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.”