Eclampsias . . . 4 of them and a Maternal Death

After the last post about a maternal death due to eclampsia, we've had 5 more cases of eclampsia. We managed 4 of them and all of them are doing well so far. One went to a higher centre. All of them were quite sick. Just few lines about the worst of the four cases and then the latest maternal death . . . 

The first one of the four, MD was one of the worst cases of eclampsias I've ever seen. MD was pregnant for the first time and she had completed about 8 months of her gestation. Then, she developed chicken pox. 8 days after she developed chicken pox - she developed seizures. And like many of the other cases of eclampsias, she had been having headache and a sense of ill-health since the last week.

The blood pressure was quite high and her urine albumin was 4+. She had rashes all over her body. We gave the option of referral - the relatives were exploring the options when she developed a bad respiratory arrest. Within minutes, she was hooked onto the ventilator. We did not give her much of a chance. We delivered the baby by Cesarian section. The baby weighed about a kilogram and was dead within 5 hours of delivery. 

MD was on the ventilator for 2 days. However, she made a miraculous recovery. 

She was discharged yesterday. Her total bill was 42,000 INR. The family could afford only 28,000 INR. I wish we had a caucus fund to write off such bills. 

Now, about the maternal death. 

NB, a young 19 year old pregnant lady came to us sometime early morning. She was pale and had a hemoglobin of 7 gm%. Her baby was lying transverse and she needed a Cesarian section. A diagnosis of severe anemia and a transverse lie was made elsewhere too.  There was a hoard of male relatives. Nobody was ready to donate blood. And they were not ready to take her to Ranchi. Our staff tried their best to refer her from NJH to a higher centre. 

Then they took a decision to bring blood from Daltonganj. In between someone decided to do a per vaginal examination. It was a cord presentation. And she had started to contract. 

Meanwhile couple of relatives had gone to get some blood. We talked again with the relatives. They assured that the blood is on the way. We decided to start with the surgery. It was uneventful. The baby was healthy, weighed 4 kilograms. The blood had arrived as soon as surgery was over. 

The next thing we hear is about the patient collapsing in Post-op care. It was baffling. My colleagues had already put her on the ventilator before I arrived.

That was when my eye fell on the bag of blood which was being transfused. It was more of water than blood. We get similar blood bags regularly. My first diagnosis was a blood transfusion reaction. Hydrocortisone went in followed by Injection Adrenaline. Nothing happened. 

Other possible diagnoses were rushed through - pulmonary embolism or amniotic fluid embolism. I wanted a medicine consult. Most of those whom I knew were far off. It was good to get through to our Director. He asked me to looked at a Right Axis Deviation in the ECG. The monitors were not showing any. With the ventilator she was maintaining saturation. 

We had to put her on dopamine as her blood pressure started to fall. Another possibility which we entertained for quite some time was a post-partum eclampsia. However, by late evening, we were sure that she had most probably gone into cardiac failure secondary to anemia. 

One of our staff kids volunteer to donate blood. But, it was quite late. She was sinking. 

By early morning today, we had lost her. 

It was sad . . . For the husband, who was just 20 years, he had become a widower for the second time. His first wife had died 2 years back of snake bite. 

The total bill had come to about 19,000 INR. The family was too poor. We wrote off 5,000 INR. 

Now, do remember about the 2 pints of blood which had arrived from Daltonganj. Since we were very much conscious of a possibility of contaminated blood, I requested our laboratory to test samples from both the pints. The results were unbelievable. 

 Now, for these 2 pints of blood, the family had paid 6000 INR. To have paid 3000 INR for one pint of B positive blood is something which cannot be fathomed. 

A regular antenatal care and iron and folic acid tablets would have done more and enough for MD. The family must have been living in poverty. Because, MD's husband who was willing to donate blood and had the same group as MD had a hemoglobin on only 6 gm%. 

If I'm correct, we are not supposed to retest the blood even for compatibility when it is issued from a blood bank. Later, we found out that the relatives had brought the blood from some agent in Daltonganj. There is no receipt nor have they any idea about those who sold them the 2 pints of blood. 

The unfortunate incident has been a wake up call for all of us. The lessons learnt - 

a. The seriousness of dealing with anemia in pregnancy. 

b. To look at the blood which is being brought from elsewhere. One option would be to refuse to transfer unless they bring a receipt. 

c. Need for a blood bank at our place.

Considering the fact that the family refused to take her to a higher centre, I wonder what option do hospitals like us have?

Today afternoon, we had another patient. A very young lady who was into her 4th pregnancy had tried to abort at 5 months gestation. She came with severe bleeding. On per abdomen examination the uterus looked at least 28 weeks size. Her hemoglobin was 3 gm% and nobody was ready to donate blood. 

We took a stand of not doing anything with the patient unless the relatives bring at least 2 units blood. The relatives took quite a long time to take a decision. They looked hardly bothered to take a decision to take her to Ranchi. After the outpatient had closed, the patient and the relatives were gone. We're not sure where they have gone . . . Ranchi or Daltonganj . . . 

Availability of blood and the readiness to donate blood is something which needs to come before we think of starting a Blood Bank.