Unbelievable . . . Stunned beyond words . . .

(This post is a purely of medical academic interest and contains snaps which could be offensive to many. Kindly be careful)

I had written the  previous blog about SD and PD yesterday night but could not post it as there was no internet connection.

PD's relatives brought the 2 pints of blood requested by us by early morning today and Dr Nandamani  called me to help with the surgery.

We were definite that we would be in for few surprises.

This was what we saw as we opened the abdomen. Instead of a smooth ending slope of the uterus what we got was a beveled lower segment which was quite undermined. We decided that there must be a tumour somewhere nearby and opened the uterus where we could visualize as low as possible and delivered the baby.

Then we found out that the uterus was refusing to contract and it looked more like one of those olden days' wineskins.

Dr. Nandamani then started to search for the apparent cervical fibroid which we had found out during the ultrasound. The uterus was quite large and he had to really work hard to mobilize the uterus outside. It was then we noticed where the bleeding was from. One of the ovaries looked ruptured – must have been a large ovarian cyst.

We found out the ‘tumour’ which we were looking for – but it looked quite unusual. It was then that we realized something funny. There was one more ovary on the same side. Well, it did not take long for Nandu to realize that the uterus had got twisted in its axis 180 degrees and he had opened the posterior wall rather than the anterior wall.

And as shown in the snap, the 'tumour' was the left horn of a bicornuate uterus.

We confirmed it after few more examinations. It was quite a relief to realise that we were not dealing with any malignancy.


The rest of the surgery was uneventful. However, we realised that we've just witnessed something which was quite rare.


The best part of the surgery was that although we had to remove the flaccid right horn of the bicornuate uterus, we could leave behind the left horn intact. And maybe, she may concieve. After 4 pregnancies where she ultimately lost all the babies, we pray that she would be able to concieve.


I remember a similiar case of rupture uterus during my previous stinct at NJH, where we found out that it was a bicornuate uterus and the lady concieved in the other horn after one year and delivered a baby by elective Cesarian section.

Poor healthcare . . . Do we care?

(This blog was written on 15th (Tuesday) evening. Kindly be warned that the pictures are a bit gruesome)

We had quite an unbelievably busy Tuesday, which started off from the stroke of midnight. For newcomers, Tuesdays are usually cool at NJH as almost the whole of the local population knows that it is surgery day and hardly any of the consultants will be available in OPD. I had 2 antenatal patients simultaneously coming in, both of which should have been managed at a tertiary centre.

The first one to come in was PD who had been in labour since the last 3 days elsewhere and had a hemoglobin of 8 gm%. The abdomen looked quite odd and it was evident that it was either a malpresentation or an obstructed labour. Ultrasound confirmed that the baby was presenting breech and to complicate matters had quite a large hydrocephalus.

The relatives had already been to two hospitals, both private institutions before they reached NJH. They were very definite that they would not be able to afford going to Ranchi.

It had been quite a tiresome Monday with only 4 doctors in the outpatient department and I had been caught up with patients especially KB who was a high risk antenatal patient since the evening. My body was begging for some rest. I initially thought about doing off a Cesarian section and finishing off the work.

Somehow, my conscience did not allow me. I had read about the management of the aftercoming hydrocephalic head but had not done it before. The inquisitive side of my brain urged me to keep the patient for normal labour and later do a cranial puncture and deliver the baby. But the very thought of having to puncture the brain of a living baby was not a very comfortable idea. I weighed the options and ultimately decided on the latter option.

I’m glad I waited. The baby had multiple congenital anomalies in addition to the hydrocephalus including meningomyeloceles in the lumbar and sacral regions.

The second patient was SD. SD had been in labour since the previous evening. There was no fetal heart beat. Ultrasound confirmed that the baby was dead. Clinically SD was quite pale and she was in cardiac failure. She could hardly lie down and was quite breathless.

SD had come in within minutes of PD coming in and I was in no mood to entertain the thoughts of SD delivering at NJH. I pleaded with the bystanders to take her to Ranchi. Her previous obstetric history also was no very encouraging. This was her 4th pregnancy and none of her previous pregnancies had survived.

SD was only in her 8th month of pregnancy. Her hemoglobin was a pathetic 6 gm%. With very high risk consent with the possibility of death occurring taken, I asked the relatives for 3 pints of blood and went about inducing her with vaginal misoprostol.

Even after 3 dosages of vaginal misoprostol, SD had not responded. The relatives gave one pint of blood. However, she still continues to look very pale. On admission, she also has quite high counts with a predominant neutrophilia about which we are quite worried.

Today evening, Dr Nandamani decided to review SD. Considering the cardiac failure and septicemia, we made one more futile attempt to refer her to Ranchi – but to no avail. Armed with one more set of high risk consents, Dr Nandamani set about to find out if anything else was wrong – considering that she had lost her babies in the previous 3 pregnancies.

He felt something wrong with the pervaginal examination. An ultrasound revealed that there was a fibroid in the cervix. We brought her back and did a repeat per-vaginal examination. Nandamani’s surgical brain ensured that he did a per-rectal examination too and it confirmed quite a large fibroid in the posterior uterine wall almost blocking the entire internal os. So, that explained the failure of induction.

During the ultrasound examination, we also found some heterogenous masses within the placenta. We are worried about what we would find when we take her up for surgery. We had one more round of talks with the relatives. They are quite definite of not taking her to Ranchi.

We have agreed to operate once we have blood. Even after 2 pints of blood, her hemoglobin continues to remain at 6 gm%. Either, her septicemia is worsening or she was in a state of dehydration when she came in. We wait for 3 pints of blood to come in before we can do anything.

Both SD and PD had spent quite a long time at healthcare institutions both public and private before they came here. I’ve understood that both of them were not seen by any doctor during their opportunity of contact with the healthcare institution.

I started to write about SD and PD to counter a comment by one of my friends which I thought suggested about the need for more awareness among patients rather than looking at the possibility of improved healthcare facilities in our towns and villages. (Please correct me if I interpreted wrong.) Mind you, SD and PD came from the healthcare institutions in our district headquarters to NJH, which is situated in a rather remote area.

Even my previous story about KB also echoes the poor healthcare facilities available both in terms of qualified and committed personnel and infrastructure. Improving our health delivery system needs to find high priority before we start to think about educating the masses on timely access to healthcare. And I have reasons to strongly believe that the latter part would be taken care once we concentrate on improving development indices especially in terms of literacy and uplifting the girl child.

Close Call . . . And a poor Healthcare system

We had a very difficult antenatal case to deal with over the weekend. It was KB's first pregnancy and when she gave her history, it was a bit difficult to believe it. I had to ask the family over and over again whether what I was hearing was true.

The poor lady had been in labour for the last 5 days before she reached NJH. Her labour pains had started the Monday of the previous week. Initially, it was very mild pains. She went to the nearby Ranka Primary Health Centre where she was admitted till evening. She went back home the same evening as the family felt that nothing much was happening. She continued to have pains overnight and she was again taken to the PHC on Tuesday morning. She was there for the whole morning and when nothing happened, she returned home.

On Wednesday morning, as told at the Ranka PHC, the family took KB to the Garhwa district hospital. The family was told by afternoon that she cannot be managed there and therefore needs to go further. The family had already spent quite a lot of their finances by then. They went back home so that they can plan as well as arrange some more finances.

Overnight, she felt that she could not feel the fetal heart anymore. They family thought that now that the baby was presumably dead, they could do the deliver at the Ranka PHC and took her there on Thursday morning. The staff at Ranka told her that she needs to go to a higher centre. Since, they already had been told to go ahead to a higher centre at the Garhwa district hospital, they decided to take her to Daltonganj, the adjacent district headquarters.

KB was in the Daltonganj district hospital over the day and by morning when nothing much was happening, they decided to bring her to NJH. KB arrived sometime in the late in the morning last Friday. I was on call.

On examination, KB was quite toxic. The baby was of course dead. The cervix was about 8 cms dilated and there was marked Cephalopelvic disproportion. As always is the case here, she was quite pale. Her hemoglobin was 8 gm%, but I suspect that she was quite dehydrated after all the trouble she had been having over the last 5 days. But, more worrying was that her total counts was about 25000 with about 90% neutrophilia.

With the patient being in septicemia and her having been in obstructed labour for quite a long time, all the possible complications raced through my mind. The easiest option was to refer her to Ranchi which I did. But they were in no mood to go citing lack of finances. After taking a high risk consent and a discussion with my other colleagues, I decided to take her in.

This time, I decided to get at least couple of pints ready before I intervene, so that I do not end up in a situation last week when the uterus went into atony and I did not have blood.. None of the relatives' blood group matched. Unfortunately, her cervial dilatation stayed at 8 cm till around late evening. I started weighing the option of doing a craniotomy. I hate the procedure, as mentioned in my previous blog. The relatives went off to Daltonganj to get blood.

I started to get worried about the possibility of a rupture uterus as the uterus had been contracting against a non-dilating cervix. I did not have any other choice other than to pray. Sometime in the night, the relatives informed me that they may not get blood until morning.

We took a decision to act. With no blood available, it was dangerous. However, one of the nurses offered to donate blood if there is a dire need. With everything made ready for craniotomy, I positioned her to find that she had dilated fully.

The baby was delivered without any problem. We had taken all the precautions - however, it was a blessing that we did not have any of the problems that we had anticipated. The baby and the membranes were stinking. However, she responded well to antibiotics and was discharged today.



However, I had no inkling that we were going to have more challenges over the night.

Maternal Near Misses - Previous Cesarians

Doing Cesarian section in hospitals located in remote locations of developing nations used to be quite unpopular. Quite a lot of obstetric procedures developed in the good old days which were designed to prevent Cesarian sections.

I never understood the gravity of the problem of doing Cesarian sections in remote areas such as ours till an incident during my previous stinct at NJH during 2004-05.

I had gone to one of the remote villages as part of the community health outreach programme. After I reached quite a remote village, someone informed me that there was a woman in one of the houses who was having a delivery. Quite fresh from home in Kerala, where attempting a home delivery was unthinkable, I dreamt of myself being a messenger sent at the most appropriate time to help out this poor lady attempting a home delivery.

I rushed to the house where the delivery was taking place. Just as I reached, I realised that the baby was already out. I was not allowed into the house as it was quite filled with women of all ages and a very old woman came out with blood caked all over her hands and sari. She muttered something in Hindi and then there was a big cheer all around.

Hardly anybody was bothered about any of us standing around. Later, one of our lady staff volunteered to request one of the family members to have me look at the lady who delivered the baby. Quite fresh and brimming with enthusiasm, I was prepared to do a good postnatal examination. To my horror, the first thing I noticed was a long scar which run through the middle of her lower abdomen.

When I asked about the same, the husband happily informed me that the first baby was delivered by a Cesarian section. He also told me about the indication. She was taken to NJH as she developed seizures and had bloated up - most probably eclampsia. The baby was delivered alive but died soon after. It's been 2 years and for the present pregnancy, she has not even had a single ante-natal check up.

But for the family - the present pregnancy was a success. They had avoided a institutional delivery and had a healthy boy baby.

Unfortunately, the attitude towards Cesarian sections has not improved much. Over the last week, we had two pregnancies who had previous Cesarian sections, who came quite few days after the expected date of delivery.

The first one allowed us to do the Cesarian section as soon as she came in. When Dr. Nandamani opened the uterus, this was what he saw.

The second one was more horrible. The lady did not allow us to admit her the same day and came with much hesitation the next day. I was operating and Dr Nandamani had his video camera on.

In the olden times, procedures such as symphysiotomy and cervical incisions used to be quite commonly done. I wonder if any of the present trainees in the speciality of Obstetrics know much about them.


Both the women could have died - both near maternal misses. it was a miracle for both of them to be alive and more miraculous to have live healthy babies.


Talking of obsetetric procedures, another gruesome procedure is Craniotomy - which has also become not a common procedure in recent times.

Well, I hate doing craniotomies but almost ended up doing one couple of days back. More on that in the next blog...

Malignancies Cont'd. . .

After the story I wrote about KD who had a extensively invasive oral cancer we had been having quite a number of patients with malignancies who came to OPD. Although most of them look quite bizzare, just wanted to draw your attention to an unmet need for care for cancer patients in rural India.

12 year old boy with a biopsy proven soft tissue malignancy of the chest wall musculature who has been running from hospital to hospital for some sort of treatment. We were not equipped to treat it and we ultimately referred him to the Department of Oncology, Banaras Hindu University Medical College. It has almost been a year since the swelling started the size of a pea. I wonder if it is too late to do anything. The boy had quite a number of files of consultations at various centres – but none of them venturing into a definite treatment.     

40 year old man with history of oral ulcers who came from almost 200 kms away in Bihar. I just could not understand why he did not go to a higher centre at either Gaya or Banaras which is nearer to his home. The lesion was quite invasive with the cheeks perforated at 2 places.

50 year old lady from one of our nearby villages who had an ulcer of the tongue. Surprisingly, a well known superspeciality teaching centre in a nearby city refused to entertain the possibility of malignancy. However, the family decided to take a second opinion where a biopsy was done which confirmed squamous cell carcinoma. The family wants to take the patient for treatment at either Mumbai or CMC, Vellore.

50 year old man with the history of a swelling of the right tonsil for the last 15 years which has started to bleed since the last 2 months. I’m definite that there is malignancy. He has requested for a referral to CMC, Vellore.