2 Eclampsias - Different endings . . .

Last week, we had 2 patients come in with very bad eclampsia. We managed one very much pro-actively whereas the other we could not do much as her blood parameters were already quite bad. The first made it and the latter died within 4 hours of arrival to the hospital.

SD, had suddenly thrown off fits sometime mid-morning and had come through couple of other hospitals before she landed up here. SD was very sick - her bladder was empty - rather there was some amount of darkish red fluid coming in the urobag, her creatinine levels elevated, Glasgow Coma Scale of 3 and Platelet Count of 59,000. And the baby was dead. And the birth canal was tightly closed. 

I was in a half mind to operate but the low platelets prevented me. The fact that operating rooms were not free made the decision easier. Unfortunately, she had a cardiac arrest sometime late evening and we could not resuscitate her. She was dead.  

However, there was another patient, UD couple of days before SD arrived. In fact, when SD had arrived, we showed UD who was on the adjoining bed. 

UD came to us after having been to couple of hospitals. She also came sometime late evening. We had done an emergency Cesarian to deliver a pair of undiagnosed twins. Both the babies were sick initially, but recovered over couple of days. UD had been having seizures over the whole day before she reached here. To make matters worse, when UD came in, she had a Glasgow Coma Scale of 3 and suffered a respiratory arrest in the labour room. 

We got her intubated and shifted her to Acute Care. After some amount of mechanical ventilation, we took a decision to do a Cesarian and deliver the baby. 

After the Cesarian, we were surprised to find out that she could be easily weaned out of the ventilator - but later found out that she had developed a focal neurological deficit - a left side lower limb hemiplegia which has since improved. 

We never expected UD nor SD to make it. We sometimes wonder what was the difference between the 2 ladies. Regarding SD, the facts that stood against her was the overt edema, sudden onset of symptoms, total renal shutdown and thrombocytopenia. UD did not have edema and all her blood parameters were normal. The blood pressure was high with a Urine Albumin of 3+. 

Now, the saddest part of the whole narration. UD's relatives were very upset with us after the surgery. The twins turned out to be girls. And UD already had a little girl of 3 years at home. After UD had become fully conscious, she was also psyched out by one of her relatives for her 3 children being girls . . .We had a tough time convincing UD that it is perfectly fine to have 3 girls and is possible to bring them up to be responsible citizens of the country . . . However, she is going to have a tough time doing that . . . I feel happy that the 3 girls will have their mother to be with them alive and well and raising them . . . I wonder, whether the family agrees with me . . . They may have wished that the mother and 2 girl babies had died rather than lived . . . How sad ? ? ? Most probably, UD will be under pressure to have one more baby . . . to try to get a boy . . . 

Praise and Prayer Bulletin . . . May 1

1. Dr Johnson's father passed away last week. Kindly pray for the family as they go through a difficult phase in their lives.

2. We had been busy over the last couple of weeks. We thank for the patients whom we could save. Please pray for families who lost their loved ones especially the family of the boy who died after 3 members of the family got burnt.

3. The last financial year has been a mixed experience for us. Although our statistics has been on a constant rise, we've had quite a lot of expenses which has kept us in the red. We pray that we would be of help to the surrounding poor communities and shall be witnesses of the love of Christ in the year ahead.

4. We thank the Lord for the safe deliveries of Dr Angel, Sr. Chandrakala and Sr. Kanchan. All the mothers and babies are doing fine. 

5. We praise God that there has been quite a major improvement in the quality of the road to Daltonganj. In light of this, we look forward towards purchase of a school bus for the children. Kindly pray for this need. It would cost us about 1,300,000 INR (26,000 USD/AUDs, 15,300 GBPs). The present vehicle is almost 12 years old. 

6. The public electricity supply in this region continues to be quite pathetic. We spend about 150 litres of Diesel per day to run the generator, which is a major expense to the hospital. We look forward towards exploring alternate sources of energy. Kindly pray that we would make some sort of progress in this area.

7. Obstetric care continues to be on the rise here. We thank the Lord for the joys we have had over the last couple of weeks. However, we have felt that we need to train more of our staff in obstetric care. It would be wonderful to have a full time neonatologist to help us in the work.

8. In addition to the pediatrician, we also look forward to have a medicine consultant. Cases of fever and complicated cases needing intensive care has been a major challenge for us. We pray for a pediatric consultant.

9. Summer has started. It looks like it is going to be quite a harsh one. Please pray that our water reserves would see us through. Do pray that the staff will be protected from sickness during the harsh weather. And that we would receive timely and enough rain once monsoon sets in.

10. After a gap of 3 years, we had a plentiful harvest of fish (112 kilograms) from our pond. We thank the Lord for this encouraging sign.

11. RSBY has been well received by the local community. We had over 350 outpatients and about 80 in-patients since its inception. Please pray that we would receive funds from the insurance agencies in a time-bound manner. On May 4th, the District RSBY Office has organised a Medical Camp at Satbarwa to mobilise surgery patients. We pray that we would have enough learnings in the process. 

12. Please pray for our lawyer, Mr. BK Pandey. He lost his wife couple of months back and had gone into a bad depression. We had been managing him. Thankfully, he has recovered well. 

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. 

Malaria . . . Challenges . . .

Yesterday was World Malaria Day. It was not uncommon to see quite a many programs and rallies all over the world including India. . . Quite a lot of us are being made to convince that malaria is slowly on its way out. I find it difficult to comprehend numbers. In India, we've had much of a controversy last year over mortality statistics which were arrived at by researchers and the government. As usual, the government claims a much lesser mortality than the research group.

Well, over the last week, we've had malaria cases coming back. I thought of jotting down few observations on malaria over my stint at NJH.

1. Malaria continues to be a major clinical issue in rural areas of Jharkhand.

2. The major challenge is the possibility of evolution of drug resistance due to the rampant misuse of anti-malarial drugs. There are multiple issues here. Let me illustrate. 

Over the last week, we had about 10 patients who presented with symptoms suggestive of malaria. Only 2 of them tested smear positive for malaria. All the rest were negative by smear. 3 of them (all smear negative) had low platelet counts. Two of them died. 8 of the patients who had tested negative for malaria smear had a history of at least one contact with another health provider who had invariably given them anti-malarial medicine - all of them had received oral Artesunate and few even intravenous Artemesin derivative. And only couple of days treatment. 

As I had mentioned in previous posts, the question of a proper diagnosis looms over the conclusion that malaria is the only major killer. I'm sure that we are dealing with other infections like dengue, rickettsia, Japanese encephalitis etc. 

The partial treatment of all fevers with anti-malarials makes the issue only worse. 

Both our patients who tested positive for malaria smear had come straight-away to NJH. And they've gone home fine without any complications. 

Well, we've reports coming in that malaria continues to be a scourge in Jharkhand and Orissa. It was interesting to note the comment in the last part of the above article - 'The only solace, maintained state health department officials in Jharkhand, was that there has been no malaria deaths so far in the year.' 

How will there be malarial deaths, when we have so much of partially treated malaria who will have no laboratory evidence of malaria when they come terminally ill?

It is sad. Almost all of our public health system appears to live in a 'Fool's Paradise'. Someday, the situation is going to get the better of us. What concerns me is the emergence of non-communicable diseases in a big way in places like ours. Within 10 years, if we do not take control of our problems with malaria and tuberculosis in addition to the maternal and child health issues, we could be neck deep in trouble where the development of the country could be in doldrums because of the abysmal healthcare situation of the country. 

It would be unfair if I do not suggest at least couple of simple steps which could be taken  - 

1. A robust Disease Surveillance Programme where each case of fever death is accounted for.

2. Full fledged research into causes of fevers in remote areas of the Empowered Action Group states (the old BIMARU states)