The hidden pregnancy . . .

(All the pictures in this post are per-operative pictures which could look gory - kindly view with caution)

Well, here is the first of the interesting cases that we had last Saturday. 

GD, had come to us with a history of abdominal pain after having been pregnant for about 4 months. She was pale, tachycardic and had been diagnosed elsewhere to have an intrauterine death. 

She had been sick for the last 4 days. We did an ultrasound. Surprisingly, the dead fetus was outside the uterus. Well, the possibilities - 

1. The family was not giving us the full picture. She could have gone for a septic abortion using a stick. The stick could have caused an injury pushing the fetus into the abdominal cavity. 

2. It could be an abdominal pregnancy . . . 

We once again confirmed the history. They were very definite about not being in the former scheme of things. 

Well, what was she doing for the last 4 days. For the first 2 days, she was in our adjacent district headquarters trying to get a diagnosis. They had treated her anemia. Investigations elsewhere showed a hemoglobin of 5 gm%. She had already recieved 2 pints of blood. She was referred to the nearest district headquarters as nothing was happening. The family informed us that they were waiting for the dead fetus to be expelled. 

At the adjacent district hospital, they went ahead and induced her for delivering the dead fetus. The lady was there for more than a day. 

Since, 'nothing' much was happening, they decided to come down here. 

We told the family that she needs to be operated on. The family was well off. And as Nandamani and the rest of the team discussed the case, possibilities of intestinal involvement etc. weighed on us. We gave them the option of going to a higher centre. The family was tired after having visited quite a number of hospitals. 

The next problem was the availability of blood. The family had already arranged 2 pints of blood. They tried their best and arranged one more. One of our staff volunteered to donate so that we could start the surgery soon. We were already looking at the possibility of septicemia as she had been sick since the last 4 days. 

Below are the snaps from the surgery - 

As we opened the abdomen

The pregnancy in the broad ligament. The uterus and the right ovary can be clearly seen

Placental adhesions to the intestines . . . 

The diagnosis - Left broad ligament pregnancy ruptured with adhesions of the placenta to the sigmoid colon and the small intestine. . . 

Twelve pregnancies . . . Experiences varied . . .

Yesterday (28th April, 2012), our youngest doctor, Dr Titus was on duty. And what a duty did he ultimately end up having. . .

I'm very sure that a post-graduate in Obstetrics in a pretty big Medical School would turn green on hearing the cases Titus ended up managing yesterday. Of course, it was with active support from the others including Nandamani.

Altogether, he ended up managing 12 pregnancies . . .

I shall try to narrate the significant ones in a later post . . . Here is the list with a brief account of the history . . 

1. AB – a primi who delivered without much problem.

2. BD – another primi, but had been trying to deliver at home. Was about 9 cm dilated at arrival with Grade 2-3 Meconium Stained Amniotic Fluid.

3. NDD – a primi, a bit towards the elderly side. Had been coming to us for antenatal check-ups. We had diagnosed Intra-uterine Growth Retardation quite early and referred her to Ranchi. The family could not afford the trip and tertiary consultation. We had to ultimately do a Cesarian for her. Mother and child are doing well. 

4. SB – another routine delivery without any complication.

5. BD – the first pre-eclampsia to come in. We induced her – but deleloped fetal distress in no time. Post Cesarian it turned out to be good decision as per operatively, the baby was sick.

6. AD – a G2P1L1 routine delivery,but with very anxious relatives who gave us a harrowing time.

7. SD – A G6P5L4D1 – Had been trying at home since early morning. Did not have any clue why she was not delivering. Ultimately decided to come to hospital. Reached NJH at around 10 in the night. We did not need an ultrasound to diagnose hydrocephalus. Of course, we confirmed with an ultrasound. Delivered after craniocentesis. Baby was dead. However, she was lucky to have got away with it as she could have ruptured her uterus. 

8. MD – A primi who came in with an IUD. She had been kept for normal delivery elsewhere. I wondered how someone could have missed the very obvious Inadequate Pelvis. Problems with not having followed protocols too as the patient has been in active labour for more than 16 hours. 

9. ND – the second pre-eclampsia of the day. However, ended up with an normal delivery after periods of uncertainty and anxiety.

10. SD1 – Someone we had induced. But ultimately ended up with an obstructed labour and a Cesarian section. Baby and mother turned out to be fine. Thank God for Partograms and Protocols. . 

11. GD – Very confusing history. But an ultrasound gave it away. It was an abdominal pregnancy – the sac had given way. The baby was about 20 weeks gestation. Shall do a detailed post on that later.

12. SoD – Maternal death. Did not deliver. Came with history of seizures. Had anuria, thrombocytopenia and was unconscious. Died within 4 hours of admission. We tried to ventilate but her heart would not yield to any medication. Again will give a detailed post later. 

This is the obstetric work alone. In addition, we had the sick babies getting admitted to NICU to be looked after, surgical and medicine patients needing extra attention. . . . The list goes on and on. Well, there was one more patient, UD who had come in with a history almost similar to SoD who's in the process of pulling through in the Acute Care Unit. That would also deserve a detailed post later. 

Well, ultimately friends, we need help. Looking forward for medicine and paediatric consultants along with nurses committed towards work in under-served areas.