Ending 2013

We had amazing last few hours in the labour room on December 31, 2013.

3 patients . . . and they made our day.

All of them very very high risk patients who should have gone on to a tertiary centre. All of them poor and . . . coming here just because they could not afford a trip to Ranchi. They trusted us . . . wrote the high risk papers . . . we could only pray . . . and the Lord gave them deliverance and healthy live babies.

The first one, JB, who had come around noon-time. She was one of our regular ante-natal care patients. We had told the family that it would be good to have her delivery in Ranchi. The reason – she had lost her first baby. But, the family could just not afford to go ahead. To make matters difficult during admission she had couple of high blood pressure readings. Thankfully, the BP stayed normal after admission. She responded well to induction and delivered a girl baby just before the clock chimed 12 midnight.

The second one, SD had all of us in tenterhooks for quite some time. SD had lost both her babies the previous time and the family did not seem it worth to get her a regular antenatal care when she was pregnant a third time. And both the previous pregnancies had delivered by Cesarian section elsewhere. A G3P2D2L0 with both previous Cesarians. The only saving grace was that her haemoglobin was 11 gms%. After the customary high risk papers were signed, we sent off the relatives for one pint of blood. I took a decision to operate only if I’ve a pint of blood. We’ve had previous experiences of patients bleeding heavily when they’ve had a Cesarian elsewhere.

To our horror, SD went into full fledged labour pains. She had terrible lower segment tenderness. We decided to take her for Cesarian without the blood having arrived. We were afraid that she would rupture. To our surprise, we found that she had dilated fully by the time we took her to theatre and to cut the story short, she delivered normally. The baby and the mother are doing fine.

The third one, TB came from another centre after she was referred for pre-term labour. We found out that she was in fact term. But, there were issues. Her haemoglobin was only 7 gm% and she was in sepsis. She had been leaking for almost 48 hours which the family had ignored. She also progressed so fast that the baby was delivered normally and the mother has done well so far.

It was so satisfying to finish the year having been part of the management of these three ladies all of whom had come to us expecting a miracle.

We thank the Lord for using us to be a blessing to these families. 

Shadow of death . . .

Since yesterday night, we are sitting on tenterhooks regarding the second patient whom I mentioned in my last post.

It’s more than 24 hours since this lady came in. Her haemoglobin had been around 5 gm% for almost the whole of her antenatal period. She had a Cesarian section after she had eclampsia. Unfortunately, the baby died soon after birth.

It’s been two years. After she got pregnant, the family had been taking her for regular antenatal care in the nearby town. There is mention of her low haemoglobin during each of her visit and Iron appears to have been prescribed.

She’s come in labour yesterday. We had wanted to do a Cesarian section as I felt that there was not much space for the baby to come and there was grade 2 meconium. Her haemoglobin was 4.6 gm%. We told the family that we would touch her only after the family arranges at least 2 pints of blood.

The relatives are yet to arrange blood. But, the lady’s found favour with the Almighty. We were quite worried and could only pray.

She delivered normally late yesterday night . . . of course, the baby was severely IUGR. The labour room team worked hard to ensure that there was not much bleeding.

The problem is the haemoglobin. Today morning, I did it just to find out how it was. She looks a bit uncomfortable. It was just 2.6 gm%.

I can only pray that at least one pint of blood comes before she goes into a hemodynamic complication . . . Once again, another case which would have benefited from UDBT.

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. 

Maternal Death . . . 3 Orphaned . . .

Yesterday, we had a maternal death. 

Not much to write about. Considering the previous death, this one was fast. 

We did not get much time to do anything. 

Because, she died within 15 minutes of arriving at the hospital. 

She was pale as paper and it was an obvious rupture uterus. Usually, we don't get many cases of rupture uterus who dies. Most probably, she was severely anaemic even before the rupture happened. 

The interesting thing about her. She did not have an intravenous line put on even though she had been to 3 hospitals. When we asked about the same to the relative . . . it was difficult to believe the reply. 'The patient's body is too swollen to put an intravenous line'. 

She had got couple of intramuscular injections throughout the day. Her contractions had started at 3 AM same day morning. Since, it was her fifth delivery, (3 children alive and one still birth), the family had decided to attempt a home delivery. 

Since nothing was happening, they took her to a hospital at around 9 AM. 

She reached at NJH a full 12 hours after that. 

The case sheet reads . . . Time of arrival: 9:30 pm, Time of death: 9:45 pm. 

There was no point in resuscitating as she was pale like paper. And there was no way we could get blood so fast. 

2nd maternal death of the month (February 2013) after a maternal death free month in January 2013. 

Last week, we were forced to tabulate the number of maternal deaths in 2012. Below are the numbers and the causes . . . 

Nos. of maternal deaths in 2012 (Jan-Dec)		CAUSE OF DEATH	Nos. of maternal deaths in 2011  (Jan-Dec)
•27 deaths •Total deliveries: 1544 •LSCS: 482	18	Eclampsia /Pre-eclampsia	11	•  24 deaths •  Total deliveries: 1280 •  LSCS: 439
	0	Septic abortions	3
	1	IUD	3
	1	Unknown	2
	0	Valvular heart disease	1
	0	Obstructed Labour	1
	1	Rupture Uterus	1
	5	Sepsis	1
	1	Malaria	1
	0	Severe anemia	0

One gram hemoglobin and survived - The Miracle

SD came today afternoon to my office. I thought we had discharged her. She told me that she wanted to go only after she was absolutely sure that she would survive. So, the delay in discharge. She had been with us for almost 4 weeks.

She was quite thankful. Her family had gone through the valley of the shadow of death. She had seen my anxious face as she was wheeled in. She might have even got a glimpse of my gestures while I explained to her husband that there was very little chance of her making through.

For all of us in the hospital, it was a miracle. With hemoglobin of 1 gm%, I’m not sure on how many could have survived.

It has been a long haul for the family. They had to face quite a number of hurdles. She received a total of 7 pints of blood during her time in the hospital including the one given by Mr. Dinesh, our maintenance supervisor. In addition, getting poor quality blood from the blood bank in town did not help.

We waited for the hemoglobin to rise before we could attempt anything regarding her placenta accrete. Ultimately, we decided to go ahead with a hysterectomy with a hemoglobin of 3.2 gm%. When we saw the uterus, we were sure that it was a miracle that SD has pulled on so far. It was stinking so bad and the placenta was so well adherent to the uterine wall.

The gangrenous uterus along with the adherent placenta

SD has two little boys. She looks forward for a new life with her family and she knows she is extremely blessed to have survived against all odds.

There is a sad part of the story too. The treatment has taken a toll on SD's families' finances. The total hospital bill had come to a whopping 26,000 Indian Rupees. In addition, they must have paid quite a lot of money to get the 7 pints of blood. SD's husband was not going for work. And there were mouths to feed in the house.

When SD's husband came to pay the bill, he told me that he was ready to pay Rs. 5000. I asked him how he managed that much money. He had sold quite a lot of his land. It was heartbreaking to hear that. Another family pulled into selling off valuable assets just for want of poor public healthcare.

CHILD DEATH . . .

We had a horrible beginning of a day today. After devotions, I found out that there was a little girl, AK aged just above 2 years who had come in with a history of fever for the last 10 days. I wondered what the family doing for that long time. Unfortunately, I did not have much time to take a detailed past history or socioeconomic history.

AK was very sick with labored breathing. She was so pale – that I knew that her hemoglobin would not be more than 2 gm%. Her saturation was about 70%. If she had to survive, she needed blood and mechanical ventilation.

Luckily for AK, the ventilator was free and we could hook her onto that soon. The problem was with the blood. I went along with the father of the child and ensured that he checked his blood group. It matched. He requested 10 minutes to go and have food as he had not had anything to eat since the last 12 hours.

The laboratory results left me stunned. The father told me that she was on Injection Artesunate. You can see the laboratory results in the snap beside you. Later, Mr. Anil told me that 60% of the RBCs were filled with the malarial parasite.

She did not have much chance unless she had the blood. I went back to her bedside. She had suffered a cardiac arrest and the nurses were already starting a CPCR. The father who was supposed to be back could not be found. With a hemoglobin of 1.4 gm%, I knew that we did not have much of a chance.

The father came after about half an hour. Her heart had started to beat again. I had rushed fluid. As a last ditch effort, I started her on a dopamine drip – which was foolish considering her pathetic hemoglobin. She suffered another cardiac arrest after which we could not revive her.

She died at 10:00 AM exactly 2 hours after she had come in.

I’m concerned about 2 things.

The first one is about the injectable artesunate which was used. There can be only two things which can be concluded. Either it was a duplicate medicine or there is resistance emerging to artesunate compounds in our region. There are reasons to believe either of them, both of which are reasons of major concern to us.

Duplicate drugs are a major issue in most parts of the country.

However, there is much reason for us to believe about emergence of artesunate resistance as during the last 2 months; we have quite a lot of patients who had been started on artesunate derivatives from outside, especially the quacks as well as legitimate doctors. They had no relief and we have seen them respond to quinine.

My second concern was about the attitude of the father to the condition of the little girl. He could have at least tried. I’m not saying that the girl would have survived if we got the blood. He was least bothered when he came in first.

Neverthless, I saw him weeping silently after I told him that his daughter has died. But, if he had brought her in earlier she would have definitely survived.  

After this little girl left, we had 2 more admissions in the Acute Care Unit of similar patients with a similar history. More about them in the next blog.