Ignored symptoms

I'm not sure about the category into which this blog post will fit. This is more of an educative post. 

It's going to be 4 years since I've been at NJH for my second stint. There are 2 conditions in pregnant women which I've found here that people do not take seriously. 

The first one is preterm rupture of membranes and second one, urinary tract infections. 

First - Preterm Rupture of Membranes. Over the last 2 days, I've had 4 of them. All mismanaged elsewhere. 2 of them sent home with no proper advice, leave alone antibiotics. One turned out to be so bad that the endometrium and the baby was stinking. 

Even I've found that it's very difficult to convince people that once the waters have ruptured, it is almost a irreversible thing. Two days back, we had a lady who had been leaking since 8 days. Her liquer volume had come down to dangerous levels, but she and her family just could not understand that it was dangerous for her and the baby. They only wanted us to give them some medicine to seal the leak. 

We were horrified when she opted to go back home. 

I would like advice on how to put it across to our patients. I've used many analogies . . . equating the amniotic cavity to a balloon filled with water . . . how difficult it is to close . . . ascending infection etc. etc. 

However, I've failed quite a lot of times. 

The second one - Urinary Tract Infections. Interestingly, many of our diagnoses of Urinary Tract Infections are made per-operative and retrospectively. I'm sure quite a few obstetricians will find it quite interesting. I wish I could do a study on this. 

The history is classic . . .  failure to induction. Then we do the Cesarian . . . only to find a thick bladder quite adherent to the uterine wall . . . many a time with quite a bleed when bladder is pushed down along with peritoneum. Then the history of pain of passing urine is asked for and there is it . . . they give a great history of a urinary tract infection. 

I ask them if they felt it was unusual. The usual answer I receive is . . . they were told that it is quite normal to have a bit of pain/discomfort while passing urine when one is pregnant. 

Now, as most of us know, urinary tract infection in pregnancy can be quite asymptomatic. Public health specialists have always advised screening for Urinary Tract Infections using simple tests. Although it has been advised in most primary healthcare manuals, the sad fact remains that it is hardly done in most public health facilities. 

I would be quite interested to find out the burden of neonatal loss due to these two conditions in pregnant women - Delayed diagnosis and treatment of Preterm Rupture of Membranes and Urinary Tract Infections. 

Would appreciate feedback from the experts . . . 

Essential Drugs

Recently, there has been reports of a major study which brought out the fact that cheaper effective drugs are not being used to combat non-communicable diseases in the country.

Although I did not read about this study in 'The Lancet', I’m reminded of the umpteen number of patients that I see with very expensive medicines given for diabetes and hypertension. Couple of hours back, one of the patients’ bystander, BBM whom I discharged today came to me very discretely and wanted to know if the patient needs to continue the drugs which she is taking from elsewhere. I was a bit taken aback as during admission we had asked the patient about previous treatment being taken. The relatives had replied in the negative.

She was admitted with septicemia and urinary tract infection. The treatment has been quite expensive for the family.

Now, here was a relative of the patient whom I had not seen before standing in front of me saying that she had diabetes and hypertension and she was on quite a lot of treatment. She had 3 different medicines for her hypertension, 3 other medicines for her diabetes, one drug for lowering cholesterol, one for lowering triglycerides, couple of vitamin tablets and two drug to prevent platelet aggregation. The total cost of her medicines for one day was about 60 rupees. It was only 3 months since she has started on the treatment and the family was already feeling the pinch.

If you thought that she must have been a very obese lady looking very sick, you are mistaken. She was quite fit and when she got discharged she looked quite fine. Her blood pressure was normal throughout admission and her random blood sugar was a bit on the higher side. We were planning to do a FBS/PPBS sometime during admission which we missed out.  

Well, I did not know what to say to this man. First of all, this family had not mentioned anything about her medical problems during admission and now they want me to take a decision on whether she should continue on her present medicines, almost half which I've no idea about.

BBM was already discharged. Her blood pressures were normal. I’ve asked the family to bring her in after about a week where I would be checking her FBS/PPBS and other parameters. I hope that I would be able to start bit more simple medicines for her when she comes back next week and enable to make her treatment more affordable to the family.