’t going to last long. I decide to treat her for pneumonia with Ceftriaxone. Her has to buy it from a pharmacy in town, as it is not available in the hospital. He starts to leave, then pulls me aside to ask if there is anything we could use in the hospital that he wouldn’t have to buy. I feel for him. They are so poor. In the hospital, then have penicillin (useless for anything other than syphilis, but used all the time), Gentamicin, and Flagyl. It’s possible that they might work, but the first line of treatment is Ceftriaxone. She is so sick that I don’t want to take any chances – if I wait until morning to see if the other antibiotics work, she could be dead. I know that Ceftriaxone is very inexpensive here, and although I feel badly for making him spend what little money he has, I know it is necessary. I gently insist.

Her respiratory distress could also be a pulmonary embolus, but if so, there is no hope. I won’t be able to get her adequate anticoagulation. But with this history of fevers, pneumonia is a definite possibility.

I am worried that she won’t make it until her husband gets back from town with the Ceftriaxone. I pull the midwives in to see the patient, and they all realize how sick she is. They help me drag the heavy oxygen concentrator all the way over from Labor Ward, and hook her up to the nasal cannula.

I hang around, writing notes and seeing patients. As soon as her husband comes back, the nurses give the Ceftriaxone. The patient reports some slight improvement on the oxygen. As we are standing there talking to her, the Principal Nursing Officer appears in the window, requesting the oxygen concentrator for a very sick child on Peds ward.

After the incident on Peds ward, I am determined not to lose another patient. I go over to the lab to find out about the blood situation. The head of the TDH lab is a very nice man, and he always welcomes me with a warm handshake. I tell him my problem, and he takes me over to the blood bank refrigerator, where I can see lots of blood in the B+ shelf, and all the other shelves are empty. I tell him that we have a car going to Mbale today, and that we can pick up blood for their blood bank. He is very grateful, and gives me a cooler to transport the blood, as well as a requisition form. I see he has requested for 10 units of my patient’s blood type, as well as multiple units of other types. I give the cooler and the requisition form to our driver to take with him on his afternoon trip to Mbale

The next day, Tuesday, the patient looks remarkably better. Her breathing isn’t perfect, but it is much improved. Her retractions have lessened, and she looks more comfortable, especially when on oxygen. Her husband reports that she slept better overnight. I am relieved, but will be more relieved when this pregnancy is out.

I go to find out about the blood. I learn that although our driver was able to obtain blood yesterday, they only had 1 unit available in my patient’s blood type. AARGH. Seriously??

I am fed up. I am not waiting anymore. This one unit will have to suffice. I can’t wait for her to decompensate completely. She needs this molar pregnancy out of her body today. I call the anesthetist, and he agrees to come and see the patient.

An hour later, the husband finds me walking across the hospital grounds, and he is very upset.

“This man came, and he is telling us why don’t we go to Mbale. I have no money, I can’t afford Mbale,” he tells me.

“I am not referring you, don’t worry. Who is this man?” I ask.

“He is from the blood bank.” That doesn’t make sense, so I walk with him to the Gyn ward to see if the man is still there.

When we get there, it is the anesthetist who is there, doing a preoperative evaluation. Now I realize he has been telling the patient’s husband to go to Mbale. I pretend not to know any of this.

I greet him. “So, can we do the case today? She is really suffering, I would like to get it over with. If we use the MVA, I can do it very quickly.”

To my surprise, he doesn’t say anything about Mbale. He agrees to do the case, although he complains about her respiratory difficulties. I agree that it is a problem, although now that I am treating her pneumonia, it is improving. He says something about how he can’t use ketamine with this patient because it can cause respiratory depression. I am not in a position to argue; I just want to do this case, and I don’t care what kind of sedation he gives. He tells me he will use a small amount of morphine instead. I know that morphine can cause respiratory depression, but I don’t put up a big argument, because we will probably be using small doses, and so it won’t matter anyway. This woman needs her D&C, and this anesthetist has stalled too long. We agree to meet in an hour in the theatre.

When I arrive in theatre, the anesthetist is not there, nor is the patient. I go to Gyn ward, and find her there with no one ready to move her. I ask the midwives to help me get her moved to theatre. I call the anesthetist to find out where he is. When he picks up, there is a lot of noise in the background, and he tells me that he has gone to St. Anthony to do a cesar. St. Anthony is the private hospital nearby, and apparently he has a second job there. So although he knew we were going to do this case, and this patient was very ill, he left to go do a case somewhere else. I am annoyed, but I can’t show it. He tells me to look for the other anesthetist. Fine, whatever.

The other anesthetist is there, and is perfectly willing to do the case. Phew. I find two theatre nurses reading the paper. They tell me that the D&C kits – which contain all the instruments needed for the D&C – are locked in a cabinet, and only the first anesthetist has the key. He has gone with the key to St. Anthony.

You have got to be kidding me. No way. I have spent 5 days trying to get this poor woman a simple D&C, then the guy disappears at the last minute, and takes the key to the supply cabinet with him. What the hell? I am about to be furious.

I make several confusing phone calls to him, trying to figure out what the hell is going on. I keep getting disconnected, or else he doesn’t understand and thinks that the second anesthetist has the key. There goes my last nerve. I don’t want to show my extreme irritation, so I try to stay very quiet, and just manage the completely ridiculous situation.

The second anesthetist helps me look for additional instruments. He opens the autoclave and starts pulling out instruments that might be useful. I am very appreciative that he actually seems motivated to get this case done, unlike the other guy. I start looking through the instruments myself, but I can’t really find what I need. There is no speculum either, but I suppose I can use an abdominal retractor in the vagina. Sheesh. But I can’t find a ring forceps or anything similar. I am nervous to do this case without at least a ring forceps to pull out a mass of tissue. She could really bleed, and I need to have at least some semblance of adequate instrumentation.

Finally, the first anesthetist tells me by phone that he is finished at St. Anthony, and he is bringing the key. I get an MVA from our stash in the clinic, and I change into scrubs. The theatre staff gets the D&C kit out. I put on a plastic apron and a gown, making sure to cover from head to toe in case of heavy bleeding.

I love the MVA (Manual Vacuum Aspirator). A typical D&C (Dilation and Curettage) is done using mechanical suction, which requires electricity. The suction allows you to remove products of conception and blood quickly, and less scraping (curettage) is needed. Here, the D&C is done without suction, because of a lack of appropriate attachments to the suction machine (which is hardly used even when needed). They just scrape away with a metal curette. It takes much longer, and is more crude and rough on the uterine surface. The MVA eliminates the need for mechanical suction. The MVA looks like a giant syringe, and on the tip of it you attach a plastic curette, which is blunt/round at the end, and has a hole with a slightly sharpened surface for scraping while suctioning. You engage the air seal, then pull back on the syringe handle, creating a vacuum in side the syringe. You then insert the curette into the cervix, and release the air seal. The vacuum pressure then causes suction to remove all products of conception from the uterus. You do that as many times as needed to completely clear the uterus.

Many things are nice about the MVA. It is extremely portable, so you can bring it with you anywhere – to the ER, to the OR, to Uganda. It doesn’t require electricity. Its suction is more gentle than mechanical suction, so usually the pain is less if the patient is awake. If a patient is really bleeding heavily in the ER, and you think that moving her to the OR will cause a delay that will allow her to bleed even more, you can just insert an MVA very quickly and finish within 2 minutes. It’s truly amazing.

In this case, the MVA is fantastic. The second anesthetist gives the patient light sedation with ketamine (apparently not a problem for him). Her cervix is already dilated enough to accommodate the curette. I set the airseal, create the vacuum, insert the curette, and release the seal. Immediately, blood and products of conception zoom into the syringe chamber. The products look exactly the way one would expect for a molar pregnancy.

To my surprise, there is no immediate hemorrhage when I start the procedure. I work quickly, emptying the syringe and reinserting the MVA over and over. There is a ton of stuff in her uterus. I save some of it for pathology, and dump the rest in a large orange garbage bin just below the operating table. I keep going and going. The anesthetist and the theatre nurse become curious, and move closer to observe the MVA in action. It is so neat, and so efficient, they can’t help but marvel.

As I continue the suction, I finally feel her uterus start to contract down and become smaller. What a relief. I continue, being sure to clear everything out of the uterine lining. Finally, it is done. All four walls of her uterus are clear of products, and feel gritty when I scrape. I have done the entire procedure with the MVA. I massage her uterus to confirm that it is firm and that no more blood is coming out. It is several times smaller than when I started. Before the procedure, it was between the size of a watermelon and a pineapple. Now, it is the size of an orange.
The theatre nurse and the anesthetist want to see how this amazing MVA works. I demonstrate the air seal and the vacuum, and they marvel over the device.

The patient didn’t lose much blood other than what was already in her uterus, which was a lot. But since she is so anemic and so sick, we agree that she should receive the unit of available blood. It might help her respiratory distress as well.

The next day, the patient looks great. Her breathing is almost normal, she is comfortable, and she is even smiling. I haven’t seen her smile since she arrived. I am overjoyed. Her husband looks relieved, and breaks into a huge smile when he sees how thrilled I am with her appearance. Everyone in the Gyn ward gathers around, even the ones who are not related to the patient. They know how sick she had looked, and can see how much better she looks now. My reaction is confirmation for them – everyone breaks out into smiles and chatter with each other. Several of the women gathered around shake my hand, as does the husband.

I keep her in the hospital a couple of more days. She is still very fatigued, and I want to complete the treatment for pneumonia, just in case she really did have it. Finally, I send them home with instructions to see me in my Wednesday clinic in 2 weeks. I take the pathology specimen with me to Kampala, and drop it off with a pathologist I know for evaluation. I hope that this mole doesn’t have malignant transformation, but I will deal with that possibility later. For now, I am so relieved to have finally done this much-needed D&C, relieved that it helped the patient so dramatically, and relieved that she didn’t hemorrhage during the procedure. Go go gadget MVA.

Friday, March 19, 2010

Growth Restricted

Every Wednesday, I hold a clinic in the Antenatal Clinic at TDH. It was originally intended to be a high-risk clinic, in which I would see women with complicated obstetrical problems, HIV, etc. The nurses in the clinic called it the “Risk Mothers Clinic.” In reality, I see any patient that the midwives don’t know what to do with. Sometimes, these are complicated cases, but sometimes they are very simple, like urinary tract infections, or benign abdominal pain of pregnancy. Still it makes me realize how much the nurses need the help – they are trained to be nurses, not diagnosticians, but they are forced, by the lack of trained physicians, into a diagnostic role that they are unprepared for.

There is no chart or patient file in the clinic. All information is recorded on an antenatal card, which is very limited in what it can contain, but also very dense. It has a lot of information about the pregnancy (dates of visits, blood pressure, fundal height, fetal presentation, doses of malaria and worm medication, bed net distributon) but not a lot of information about anything else – like pregnancy complications. The patient carries the card with her to each visit, and home after the visit. Surprisingly, it is very rare to get a patient showing up for antenatal clinic or in labor without a card. The women are very careful with their cards.

Usually, I can tell from the card why the woman has been sent to my Risk Mothers Clinic. Some of them have previous cesarean deliveries, some have HIV, some have abdominal pain. But sometimes, I can’t tell at all, so I ask the patient.

One particular woman was sent to me today. She is wearing a lavender dress in a style common in the villages here, and her hair is shorn very short. She speaks English, which is a relief for me. When I ask her why she has come to see me, she smiles broadly but sheepishly.

“When I lie down, my belly goes away.”

What? That doesn’t make any sense. She is laughing as she tells me, knowing it doesn’t make sense. I look at her abdomen – she looks about 30-32 weeks pregnant. I look at her card to see her last menstrual period. I use my pregnancy wheel to determine that if her period is correct, she should be 39 weeks pregnant today – her due date is in 1 week. That’s strange, as she looks too small to be full term, but perhaps she carries well. I ask her for her last menstrual period, and she confidently confirms what the card reads.

I have her get up on the examining table, and when she lies down, I see what she means. Her belly has disappeared. Now it is only a tiny mound on her abdomen – it looks about 22 weeks in size. I measure the uterus with a tape measure, and find that it measures only 24cm – equivalent to 24 weeks of pregnancy. How could that possibly be? She giggles at my surprise – knowing that I see now what she sees. Bizarre.

A nurse comes in, and I show her what I have found. She is surprised, too. She palpates the abdomen (they never use a tape measure) and declares that the head is low, and that the baby feels about 32 weeks in size – still smaller than 39 weeks. She hears a fetal heartbeat, but very deep.

It is clear that this woman needs an ultrasound, so I have her wait until I see the other patients, then I bring her to the research clinic to do the scan.

On the ultrasound, I see a head that looks bigger than 24 weeks. Then I notice that there is no fluid. I check for a heartbeat – it is there. Phew. I measure the fetus, and what I find is very strange. The head measures about the size of a 30-week fetus, the abdomen measures the size of a 24-week fetus, and the femur measures the size of a 34-week fetus.

When a fetus is growth restricted, it usually occurs in one of two ways – symmetric or asymmetric. Symmetric growth restriction means that the fetus is growing slower than expected, but all of the parts are proportional. It usually reflects some kind of intrinsic problem – a chromosomal abnormality, or bone abnormality, or even just a small but healthy baby (especially if the parents are small). Asymmetric growth restriction usually results from placental insufficiency – the placenta is not giving enough blood flow to the fetus.

The placenta implants early in first trimester, but its period of rapid growth is in second trimester. This is also when the fetus is growing rapidly. If something occurs to disrupt the growth or attachment of the placenta to the uterus, then the placenta can’t match the fetus’ requirements and gives an insufficient supply of oxygen and nutrients. This is placental insufficiency.

Placental insufficiency is usually slow in onset. The first reaction of the fetus is brain-sparing. The fetus shunts blood to the head, to preserve brain growth and function. This means that the abdomen is usually starved for supply, and the abdomen slows growth while the head continues. Before the overall growth restriction is evident, the abdominal circumference will be smaller than the other measurements. This is called an AC (abdominal circumference) lag. Sometimes, it means nothing, but sometimes it can be the first sign of impending growth restriction.

Once the placental insufficiency worsens, the fetus can no longer spare the brain, and the head growth slows as well. The femur length – the large long bone of the thigh – usually matches the actual gestational age fairly well, as those bones don’t tend to be as affected by overall growth restriction, but it can be slightly small.

At that point, the fetus will measure very small overall for its expected gestational age. However, it is still reasonably stable. Once the placental supply diminishes too much and the feuts is no longer getting sufficient blood flow to function, it ceases to urinate. This causes the amniotic fluid to become low, and eventually disappear altogether. Last, as the fetus becomes weaker, it will stop having spontaneous movements, lose muscle tone, and finally its heart will stop beating.

In this woman's case, her fetus clearly has severe asymmetric growth restriction, and anhydramnios (total lack of amniotic fluid). The fetus has a heartbeat and is still moving spontaneously, which is good. But it is clear that the fetus will not survive long in the womb. It needs to be delivered.

The first question is, what is the gestational age? The woman is very certain of her last period, had quickening and abdominal growth at the right time, and so should be about 39 weeks. But the femur is measuring 34 weeks – perhaps that’s the real gestational age. It is impossible to know. Regardless, a 39-week fetus and a 34-week fetus will do well outside the womb, and will die inside. This will not change my management, so I stop worrying about it.

Second, how to deliver? Ordinarily, I would want to try inducing this woman. Especially here, where cesarean deliveries are so morbid, and women have so many children, it is worth trying an induction. But would the fetus tolerate the induction? There is already no fluid, and it might be severely compromised and not tolerate labor. There is no fetal monitoring at all, and it’s unlikely that the fetal heart will be auscultated more than once or twice a day, even during the induction. But again, this question doesn’t matter, because this woman had a cesarean for her last delivery. Because she has a uterine scar, I can’t induce her labor. It might be possible back home, but it is much too dangerous here, with no real monitoring of oxytocin dosing, contraction frequency or fetal heart. And misoprostol induction is definitely contraindicated when a patient has a uterine scar. Therefore, she needs to have a cesarean.

I explain all of this to the woman. She understands, but is surprised and nervous. She didn’t bring anything with her to her antenatal visit, so she would need to go home and collect her things. This is common here – no matter how sick they are, the patients are always allowed to go home and collect their things. I have had some really sick ones who don’t come back, and I wonder what happened. She tears up, and we ask her what’s wrong.

“I have no one to cater to me.”

Here, women have to bring at least one attendant to care for them when they are hospitalized. That person cooks their meals, cleans their clothes and linens, gives medication, and basically does everything for them, depending on how incapacitated the patient is. The attendants are usually mothers, sisters, sisters-in-law, cousins, aunts, etc. I don’t know why she doesn’t have anyone, but I feel badly that she is so upset.

“What about your husband?” I ask. She doesn’t answer. “Tell him the mzungu doctor says that he has to come and care for you so that his baby can be born.” She laughs.

We agree that she will sleep in the antenatal ward overnight, and I will do the cesar in the morning.

The next morning, she comes to the clinic early with her husband. I do an ultrasound right away – and see that the fetus is still alive. They are relieved. The husband wants me to explain what is going on, so I review everything for him again. I explain the growth restriction, the danger, the need for cesarean. He agrees, but says something cryptic.

“Doctor, I understand. She needs this operation. I have nothing. What can you do for me?”

I am not sure what he is asking. He repeats this a couple of times. He might be asking if I want a bribe, I am not sure. I am too unsure and uncomfortable to address this directly, so I pretend not to notice and instead I say “I am going to do this surgery. We are waiting for theatre to be available, and then I will do it. Don’t worry.” After a couple of repetitions back and forth, he stops asking.

Then they want to talk about family planning. I know that they have had three deliveries – the first two were vaginal deliveries, and those two are alive. The third child was a cesarean delivery, and was stillborn. I ask how many more children they want, and they say they don’t want more.

“What if this child does not live?” I ask. “It is very small. I think it will be ok, but it could have problems, and may die. It is hard to know.”

It seems that the husband is still certain he would not want more children, because he does not want his wife to go through more cesareans. But the wife does not seem so sure.

“It is her decision,” he says.

I discuss tubal ligation, and then I bring up the possibility of an IUD. People don’t use IUDs much here – they are not culturally sensitized to IUDs, and no one really discusses them with the patients. People really like the injection, called Depo Provera. I find that acceptance of contraceptive methods in every culture (including my own) has more to do with cultural acceptance, norms and myths than to individual preference or knowledge about the methods. It takes a lot of education to overcome those myths.

Tubal ligation comes up again. I offer that if the baby seems fine when it comes out, I can cut the tubes, but if the baby is not fine, we can ask the husband (the wife would be under general anesthesia) and he can decide. They consider that, but have a different question.

“Doctor, in our village, there is work, in the fields. Cutting the tubes, it is difficult for the work. Can you do something else? Can you turn the – the what? – the tubes?”

I don’t understand this at all. It sounds like they want a tubal ligation, but instead of me cutting the tubes, they want me to “turn” them. In the US, a common misconception is that we can “tie” the tubes instead of cutting them. It’s an unfortunate misunderstanding due to the fact that we say “tie the tubes” when really we are cutting them (or burning or clamping, but in any case we are permanently damaging them akin to cutting, and leaving them permanently blocked).

I try to explain this. I tell them that they may have heard from other women about “turning” but it is really all cutting. They are not following.

“Maybe it is not the tubes,” says the husband. “It is turning. Is it the womb? Maybe you can turn the womb, so she won’t have problems in the fields?”

I have no idea what they mean, so I bring them over to antenatal clinic, where I can get a nurse to translate, and I can show them an IUD.

There, the nurse greets them and reviews everything in their language. Then she turns to me to explain.

“Doctor, they are saying that they have two children at home, but one child had cerebral malaria and now is not ok, is not normal. So for him, he is counting them as two children, but for her, she is counting as only one. She is not counting that sick child. So, he wants tubal ligation, because he doesn’t want her to suffer with more operations, but she is not sure.”

This is the perfect lead-in to my IUD spiel. In residency, I did a study of transcesarean IUD insertion – which means inserting the IUD through the uterine incision during a cesarean. It is surprisingly easy – you take out the baby, take out the placenta, insert the IUD, and sew up the uterus. What I studied was how often the IUDs fell out. When you insert an IUD after a vaginal delivery, it falls out a very high percentage of the time, and if the IUD is expensive (which it is in the US), this is a real waste. (When it is cheap, who cares? Put in another one. IUDs are very cheap in some countries, like Mexico). But after cesarean, the cervix is often not fully dilated, and you can insert the IUD very high in the uterine fundus, so it is less likely to fall out. Inserting during a cesarean also avoids the discomfort of insertion, and avoids the possible contamination from the vagina. When I studied this process in Mexico, it seemed to have a lower rate of falling out, but I was examining records of patients who had already had it inserted before. I designed a study to test the hypothesis prospectively in my residency hospital, but graduated before I could complete it, and passed along the study to a fellow resident.

Still, here, the IUD is not expensive. And in this woman, who is about to have her second cesarean, and who has a highly complicated pregnancy, has a large stake in not getting pregnant again soon. The best part about the IUD is that it is as effective as tubal ligation, but is reversible. If she does want another child in the future – whether in 1 year or 5 years or whatever – the IUD is very easy to remove and she remains just as fertile as she would have been without the IUD.

So I bring up the IUD with the patient and the nurse. As soon as I mention it, the nurse takes my lead, and brings out helpful pictures to show an IUD inside a uterus, and we show them a sample IUD – which is always reassuring to patients because it is very small. I am happy to see that the nurse is as comfortable explaining IUDs as other methods, and doesn’t seem to have qualms about it. I talk about inserting the IUD intraoperatively, and the nurse has never heard of this, but likes the idea. The patient likes this option, and therefore so does the husband. We decide on transcesarean IUD insertion.

Then starts the arduous carousel of trying to get the cesarean to actually happen. I go back and forth between the labor ward, the theatre and my clinic, scheduling and juggling other things. There is another surgery still going, so we need to wait until it finishes. Then the power is out. Then the power is back. Then there is no water. Finally, I decide that water or no, I am doing this cesar. We wil use water from jugs to wash. Luckily, the anesthetist agrees to this. It still takes another hour to bring the patient from labor ward to theatre. I’m not sure why. I try to expedite, but she is not in her bed, and she is not in theatre – where is she? I see the patient’s mother – who is her attendant – waiting outside the theatre. She waves to me, but doesn’t know where her daughter is.

Finally, she arrives. I am doing the cesar with S, a family medicine resident from Wisconsin visiting for the month. S is also struck by the patient’s tiny belly. It’s hard to believe that there’s a viable fetus in there. We get started on the cesar, and things go very well. There are very few adhesions. The uterus is so small that I have to do a classical incision on the uterus – vertical instead of horizontal – in order to have enough room to get the baby out. We deliver the baby easily, and it is unbelievably tiny, but really, really cute. A girl. She makes crying faces and moves around, but no sound comes out. There is meconium on her skin – it’s the baby’s first defecation (which is sterile) – and a sign of either stress or fetal maturity. There is no amniotic fluid. We are getting this kid out in the nick of time.

We start to stitch the uterus before I remember the IUD. We have the nurse open the IUD, and then I insert it very easily. I hope it stays in place. Meanwhile, the midwife who is resuscitating the baby is remarking how this baby is tiny but has all the signs of postmaturity.

“She looks like an old man!” she exclaims.

Even the cry is like a full-term infant, not a preterm one. The midwives can recognize this better than I can. The midwife is laughing at her surprise in seeing such a tiny, mature infant. We close the uterus and the rest of the operation is uneventful.

After we are finished, I leave the theatre and I find the patient’s mother still sitting outside, waiting. She shakes my hand very warmly, and says “Thank you” over and over. I see her again later after the patient and the baby have been brought to the ward. The patient is still sleeping but the mother shows me the baby. She is tiny and perfect. I suspect she was actually 39 weeks and severely growth restricted. “This is your baby,” she says. I laugh and say, “Mzungu baby,” and the mother and the other attendants laugh as well.

I return to the clinic, where the father is waiting for me, still looking worried. Maybe he doesn’t know that the operation is over and went fine.

“Everything is fine,” I say. “Mother and baby are both doing very well.”

“Yes, doctor, thank you. But I have a problem now. The baby is over-crying. What should I do?”

“Over-crying?”

“Yes, it is too much. What do I do?”

I laugh. “There is no over-crying for babies. There is only crying. A crying baby is a healthy baby.” He looks skeptical. “Don’t worry. Your baby is perfect, she is fine. She was just in the womb, and now she is out, so she is surprised. She might be cold. You hold her, keep her warm. She wants love.”

“She wants love,” he repeats, and breaks into a huge grin. “Thank you, doctor. Doctor, do you like pineapple?”

I know what he is getting at, but I don’t want him to feel obligated.

“Don’t worry about it. You are welcome. Everyone is fine, don’t worry.”

“Do you like pineapple?”

“Ok, yes, I love pineapple. But really, don’t worry. It is fine.”

“You love pineapple? That is great. Ok, see you tomorrow doctor.”

The next day, I find out the baby’s weight, which was 1.3kg, or 2.8 pounds. I visit her, and she is tiny and adorable. The mother is doing well too – smiling and comfortable, even though there is no morphine or codeine for pain – only diclofenac, which is like an IV version of ibuprofen. This baby was so lucky that her mother came for an antenatal visit when she did. Otherwise, she probably had very little time left in that womb.

The mother has a surprise for me. She turns in her bed to face me, smiling. “Her name is Veronica.”

Sunday, March 7, 2010

Oxygen

I am in the Labor Ward tending to a very ill patient and giving instructions on her care to the midwives when the Principal Nursing Officer suddenly appears in the window. She asks to borrow the oxygen concentrator from Maternity for a very ill child on the Pediatric Ward.

Oxygen is one of the most basic medical treatments available. Oxygen is routinely given during and after surgery, because their respiration can be depressed from anesthesia. People are given oxygen for asthma, any respiratory ailment, any cardiac ailment, sickle cell crises, and even certain types of headache. It is a very valuable and often lifesaving tool.

In an American hospital, oxygen is ubiquitous. Every hospital room has oxygen that flows from the wall, so that each hospital bed is equipped with oxygen if needed. Stretchers and wheelchairs are designed to have a place to secure an oxygen tank, so that a patient can be remain on oxygen in transit. If you need oxygen in an American hospital, you will get it.

This is not the case in Tororo. Oxygen tanks are difficult and expensive to transport, so there are none at TDH. There are oxygen concentrators, but very few and they often break and are not repaired. The theatre is supposed to have an oxygen concentrator, but it works only variably, and none of my patients have ever had oxygen in surgery – even when under general anesthesia.

The Labor Ward also has an oxygen concentrator, used for resuscitating infants after delivery. Infants are often quite hypoxic (low oxygen) after the strain of delivery – in fact, fetal physiology allows fetuses to routinely maintain levels of hypoxia that would be fatal to an adult. However, some fetuses develop such severe hypoxia in labor that they are stunned and fading when they are delivered, and require resuscitation. Such efforts are remarkably lifesaving – an infant that seems blue, limp and lifeless can be screaming within a minute or two, as long as the right techniques are performed. Teaching basic infant resuscitation to midwives is very effective at reducing the incidence of stillbirth (because some of those “stillbirths” are still, but not yet dead).

The child in Pediatric Ward needs oxygen, but I don’t know what to do. My patient needs the oxygen – so much so that I went to great lengths to drag the heavy concentrator over from Labor Ward to Gyn Ward, remove a different patient from her bed and move that bed away from the wall plug to plug in the concentrator, and set up the nasal cannula (the only available attachment) so that it fit the patient. But if this child is sicker than my patient, then perhaps we should give the oxygen to the child.

I decide to go over to the Pediatric Ward to assess the child myself. I walk there, and find a nurse, who takes me into the triage area where a woman is sitting with a two-year-old child in her arms. The little girl looks terrible. Her skin is wan and dry, her eyelids are half-closed, she is limp and her head is leaning backward, supported only by her mother’s arm. She is gasping for breath weakly. Good grief. I don’t know anything about children, but this one looks bad.

The nurse gives me a quick history that the blood smear was positive for malaria, and the child had recently been admitted at a private hospital for several weeks, but was sent home. I quickly assess her skin for rashes, injuries or marks, then pull out my stethoscope to listen to her heart. I am having trouble hearing through the coarse cloth of her shirt, and the neck hole of the shirt is too small to fit the stethoscope down, so I pull her shirt up to expose her chest. As I do that, I see a subtle change – she was limp before, but she suddenly goes slack. What the…? It can’t be. I put a stethoscope to her chest, and I can’t hear a heartbeat. I listen all over. I know that pediatric stethoscopes are smaller than adult, so I try using the small side of mine, but can’t hear anything. I am feeling for a pulse on her neck when I see the nurse looking at me ominously. She knows. She shakes her head, confirming what I want not to be true. The child is dead.

We don’t say anything to the mother, because we are both a bit stunned. The nurse informs me that she is not the mother, but the stepmother. The mother abandoned the child during the previous hospitalization, and this is the husband’s second wife. “The husband has just gone home to get some supplies,” the nurse laments.

What am I supposed to say? It’s hard enough to inform family of a loved one’s death in my own culture, but this is a totally different culture. What are the right words, the right actions? And did this child really just die in front of me? Should we have brought the oxygen sooner? And should I be resuscitating right now? I look at the girl’s lifeless body, her ruffled black denim skirt and black shirt with a red heart stitched on it. I look at the size of her body, and picture the child CPR I am required to re-learn every year. Is there a point to doing CPR? Then what would we do? We don’t even have oxygen, much less a defibrillator, a respirator, or basically anything that would keep this child alive. No, the aggressiveness of CPR would just shock and horrify the stepmother and every other mother lingering just outside the triage door.

The nurse hands me the chart, and I search it futilely for information. There is no information I will find that will bring the child back to life. I know this; I am reading the chart to avoid accepting the reality, for just one moment, that this child is dead.

I look at the child again. Who is she? Who would she have been? Would she have been a mother? Would she have stayed in school and become an educated young woman? Would she be playing with her brothers and sisters right now in a yard somewhere, maybe crying when she falls down? Would she see me in the road and shout “Mzungu!” while shrieking with giggles? It doesn’t matter, she’s dead.

The nurse looks at the stepmother. “The child has died. You must be strong. She is gone. You must be strong for her. You must not cry. She was too sick. You brought her here, you tried, that was good. But she was too sick. You must be strong.”

The stepmother’s face doesn’t change much, but she listens intently. Like many people here, she is very stoic. Then I see her lips twist a little. The nurse says a few more words of comfort. The stepmother says, “Then let me go home.”

“How will you get the body home?” asks the nurse. The stepmother shakes her head. “You will leave the body here?” The stepmother nods. “You must call a mortuary,” advises the nurse.

I don’t know the procedures, the customs, the rules. I feel useless, standing here, not able to say or do anything helpful. But I don’t want to interrupt either. I watch their interaction until it seems to end, although I’m not sure what the decision is. And this child is still in her stepmother’s arms, dead.

“I’m very sorry,” I say. I put my hand on her shoulder. It’s what I would do in the US, at a minimum. I don’t want to be too touchy in case it’s inappropriate, but I don’t know what else to do, and I want to show sympathy. I usually get some leeway for being a mzungu; our strange behavior can be chalked up to our foreignness. She doesn’t acknowledge my sympathy, but she doesn’t recoil, either.

The nurse thanks me for coming to help them. She is genuinely appreciative. I watch her for a moment, and imagine all the children she must see die in that triage area, without any guidance or assistance from any doctor. I don’t know how she does it.

I walk out of the Pediatric Ward. The other mothers don’t seem to know that anything has happened. On the cement walkway between Pediatrics and Maternity, I encounter a Pediatric nurse and one of the midwives pushing a stretcher containing the oxygen concentrator. They are having a hard time maneuvering over the chipped, uneven concrete with the concentrator sliding around on the stretcher. I wave at them to stop moving in this direction.

The stop, and look at me apprehensively, knowing what this must mean. “The child has died,” I say. They are both disappointed. The midwife shakes her head mournfully, and the Pediatric nurse laments aloud – telling us how difficult it was to get the IV in the child, how sick she looked when she arrived.

I feel a little bit shut down. I haven’t processed yet. If I had sent the oxygen concentrator sooner, would the child have lived? Later, I realize that the child was well beyond that. She was severely malnourished, and the malaria pushed her over the edge. She had been that sick for several days, as they had told me. Oxygen can be lifesaving, but not for a child that sick.

Children are dying like that all over Africa and all over the world. I know that, and it would be easy to write off this death as “just another one.” I don’t ever want to be the person who does that. I want to stay the person who is upset and moved by death, who needs a moment to recover after something like this. That child was someone; she was me, really, separated only by geography and luck. Maybe mourning this death is na├»ve or sentimental. I am not a particularly emotional person, but I don’t want to be so cynical that I see this death as anything but awful.