Maddening Obstetrics

I thought that the 2 rupture uterus patients had given us enough trouble for the next 24 hours. 

I was terribly wrong. 

At 2 am early morning today, came a lady nearing term in very early labour. Thankfully, she had come 2 months back at around 32 weeks to us. And she had our documents. 

Documents . . . which made me shudder. 

G3P2D2, the first one a still birth and the second one a late neonatal death, with a hemoglobin of 4 gm% at 32 weeks whom we had referred to Ranchi as the pregnancy was so so precious. The second delivery was a Cesarian section. 

Clinically, the hemoglobin did not look any better. Her conjunctiva was papery white. 

The family did not take her to Ranchi when we had referred them to a higher centre 2 months back. They had gone home. 

The family wanted me to do whatever I could. With hemoglobin of 4 gm% and the rules on blood transfusion making UDBT totally illegal, I had to refer them. 

I wonder where they have gone. They are from a nearby village. Therefore, I will be able to find out if they really went. Or if they went home and she had a miracle delivery or ended up as another maternal death. 

The tamasha continued later in the day too. 

I just came back from Labour Room after admitting a 21 year old G2P1L1 at term who had a previous LSCS for eclampsia. She was in the ventilator for quite some time and she lost her baby too later. 

This lady had her antenatal care elsewhere. She had consistent values of hemoglobin values less than 6 throughout her antenatal period. The family appeared to have no clue. Or did they want to convince me that they had no clue. 

When I did per-vaginal examination, the situation turned for the worse. She had ruptured her membranes and the liquor was heavily meconium stained. And she had a badly contracted pelvis. 

Shivnath, our lab tech, called me and told that the hemoglobin was only 4.6 gm%. 

The relatives were so poor to take her elsewhere. 

I've send them to Daltonganj for at least 2 pints of blood. 

I wonder if I would get a healthy baby. I can only pray. 

By the way, thanks for remembering KD in your prayers. She held on with a pre-operative hemoglobin of 7 gm%, in spite of periods of shock, till her relatives turned up with one pint of blood late in the afternoon. 

The Precious Baby

Today Shahana Khatun got discharged. SK was a high risk pregnancy under our care.

SK and her husband, Mr. Khudoos Ansari were married 5 years back. They had got married against the wishes of Mr. Ansari’s parents. The major reason – Shahana was an orphan and had no-one to take care of her.

SK had first come to us in 2010. She was having non-stop seizures towards the fag end of her pregnancy. We had to ventilate her and there was no progress of her labour after we had induced her. As a last option we had offered to operate on her to remove the dead baby – something we don’t do often.

By God’s grace, Shahana did well after surgery and got discharged in about a week’s time. Unfortunately, the neglect of the family to Shahana and her husband continued.

The second time Shahana became pregnant was sometime towards the latter half of 2011. Mr. Khudoos was away in Chennai. He had made up plans to come towards the last weeks of the pregnancy. Unfortunately, Shahana went into labour a bit earlier. The in-laws did not seem it cost-effective to take her to hospital. They tried a home delivery. In fact, during her first pregnancy, it was only two days since Shahana came with her husband from Chennai that she went into eclampsia.

The end result – Shahana’s uterus ruptured and she ended up with a dead baby. Thankfully, she was brought in time before she developed further complications.

We had advised the couple to wait for couple of years before a pregnancy. However, they started coming for ante-natal care from the beginning of 2013. We tried our best to refer them to a higher centre.

The family was poor and there was no way they could even think of a journey to Ranchi for safe confinement.

After getting all the necessary consent, we made a decision to do elective surgery on her at 37 weeks. Towards the middle, she was admitted twice for pre-term labour. Ultimately, she came for elective surgery last week.

By God’s grace, the surgery was quite uneventful and the family was blessed with a baby boy. 

We thank the Lord that we could successfully manage SK's high risk pregnancy. 

Tale of 2 ladies . . . and a third one

(This post was done on Monday, 7^th October, 2013. Our internet connections are back to a very poor state of affairs. With Supercyclone Phailin on the way and the Dussehra festivities on, it looks a remote possibility that we would have fast internet connections for the next week too)

My yesterday’s Sunday duty (6^th October, 2013) was quite a light one. There were only 2 women in the labour room throughout the day. One of them was rich and the other poor.

However, both of them shared the characteristic that they were not taken very seriously by their families. The reason? Both of them were high risk pregnancies. And neither of the families was bothered about it.

The first one RD, was quite well off. This was her second pregnancy. The first one was quite an eventful one. She had severe pre-eclampsia and she had delivered a pre-term small for gestational age baby. She had come four times for antenatal care of her second pregnancy. 

Each time, she was told to come more often so that we could ensure that we make an early diagnosis of any high blood pressure. The first 3 visits were in the first and second trimester. 

Her last visit was 3 days back. She was almost nearing term and she had a blood pressure of 150/100 mm Hg. We had advised admission.

She went off home and came today after she started to contract. The blood pressure remained high. I just received news that she delivered.

I would say that her family should have been more careful with her treatment. They’ve got away with very lazy approach to her present pregnancy.

The next patient, SD was not that well off. Her blood group was O negative and her last haemoglobin was 8.5 gm%. We had seen her in outpatient more than a month back. The doctor who had seen her had well explained need for blood as well as absence of a blood bank in NJH. Of course, the difficulty of getting a O negative donor was also put across well.

The patient came in labour. There was no sign of arranging for any blood. Rather couple of male relatives vent their anger at us for not telling them things early.

SD was lucky. Being her second delivery, she progressed so fast that she delivered soon. Gladly, there was not much blood loss. The mother and baby are doing well.

Again, one more case which could have gone awry.

Well, there was a third lady too. She was not that lucky. I hope things will turn out well for her in the couple of days.

This was her 5^th pregnancy. We’ll call her CD. She has only 2 live children . . . both girls. 2 of her babies had died. The urge to have a boy child resulted in this pregnancy.

I’m not sure about her regular antenatal care. But, the relatives told me that she was not doing well since the last 3 days. And she is just into her 8^th month of pregnancy.

Her complaints . . . headache and blurred vision. They had gone to 4 hospitals over the last 3 days. In fact, they returned home after a circuit of hospital visits only on Friday evening. She was given a clean chit everywhere.

Today morning around 9 am, CD had multiple episode of seizures. The family rushed her to a hospital in the nearest town. The doctor told the family that she is very sick and only NJH can do anything. The reached around 2 pm.

Blood pressure was 210/140 mm Hg and Urine Albumin was 4+. The family had lost count of the number of seizures she had. In fact, when I reached to see CD in labour room, she was continuously seizuring.

She has not yet gone into a HELLP Syndrome. But, she is very sick. We’ve induced her. Please pray that she will deliver soon.

The first two cases were outright instances of ignorant and careless family members.

But, what about the third case? The medical fraternity had failed her. A typical complaint of pregnancy induced hypertension, headache and blurred vision, was totally ignored. The shocker. . . 

The family was very sure that nobody in the four hospitals had checked her blood pressure!!!

I have only one prescription in my hand. There is no measured reading of any blood pressure.

How long will we tolerate this sort of management?

PS: CD delivered the next day (8^th Oct, 2013). She got discharged couple of days back. 

Waiting . .. ...

(This post was written on Monday, the 29th July, 2013)

As we wait for rains . . . I’ve been waiting for something else since today early morning.

When I arrived for work today early morning, Titus had news for me about a rupture uterus which has been refusing to go to a higher centre after she arrived her at around 5 am today morning.

This is the second rupture uterus over the last 24 hours.

Dr. Shishir did the first one on Sunday evening.

MD had come sometime early morning on Sunday (28th July). MD had been in labour since 4 am on Saturday (27th July). This was her 3^rd pregnancy. By around 10 am on Saturday, the family realised that there was some problem. She was shifted to the nearby PHC.

The doctor at the PHC was smart enough to realise that there was some complication and she was shifted to the nearby district hospital. At the district hospital, it took some time before the family was told that she appears to have a rupture uterus.

It was late evening. The family was told that the best place for them would be a private hospital in the adjacent district. However, no vehicle was ready to take them to the adjacent district.

They were told that it would be dangerous to be in the district hospital. Therefore, they took refuge in a private hospital for the night.

Very early in the morning, they set out to the Daltonganj. The private hospital they were referred to refused to have anything to do with the patient. It was much beyond their skills. They promptly referred the lady to NJH.

They reached NJH by around 8 am on Sunday. The problem was that she had very high counts and her haemoglobin was just above 7 gm%. It was unthinkable to do anything without blood. We sent the relatives to the nearest blood bank in Daltonganj for 3 pints of blood.

The relatives returned by around 3 pm. Dr. Shishir operated. It was quite tough. She was in severe sepsis and appeared to be going to severe Acute Respiratory Distress Syndrome. She has pulled through the night. 

As I write this (Monday night), MD continues to be on oxygen.

The next maternal near miss, the one I mentioned at the beginning of this post, arrived today morning. RD, had a Cesarian section for her previous delivery. Similar to many of our previous rupture uterus following a Cesarian section, the family was ignorant of the fact that she needed an institutional delivery.

She was better off than MD. Her haemoglobin was 9 gm%. Still considering the time she was in labour and the long period of dehydration, we were definite that there was hemoconcentration.

RD had arrived at 5 am today. It was 5 pm by the time the relatives could arrange blood from Daltonganj. The surgery was uneventful. However, her uterus was quite damaged to conceive another baby.

To top the 2 rupture uterus, we had a severe eclampsia sometime around mid-morning. We kept her for normal delivery as she appears to progress well. However, we realised towards the beginning of her second stage of labour that there was a malrotation and she may not deliver normal.

We ended up doing a Cesarian section for her. As it was a second stage Cesarian section, there was lot of problems. The uterus was in atony for quite some time after delivery of the baby. And she lost quite a lot of blood.

Again, we needed blood. We tried to send the relatives to Daltonganj for blood. But, it was too much of an ask. We have to ensure that she does not bleed more during the night.

The availability of blood is quite a crucial aspect in the smooth running of a centre like ours.

Last year, we’ve had about 1500 deliveries. And with quite a large proportion of them accounting for high risk obstetrics, if we need to develop further, we urgently need to think about setting up of a blood bank.

And not to mention the very high chance that all three of them could have ended up as maternal deaths if NJH was not around. 

However, the big question remains about committed personnel who would be willing to come all the way to a remote location such as ours . . . and continue the good work and look at possibilities of new avenues of quality care. 

Two Maternal Deaths

Yesterday, we lost SHD. She was sick, but stable, while I saw her in the morning. I was in outpatient department, when I got a call that she had a cardiac arrest. The problem was that it was some time after that she had the arrest and the nurses could not find a doctor in the immediate vicinity to come and help.

I knew that there was no point in attempting a resuscitation. However, we tried the routine procedures. . . . but without any success.

And then we lost LD 4 days back. Couple of days after the surgery, she went into florid septicemia. She was being ventilated. And she started to pour out pus from the lungs, abdominal drain and also from her vagina. The relatives requested that we do not do anything heroic. Obviously, they were poor and was slowly noticing how the expenses went up.

After quite a long time, I withdrew life support for a young life.

Then, there was PD. A primi in her last weeks of pregnancy. She had not been doing well since about 2 weeks. Yes, 2 weeks. And she was taken from hospital to hospital. She was gasping as she was wheeled into NJH three days back. In fact, the relatives told us that she has been gasping for breath since 2 days. Dr. Johnson, our doctor on duty realised that there was nothing much he could do.

2 gm% was her hemoglobin. By the time, he found out a donor, she was dead.

So, we had 2 maternal deaths due to anemia last week. I wonder how long it will take for our guys in the thrones of power to realise that such preventable deaths are a major deterrent to development.

There is now one more near maternal miss patient in acute care. BDD, whom I wrote about in the last post has been weaned off the ventilator today morning. Kindly pray that BDD would recover completely.  

Eclampsia Galore

Dr. Shishir is on duty today. It should have been mine. I had exchanged it with him for tomorrow. 

I'm glad I'm not on call today. It has been a long day. About 130 patients in outpatient. Dr. Johnson also had not slept the previous day as it was busy. So, technically there were only 2 doctors in outpatient most of the time. And then the theatre had gotten busy. 

And today it had been eclampsias all the way. Couple of days back, we had quite a bad one. We were blessed to have saved the mother and the baby, although the baby was very sick. Of course, they took the baby to Ranchi as it was a boy. 

We had 3 more eclampsia patients today. All sick. I wonder why people don't take them to Ranchi when they are breathing well and keeping their saturations well. 

I got to put my hand in the last patient who came before we crossed midnight. Pathetic, pathetic history. We shall call her BDD. 

The family had been on the run since early morning. They resided in Garhwa district. They have knocked doors in almost all hospitals along the way till they reached NJH and decided that they could not go any further. The paradox about this patient . . . she works as a maid for a senior doctor in town. 

I'm not sure about her antenatal check-ups. 

Then, she is already going into HELLP syndrome. However there was a glimmer of hope as we found out that she was fully dilated. However, we could not get any heartbeat of the fetus. We had got everything ready for intubation. She was desaturating on and off. 

We took a decision to pull the baby out by vacuum. And then hook her onto the ventilator. 

The ploy worked out well. The best part was that the baby was alive and responded well to resuscitation. 

Kindly pray that BDD gets well soon. 

I was very proud of my ACU staff. They have put up a very good show considering the amount of work going on in the unit. 3 patients with eclampsia of whom one is now in ventilator, 1 patient with organophosphorus poisoning (on ventilator) and one elderly gentleman with a very bad cor-pulmonale . . . it's going to be really tough at night. 

Would value your prayers . . . and of course, we were expecting help from Monday for a week. I hope things get a little light tomorrow . . . for I'm going to be on call.

3 adverse maternal events . . .

Today, I'm on first call after quite a long long time. Necessitated as we are just 3 of us running the hospital from Friday last. Many a time, I wonder about how long I shall shout about adverse maternal events in this part of the country. And every time, I get an answer about what to do . . . Yes, continue to shout about it till something happens. 

We had 3 mothers today . . . all of them had gone through adverse events. Of the three mothers, one was already dead by the time she reached us. The second one was . . .  from a medical point of view . . . a gone case . . . it would need a miracle for her to live. The third one came to us on time . . . she should live. 

Their stories . . . 

The first patient, AA, was a known case of pregnancy induced hypertension. She was supposedly under treatment. However, I did not see any records. Therefore, not sure. She had started to have convulsions today early morning. They had taken her to some hospital in the nearby district headquarters. From where they were asked to go to NJH. It was too late for her. She was dead by the time she arrived. 

The second patient, BB, a primi mother had been having contractions since the last 3 days. When she did not deliver by today morning, they took her to a hospital nearby where she delivered a macerated baby. But, then her abdomen started to distend. She was given a letter to go to Ranchi. 

Her relatives brought her to us. The family was too poor. And her blood group was O Negative. She was putting out blood from her bladder. And then to our horror, found out that she was leaking urine. And on putting a nasogastric tube, there was pus coming out. Most probably, she had undergone abdominal massage when she was trying to deliver at home. 

My provisional diagnosis - Rupture uterus with bladder involvement and intestinal necrosis following abdominal massage. 

Thanks to a new fund we created following a donation from a well wisher in Australia, we paid for her travel to Ranchi. I can only pray that she survives. 

The last patient, CC. Into her 2nd pregnancy, she had a cord prolapse. And her baby was dead for almost 2 days. There was pus pouring out from the uterus. The last thing I wanted to do was a surgery to deliver a dead baby which was stuck in the uterus. But, that is what the doctor who first saw her elsewhere wanted us to do. 

I was not sure about how friable was the uterus. She was in full blown septicemia.

We took a decision to try to do a craniotomy and keep her ready for laparotomy if the uterus ruptures in the process. It's a difficult thing to do a craniotomy and I always pray that I do not end up doing one. 

As we were explaining to the relatives about all possible complications, the fortunate lady suddenly started to have contractions. And she miraculously delivered normally. It was a relief. 

It was very unfortunate . . . for the first two ladies . . . 

Next week, it is International Women's Day on the 8th. 

I pray that we would continue to make a difference in the lives of women in our surrounding communities especially when it comes to managing their pregnancies . . . 

Disappointment . . .

Someone asked me what was our setbacks in the last couple of weeks.

The first one, was a maternal death.

And the second one, a very terrible complication which succeeded one of the surgeries we did towards the end of  last year.

First, the maternal death.

SRD delivered sometime in middle January at home and was not keeping well. She came to us 20 days after her delivery. From the history, the delivery was quite a difficult one and baby was dead.

On investigating we found out that she had about a litre of pus inside the peritoneal cavity. Hemoglobin was 8 gm% and she was in profound sepsis. No blood could be arranged. 

Therefore, we did a peritoneal tap and removed as much pus (about a litre) as possible.

However, she had become more toxic on day 2. After much persuasion, 2 of our staff donated blood. Ultrasound shows more pus with loculations. We had to clear her peritoneum.

The surgery was uneventful. We removed about 1.5 litres of pus. The intestines and uterus were all caked. Most probably she had a massage of her abdomen during the delivery which would have caused necrosis of the intestines.

She did well for about 36 hours after the surgery. Suddenly, without any warning, she developed a cardiac arrest and could not be revived. We were not sure of the cause. Either the sepsis was too much for her body to cope with or she had a pulmonary embolism. We don’t know.

The other case was that of GD, who had eclampsia  on whom we had done a Cesarian section and later put a B-Lynch.

She had a wound infection which was quite expected. We had pumped her with the strongest antibiotics.

However, she was discharged with daily dressing of her wound.

She was doing well.

Last week, she came with a prolapsed uterus and it was gangrenous. Her general condition also was not good.

Most probably, she was not getting the good food and care after she went home. Our nurses had also been quite concerned about her general hygiene.

\

With a surgeon not around, we somehow convinced her to go to a higher centre.

I’ve my doubt that they’ve taken her back home to die.

It was sad, but in the absence of specialist care, that was the maximum I could do. And nutritious food and good hygiene are issues which we have not much control upon. 

Whoa . . . what a rupture?

I returned yesterday evening from the short break, thanks to the twin days of general strike. It was a risk taken . . . calculated risk . . . but really risky to drive back on the afternoon of the second day of the bandh. The good Lord was with us. However, we wanted to back badly . . . for multiple reasons.

Today morning, we had a mournful looking man in my office. Husband of Sde, a lady who had a rupture uterus in her first pregnancy. Something very unusual, but quite possible in our part of the world.

The poor lady had been in labour for almost a whole day, before the relatives decided to take her to the hospital. The first hospital they went to could sense that something was drastically wrong . . . and referred the patient promptly to Ranchi.

They dropped at NJH and wanted us to take up the case.

Dr. Shishir was on call . . . and the diagnosis was unbelievable. It was an obvious rupture uterus and of course, the baby was dead. She was lucky to be alive.

Per-operatively, the condition of the uterus was very bad. Dr. Shishir had to nick off quite a lot of necrotic tissue before he could sew the uterus back. Being a primi, he did not go for a tubectomy.

A tubectomy would ensure that the lady is abandoned by her husband. It’s been a long time since we’ve had a primi rupture uterus. Believe me, it’s really bad.

Sde had developed fever with breathlessness overnight. Either she was going into septicemia or she had atelectasis. Investigations showed the former. We’ve upscaled her antibiotics.

We hope that she would not have any more complications. Ultrasound also shows that the uterus appears intact.

In addition to SDe, we’ve had another 4 patients at some stage of eclampsia. Interestingly, we’ve got all the babies alive . . . something very miraculous.

Before I sign off from this post, just a reminder about the staff needs of the place . . .

2 very bad eclampsia patients . . .

Over the last 10 days we had 2 very sick eclampsia patients.

The common aspects of both patients . . .

-         They were very rich.

-         The relatives wanted to take the patient to a higher centre in Ranchi but could not as both of them had severe respiratory distress.

-         Both of them had GCS of 3 on arrival.

-         They had spent time at home for more than 5 hours after the first episode of seizures.

-         The decision to take to a doctor was made after 5 hours.

-         Both patients did not get magnesium sulphate from any  healthcare providers. In fact, I got the snap of what one patient got . . . You can see it below.

-         Both had pulmonary edema with pink frothy sputum coming out. In fact, the second one had coffee ground gastric contents.

-         Both had diastolic blood pressures of more than 140 mm Hg on arrival.

-         Both of them have survived the surgery.

-         They needed mechanical ventilation for less than 24 hours.  

The differences . . .

-         Both were from different castes and religious communities.

-         For the first case, the baby was dead. The second case has got a alive baby.

-         One of them is discharged, whereas the other one is yet to go home.

-         The first one, who is already discharged had to be intubated on arrival whereas the second one was intubated only for general anesthesia.

The significance of both these patients: The classical teaching of eclampsia with pulmonary edema is to stabilise them before we take up for surgery. Our experience shows that if we take them for surgery as soon as possible, they survive. However, you need to have basic ventilation.

And of course, we pray quite hard here.

Any takers for this from the speciality of Obstetrics. We have four patients who survived over the last 3 years with this sort of management. The above are the last 2 patients. The first two patients, you can read here . . .

1.    The first patient 

2. The second patient 

I’m sure that we don’t see this sort of patients in clinical set ups in most of the other obstetric set ups. However, I understand that we have such patients turning up in most of the other EHA units.

Last maternal death of 2012

The sad part was that she was one of our regular antenatal patients and she had delivered her first baby also with us. Interestingly, her first pregnancy was also complicated. She had enteric fever, later viral hemorrhagic fever and ultimately had a premature birth. 

However, for her second pregnancy, she her her regular check ups elsewhere. However, she came with a very bad urinary tract infection with false labour pains more than 2 weeks back. We had to admit her and manage her aggressively to control the infection and the pain. 

She was well controlled and later took a discharge saying that she can continue her treatment in her town. 

She had an institutional delivery at a Primary Health Centre (PHC) on the morning of 31st December. Within half an hour, she had an episode of seizures which was managed at the PHC. She was at the PHC till around 2:30 pm, when the family was told that she appears to become sick. 

We do not know the details. But, she was brought dead at around 4 pm at NJH . . .

The relatives were in a hurry to take the body home. So, I did not get the details.

I've informed the same to the concerned people. However, I'm not sure if there would be any sort of follow-up on this matter . . . 

It was a like a message for us . . . Maternal and child health continues to be a major concern of the region which we serve. It was a bit unbelievable, but year 2013 also started off with a case of maternal near miss for us which I would narrate later. We have a long way to go. I'm sure that year 2013 is also not going to be any different. We would continue to deal with extreme obstetric care. My biggest wish for 2013 is that we would be able to involve ourselves in child survival a bit more than what we are doing now. 

Wish you all choicest blessings for 2013 .. .. ..

Critical Care . . .

Something for which I was never prepared when I joined NJH in June 2010 was the amount of critical care work which I would end up doing.

Having a background in Community Medicine (Public Health), it was a challenge to get into using ventilators, managing pulmonary edema, rupture uteruses, cerebral malaria. More of a challenge since my last year in the Christian Medical College, Vellore was spent among the Jawadhi tribal community trying to convince them to come for antenatal check-ups, getting them to run small scale income generation programmes, conducting mobile health clinics etc.

From an healthcare institution point of view, NJH was quite peculiar.

Situated in the middle of a heavily forested area along a National Highway linking Ranchi with Gwalior, one would have expected hardly much of a crowd. Yeah, we do not get much of a crowd. The routine cases of malaria, enteric fever and normal deliveries are dealt by the motley crowd of quacks and dais in the villages.

So, if you come to our outpatient, you may think that there is not much work. But our repertoire of cases will put a Medical College to shame. You want to know, what we have in our 6 bedded Intensive Care Unit now. Here’s the list –

1.    A young man who’s survived a krait bite. He was in the ventilator for about a fortnight. Then he went into pulmonary edema. He’s slowly on his way to recovery.

2.    A young lady who went into pulmonary edema following eclampsia. She lost her baby. We had very little hope of salvaging her.

3.    A middle aged woman with organophosphorus poisoning. Again, we were not very sure of getting her alive. She had drunk too much of poison. She’s also slowly recovering.

4.    A little girl with partially treated meningitis. Still not very sure of what the outcome will be.

5.    A young man who’s just come in with a clinical diagnosis of cerebral malaria. For him to be admitted, we had to shift out a young lady who had a molar pregnancy. She had a hemoglobin of 2 gms%. By God’s grace, we could do an evacuation and she’s doing ok.

6.    An elderly lady with a very bad pneumonia. She has already been managed at Ranchi.

Then there are 3 more patients with severe malaria who are waiting in the General Ward. I would have wanted them also to be under close observation. In addition, there is a young lady with bad obstetric history (G6P5L1D4) having severe pre-eclampsia at 28 weeks who’s refused to go elsewhere.

I can only pray that there is no patient with rupture uterus or eclampsia coming in during the next 24 hours.

Well, what do I want to convey?

Critical care is something that we in mission hospitals need to look at very seriously. Traditionally known to be bastions of surgical care, there has been a major shift.

The major reason being that very few hospitals are interested in critical care and when there are facilities for critical care, it is too expensive for the common man.

So, along with palliative care, geriatric care, care of HIV AIDS etc . . . something very unusual is being expected from us in the form of critical care.

However, the ultimate question is about getting committed young men and women to serve alongside us.

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 . . .