Eclampsia with Pulmonary Edema

The ink had hardly dried in my pen that wrote the Death Review forms of the last maternal death. Today morning, I had another shocker of a patient. 

GD, another young mother-to-be at term pregnancy came to us with hardly any breathing, and putting forth pink frothy phlegm with each gasp and having seizures. GD had gone into labour at her home in the adjacent district yesterday evening. The family thought that everything was going on normal. 

Around midnight, GD started to have seizures and became unconscious. They could not arrange a vehicle till dawn. In between, she had 3 more episodes of seizures. 

They reached the first healthcare provider sometime around 5 am, who referred her to the adjacent district hospital. They went to 2 more hospitals, both of whom referred them to NJH. 

Something which was quite disturbing was that in none of the hospitals did a doctor examine the patient. Considering into fact that she had seizures and she was unconscious, it was quite pathetic that nobody took her blood pressure, leave alone give her a dose of Magsulf. 

Well, as soon as she reached NJH, which was around 10 am, we had to intubate her and hook her on to the ventilator. I clearly remember all the eclampsia patients who had come to us with pulmonary edema. We could only save one of them. SDe was her code name. And this is the fourth patient. The other two died. 

Accidentally, a technician from Medisys, our provider of ventilators had come down to service of ventilators. He was quite taken aback by the load which we were putting on our ventilators. He started explaining to us that we needed more high end Intensive Care Unit ventilators to deal with such patients. Well, that would cost us about 600,000 INR. 

Our basic ventilator was not enough to deal with GD's problem. We bagged her manually. And she was maintaining saturation. However, the pulmonary edema was worsening. With a huge dose of Lasix and a GTN drip, things appeared to have settled. 

However, we had more problems. The baby appeared dead and there was sepsis. Most probably a dead baby in the uterus for long. The per vagina finding was hardly encouraging. 

We discussed with the relatives and took a decision to do a Cesarian and take the baby out. I know I would have enough consultants contesting this decision. 

Per-operatively, there was pus inside the uterus. The baby was macerated. The uterus was so unhealthy that couple of times, the thought of doing a hysterectomy crossed my mind. Then after we sutured up the uterus, the uterus was not contracting. B-Lynch suturing was done. The uterus was so flabby that we had to do it twice over. 

GD continues to be on GTN drip and on ventilator. Please pray that she would make a smooth recovery . . . 

Magnesium Sulphate . . .

In this part of the world, we continue in the holiday season. Today and tomorrow is Chatt, a local festival where the Sun is worshipped. And therefore, the outpatient crowd was quite low. The inpatient is a bit busy as there are quite a number of sick patients. Mr. Loric Singh is out of ventilator, but continues to remain sick. Please pray that he'll be completely healed. 

After the quite busy obstetric crowd couple of days back, we've had a relatively free day yesterday. Although there were 2 patients with Eclampsia, one went to a higher centre and the other had a uneventful instrumental delivery

Just as I was coming out of the hospital, there was this primi lady, UD looking quite sick who was just wheeled into the labour room. With a Glasgow Coma Scale of 3 or 4 and laboured breathing with gurgling sounds, she does not look to stand a chance. She had been having seizures since daybreak. It's already crossed 12 hours. 

The only best part was that someone has managed to give her Injection Magnesium Sulphate. Injection MagSulf as it is known has become a life saver for patients with eclampsia and pre-eclampsia. There are quite a few of my friends who campaign for making Magsulf available with the ASHA workers (called Sahiyas/Mitanins etc).

Drugs given elsewhere. It is very rare that we get to know what was given elsewhere. 

I'm sure if it was not for Magsulf, UD might have had more than a dozen seizures. She's had only 3 episodes. 

However, after the Magsulf, she was not managed actively. Ideally, she should have got for a Cesarian section immediately. That did not come to pass. I think they were expecting her to deliver normally. 

She's already in severe sepsis with aspiration pneumonia.

With the customary death on the table consent, we took her for Cesarian section. 

The baby was sick . . . however, he should survive. Apgar was 5 and 8 at 1 and 5 minutes. And, UD was breathing without the ventilator after the surgery. . . quite an encouraging sign.  

The night is going to be crucial. Please pray that UD would do well. 

However, patients like UD remind us that Magsulf may only one part of the solution. Unless we have full fledged centres who are catered to deal with sick patients, we may not make much progress with controlling maternal morbidity and mortality.