The girls nobody want

One of the ladies who regularly attended antenatal care at NJH came in labour today morning. She was quite a complicated case. RnD was 30 years old. This was her fourth pregnancy. Only couple of months back, she had lost her only son to malignancy at the tender age of 4 years. She had 2 daughters.

During her antenatal check-ups, she used to insist that she have a normal delivery although her second delivery was through a Cesarian section. We had mentioned to her about the possibility of a Cesarian section.

When RnD arrived today morning, she had already been in labour at her home for almost 12 hours. She was dilated about 8 centimeters and a uneventful vaginal delivery appeared on the offing. However, I was a bit doubtful about the rotation of the head. I gave the option for a Cesarian section to the relatives. However, they were quite vehement about not going for a Cesarian section. I managed to convince them that the maximum we could wait was 3 hours.

Unfortunately, things did not progress as all of us wanted. She got fully dilated but there was a poor descent of the head. I had to take a call for a Cesarian section. To my surprise, the relatives were quite vociferous in opposing the surgery. Later, I found out that the baby had passed meconium . . . thick pea soup colored meconium.

I reviewed things with the relatives. They did not want anything to do with a Cesarian section. After a lot of haggling, they agreed. It was only in the middle of the haggling that it struck me that most probably the relatives knew that RnD was expecting a girl baby. I mentioned it to few of my colleagues. They also agreed.

Then after I had talked with the relatives, I came to the Labour Room and found to my dismay that the patient was arguing with the nurses for having to undergo a Cesarian. One of the nurses scooped up a blob of meconium and showed it to the lady and told that the baby was eating this stuff. She agreed.

We had the baby out in about 10 minutes. There was meconium aspiration. The theatre team did a good job at resuscitation. However, the process of labour had done the damage. A second stage Cesarian is many a time an obstetrician’s nightmare. There were tears of the lower uterine segment which extended to the pelvic region. It was very much similar to the Cesarian Ihad in the morning, but tougher.

Post surgery, I went to talk the relatives to tell about the sick baby and the difficult surgery RnD had to undergo. The family was distraught. They very well knew it was a girl. The husband confessed that they had found out that this pregnancy carried a girl fetus. I gave them the option of taking her to a higher centre to ensure that she did not develop Meconium Aspiration Syndrome. I could not believe my ears when they told that they did not mind even if the child died.

I wondered how many more Indira Gandhis, Pratibha Patils, PT Ushas, Sania Mirzas, Sainas, Kalpana Chawlas etc we need to see before we realise how precious our little girls and sisters are for each one of us.

As I sign off this post, one more story which could end up true . . .

I just had a lady in her fourth pregnancy nearing 8 months of pregnancy who has walked into Labour Room complaining of lost fetal movements. The ultrasound has confirmed a fetal death. As I announced it the family members I was quite taken aback by the shock and the disbelief that enveloped them. The grief was much more than what I usually witness. 

I suspect that the lost baby is a male. They must have known earlier. The first three children are girls.

I shall let you know tomorrow. I’ve induced labour for her . . .

Tale of 2 ladies . . . and a third one

(This post was done on Monday, 7^th October, 2013. Our internet connections are back to a very poor state of affairs. With Supercyclone Phailin on the way and the Dussehra festivities on, it looks a remote possibility that we would have fast internet connections for the next week too)

My yesterday’s Sunday duty (6^th October, 2013) was quite a light one. There were only 2 women in the labour room throughout the day. One of them was rich and the other poor.

However, both of them shared the characteristic that they were not taken very seriously by their families. The reason? Both of them were high risk pregnancies. And neither of the families was bothered about it.

The first one RD, was quite well off. This was her second pregnancy. The first one was quite an eventful one. She had severe pre-eclampsia and she had delivered a pre-term small for gestational age baby. She had come four times for antenatal care of her second pregnancy. 

Each time, she was told to come more often so that we could ensure that we make an early diagnosis of any high blood pressure. The first 3 visits were in the first and second trimester. 

Her last visit was 3 days back. She was almost nearing term and she had a blood pressure of 150/100 mm Hg. We had advised admission.

She went off home and came today after she started to contract. The blood pressure remained high. I just received news that she delivered.

I would say that her family should have been more careful with her treatment. They’ve got away with very lazy approach to her present pregnancy.

The next patient, SD was not that well off. Her blood group was O negative and her last haemoglobin was 8.5 gm%. We had seen her in outpatient more than a month back. The doctor who had seen her had well explained need for blood as well as absence of a blood bank in NJH. Of course, the difficulty of getting a O negative donor was also put across well.

The patient came in labour. There was no sign of arranging for any blood. Rather couple of male relatives vent their anger at us for not telling them things early.

SD was lucky. Being her second delivery, she progressed so fast that she delivered soon. Gladly, there was not much blood loss. The mother and baby are doing well.

Again, one more case which could have gone awry.

Well, there was a third lady too. She was not that lucky. I hope things will turn out well for her in the couple of days.

This was her 5^th pregnancy. We’ll call her CD. She has only 2 live children . . . both girls. 2 of her babies had died. The urge to have a boy child resulted in this pregnancy.

I’m not sure about her regular antenatal care. But, the relatives told me that she was not doing well since the last 3 days. And she is just into her 8^th month of pregnancy.

Her complaints . . . headache and blurred vision. They had gone to 4 hospitals over the last 3 days. In fact, they returned home after a circuit of hospital visits only on Friday evening. She was given a clean chit everywhere.

Today morning around 9 am, CD had multiple episode of seizures. The family rushed her to a hospital in the nearest town. The doctor told the family that she is very sick and only NJH can do anything. The reached around 2 pm.

Blood pressure was 210/140 mm Hg and Urine Albumin was 4+. The family had lost count of the number of seizures she had. In fact, when I reached to see CD in labour room, she was continuously seizuring.

She has not yet gone into a HELLP Syndrome. But, she is very sick. We’ve induced her. Please pray that she will deliver soon.

The first two cases were outright instances of ignorant and careless family members.

But, what about the third case? The medical fraternity had failed her. A typical complaint of pregnancy induced hypertension, headache and blurred vision, was totally ignored. The shocker. . . 

The family was very sure that nobody in the four hospitals had checked her blood pressure!!!

I have only one prescription in my hand. There is no measured reading of any blood pressure.

How long will we tolerate this sort of management?

PS: CD delivered the next day (8^th Oct, 2013). She got discharged couple of days back. 

A Silent Prayer

This one is a guest post by Dr Angeline Zachariah, my better half. Trained as a Clinical Pathologist (DCP, 2008 Batch, Christian Medical College, Vellore), she is a big help in outpatient department and the Laboratory. Angel, as she is popularly  known, belongs to the MBBS Batch of 2000, of Medical College, Trivandrum. 

It has been quite some time since I've been praying for MD. She has been coming regularly for ante-natal care since the last 2 months. 

Today she came about 1 week past her expected date of delivery. And we have induced her. 

The reason for my prayers . . . 

MD has been married for about 7 years. She has 2 children . . . both girls. 

When MD first visited us for ANC, she told her story. It was with much difficulty that her in-laws agreed to let her visit a hospital for antenatal care. Her husband was also not interested. The obvious reasons . . . her 2 pregnancies have resulted in 2 girls. 

She narrated how her husband had refused to see the first born when he came to know that the baby was a girl. It was when one of our nurses told him to leave the baby in the hospital that he took a peek at the baby. 

In fact, it was her brothers who forcibly brought her for antenatal care and now, for the hospital delivery. When they went to bring her to her mother's home, she was bluntly told by her husband to not return to him if the third baby was also a girl. 

However, there was something that encouraged me. She told me that she was determined to educate her daughters now that she has seen me . . . a lady doctor. 

As I talked to her every time she came for antenatal care, I realised that this lady is in the danger of being abandoned by her husband. It is not uncommon that we see wives being abandoned just because they could not deliver a male progeny. I could not help but pray that she has a boy baby. 

When I returned home, I wondered if it was right for me to pray that she has a baby boy . . . or should I fervently pray for a change in heart of the husband and the in-laws? And of course a change of heart of the communities/societies we are in. 

Syphilis . . . Forgotten foe . . .

Syphilis . . .The very mention of the term used to send shudders in patients and was the darling of medicine professors for quite a long time. It was described as 'the great imitator' by Sir William Osler. One of my professors used to tell that in the olden times, a post-graduate student of Internal Medicine was assessed by how much he knows about syphilis and it seems that the same status is presently enjoyed by HIV-AIDS. 

Well, why I started a post of Syphilis? Over the last week, I had two families diagnosed as having the TPHA test positive. None of the members of the family had any symptom. 

Here are their stories . . . I know there may be quite a lot you may want to comment on them, which I would like to hear . . . 

The first patient was MS, on whom we had to do a Cesarian Section after a complicated trial of labour elsewhere. Before the Cesarian section, MS was diagnosed to have a low hemoglobin and we asked her relatives to arrange blood. The husband had her same blood group and he was ready to arrange blood. Well, on screening of the donor we found out that he is TPHA positive. As a rule, we do not do TPHA on patients who come at term. We do them only for those who come in the first trimester.

Well, by that time the Cesarian was over. We tested the mother and the baby. Both were positive. They very well understood when we counselled them about the disease. 

When I rejoined NJH in June 2010, I had done a re-look at the blood tests we do. Since, almost all of our patients are poor, we were trying to cut down on the tests. We did not find any TPHA positives in any patient for almost 2 years. There were few HBsAg positives and no HIV positives among the antenatal patients. I decided to drop doing TPHA, the main reason being that quacks were quite prompt in prescribing antibiotics and therefore I came to conclusion that this must be the reason that there was no TPHA positive for so long a time. 

However, the protocol was do TPHA in the first and second trimester for all ante-natal patients and drop it for those who come in late third trimester or directly to labour room. 

I was contemplating on whether I should bring back the policy of doing TPHA for all pregnant patients when the next patient arrived. 

One of our antenatal patients who landed up in labour room was found to have a reactive TPHA which was missed in the antenatal period. There was nothing much we could do now other than to re-check TPHA. Unfortunately, the TPHA turned out positive and after the delivery the baby also was reactive. 

I called the father, a man in the armed police force. The fellow looked quite disturbed and a bit drunk. I told him about the TPHA reactive status of his wife and child. He seemed to be hardly bothered. The only thing he wanted was to go home ASAP. I told him that he also needed to get tested. He would have nothing of it. He told me that he had issues to attend to at home and therefore needed to get discharged immediately. 

We tried our best. Ultimately, armed with consent forms on what all will happen and accepting full responsibility if something untoward happens in the future, he was off with his wife and child. 

Questions I have in my mind . . . 

1. TPHA is expensive. Should I do it for all pregnant patients irrespective of when they come - especially when they reach Labour Room straightaway after Antenatal Care elsewhere. Most of the places, VDRL or TPHA is not commonly done. 

2. When I have patients like the latter, what do you do? They are high risk to the community. 

3. Could we have donated blood from the TPHA positive husband to the TPHA positive wife? We had a bit of difficulty getting blood after the husband was refused as a donor. Crossed my brain only now . . . it could have been done. 

2 Happy Families . . . Could have been tragedies . . .

Over the last week, in addition to the tragedy of 3 members of a single family getting burnt, we did have our moments of joy. . .

The first reason for the same was SD1. SD1 came about 10 days back in a terrible state. It was SD1's first pregnancy. There was no antenatal check up. She had turned up at the neighbouring district hospital after being in labour at home for some time. It was sometime before the people there realised that SD1 looked a high risk case.

SD1 had a hemoglobin of 5 gm%. On per vaginal examination, the cervix was edematous with dilatation of 5 cms and there was meconium pouring out. I was in a fix. The referral letter mentioned that SD1 is being referred to Ranchi. We needed blood. There was only one bystander.

I was thankful when the blood matched. But, one pint was never enough. I was sure that the hemoglobin would be lesser than 5 gm%. However, we had to do the surgery. Otherwise, we risked having a rupture uterus and a dead baby.

We went ahead with the surgery. The baby was sick. But, he somehow pulled through. The bystanders were  quite fast is arranging two more pints of blood. It was quite a relief when SD1 recovered soon to be discharged.

The challenge for us was the bill. Because it involved 5 blood transfusions and neonatal care, the total bill was around 20,000 INR. The family was too poor. It did not need much convincing that they would not be able to afford even half of this bill. They paid about 10,000 INR. The rest went as charity. It is a burden for the hospital. But, considering our vision and mission, we have to make such concessions. . . 

The next patient was SD2. Married for 14 years, the family did not have issues. The interesting aspect was that she had a whopping 8 abortions. And the saddest part was that she did not take much interest to do any antenatal check up during the present pregnancy. The delivery was uneventful. It was a pleasure to watch the joy of the family as they adored the new arrival. 

The last one was 2 days back. SS had come with usual labour pains after an uneventful antenatal period. On arrival in labour room, Dr Johnson diagnosed a breech presentation. Since she was a multi, we did not anticipate much problems. But, as soon as the breech was out, Dr Johnson was sure that there was one more baby inside. And yes, she had a surprise twin delivery to add to her already large family of 3 children. 

All the 3 deliveries, especially the first two could have ended up as tragedies. We are thankful that all the babies and mothers are doing well.

Over the last 2 weeks, the 'marriage season' has started in this region. It is very hilarious. Everything revolves around the weddings. Almost everybody in the ward requests for a discharge citing excuse to attend a wedding or to get married . . . We expect quite complicated cases to come in during this period. In addition, we have students from the Christian Medical College, Vellore visiting us for the next 2 weeks. Do continue to follow the blog . . . there should be interesting posts continuing . . .