Wednesday, September 22, 2010

Coming Back

I am back in Tororo for a brief visit. Only 2 weeks - much too short, but it's all I could fit in on this trip.

I am delayed by a day in Kampala due to car troubles, and when I finally arrive the next day, there are many hugs to be had. The midwives tell me they were excitedly waiting for me all day yesterday. It is wonderful to see them.

In the afternoon on the day I arrive, I am dashing out of the clinic to a meeting, and I see a woman sitting in the waiting area looking directly at me. When the patients who have come to see me (non-research patients) can't find me, they sit there, sometimes for hours, until they see me walking in or out. She is looking at me so intently that I know she must be there for me.

She approaches. She looks familiar, and I know I treated her for something, but I can't remember what. Maybe infertility? Pelvic pain?

"Are you looking for me?" I ask.

"Yes, for you," she says. "I have come many times for you, but they told me you are away."

"Yes, I am sorry, I have been away. What is your name?"

"P_____." I still can't remember what I saw her for, but it wasn't obstetric.

"Do you want to see me?" She nods. I can't see her now because of my meeting. I know that the next two days will be a blur of meetings because all of the investigators are coming to discuss all of the research that is going on. It should be calmer by Friday.

"Come and see me on Friday," I tell her. I give her my phone number and tell her to call before she comes, because I know that whenever I make plans like this, something comes up. I also tell her to bring any notes that I wrote, so that I can remind myself why I saw her and what I did.

The next morning, I find out that I need to go to Kampala for an urgent meeting on Friday. I feel guilty that I will miss P.'s visit, and I don't have any way to reach her. I hope she calls first. Just in case, I tell some of the study clinic nurses about her, and tell them that she should come back Monday.

While I am at work that day, I get a phone call from an unrecognized number. It is a different patient.

"Hello, Dr. Veronica! This is O______! The midwife told me you were here."

I recognize her name, because it is an uncommon name in Uganda. She is a college girl whom I treated after her illegal abortion went awry, and she had continuous heavy bleeding. I gave her misoprostol and the bleeding stopped. She was very grateful at the time and came to see me twice more to thank me before I left in July.
(The anxiety surrounding illegal abortion makes a mild complication feel life-threatening. The patients I treat after illegal abortion are often convinced I saved their lives, whether or not they were particularly ill.)

"Hello, O. How are you?"

"I am very OK, Doctor."

Now I am wondering why she is calling. Am I remembering the wrong person? Does she have an ongoing problem that I need to continue treating? There is an awkward pause. Finally, I ask.

"Are you calling me because you have a problem, or to say hello?"

"No, Doctor, there is no problem. I am only calling you to say hello and to thank you for helping me. I am very grateful. I am very happy."

The next day, I travel to Kampala. While I am on the road, I get a phone call from P. She asks if she should come on Friday and I tell her to come instead on Monday, but to call first. She agrees.

Half an hour later, I get a text from the same number: "Am so grateful thank you very much for the drug you wrote for me am happy and pregnant. God bless u. P_____."

It's good to be back.

On Monday, P. comes to see me, and I review my notes. She has HIV that is well-controlled on meds, and I had seen her for pelvic pain, infertility, and secondary amenorrhea (disappearance of menstrual periods). In order to try to determine the root cause of her amenorrhea, I started her on oral contraceptives for 1 month. When she started the placebo week of pills, she should have seen a period due to progesterone withdrawal. From my notes, it appears that she did not bleed after the 1 month of pills, so instead I gave her a 5-day course of progesterone, which is the same idea. Once the progresterone is stopped, she should see bleeding.

There are no more notes from me after I gave her the progesterone. She didn't come back.

She tells me that after the progesterone pills, she didn't see any bleeding, but about 2 months after that, she took a pregnancy test and it was positive. She is thrilled.

She had a history of two miscarriages, and had been unable to get pregnant for about 5 years. Her boyfriend (who also has HIV) left her because she couldn't produce a child. From my notes, I see that she had a hysterosalpingogram to see if her tubes are open, and she was told they are blocked. I surmise that I was reluctant to give her any ovulation-inducing agents in light of this information (no point in ovulating if the eggs can't get through the tubes), so instead I decided to focus on bringing back her menstrual cycle. As it turns out, somehow, unexpectedly (and without a period), she got pregnant.

I don't know if it was the medication I gave her that did it. I wouldn't have expected it, since she didn't have a period after either treatment. But she got pregnant soon afterward. Maybe the pills helped kick her regular cycle back into action, or maybe her pregnancy is just a coincidence. I don't know. Either way, we are both happy.

I confirm that she is still on her HIV meds and attending antenatal care. Her boyfriend is supporting her now that she is pregnant, although he is still in Kampala. Because she had no period, I decide to do an ultrasound to determine her gestational age. I'll admit that part of me is worried that the pregnancy is somehow abnormal or that it was a false-positive pregnancy test.

When I do the ultrasound, I see a healthy baby boy at 25 weeks. I turn on the doppler so she can hear the heartbeat. She glows.

As it turns out, her due date is in early January, and I just may be back by the time she delivers. I tell her to look for me when she goes into labor.