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) 

Syphilis . . . Forgotten foe . . .

Syphilis . . .The very mention of the term used to send shudders in patients and was the darling of medicine professors for quite a long time. It was described as 'the great imitator' by Sir William Osler. One of my professors used to tell that in the olden times, a post-graduate student of Internal Medicine was assessed by how much he knows about syphilis and it seems that the same status is presently enjoyed by HIV-AIDS. 

Well, why I started a post of Syphilis? Over the last week, I had two families diagnosed as having the TPHA test positive. None of the members of the family had any symptom. 

Here are their stories . . . I know there may be quite a lot you may want to comment on them, which I would like to hear . . . 

The first patient was MS, on whom we had to do a Cesarian Section after a complicated trial of labour elsewhere. Before the Cesarian section, MS was diagnosed to have a low hemoglobin and we asked her relatives to arrange blood. The husband had her same blood group and he was ready to arrange blood. Well, on screening of the donor we found out that he is TPHA positive. As a rule, we do not do TPHA on patients who come at term. We do them only for those who come in the first trimester.

Well, by that time the Cesarian was over. We tested the mother and the baby. Both were positive. They very well understood when we counselled them about the disease. 

When I rejoined NJH in June 2010, I had done a re-look at the blood tests we do. Since, almost all of our patients are poor, we were trying to cut down on the tests. We did not find any TPHA positives in any patient for almost 2 years. There were few HBsAg positives and no HIV positives among the antenatal patients. I decided to drop doing TPHA, the main reason being that quacks were quite prompt in prescribing antibiotics and therefore I came to conclusion that this must be the reason that there was no TPHA positive for so long a time. 

However, the protocol was do TPHA in the first and second trimester for all ante-natal patients and drop it for those who come in late third trimester or directly to labour room. 

I was contemplating on whether I should bring back the policy of doing TPHA for all pregnant patients when the next patient arrived. 

One of our antenatal patients who landed up in labour room was found to have a reactive TPHA which was missed in the antenatal period. There was nothing much we could do now other than to re-check TPHA. Unfortunately, the TPHA turned out positive and after the delivery the baby also was reactive. 

I called the father, a man in the armed police force. The fellow looked quite disturbed and a bit drunk. I told him about the TPHA reactive status of his wife and child. He seemed to be hardly bothered. The only thing he wanted was to go home ASAP. I told him that he also needed to get tested. He would have nothing of it. He told me that he had issues to attend to at home and therefore needed to get discharged immediately. 

We tried our best. Ultimately, armed with consent forms on what all will happen and accepting full responsibility if something untoward happens in the future, he was off with his wife and child. 

Questions I have in my mind . . . 

1. TPHA is expensive. Should I do it for all pregnant patients irrespective of when they come - especially when they reach Labour Room straightaway after Antenatal Care elsewhere. Most of the places, VDRL or TPHA is not commonly done. 

2. When I have patients like the latter, what do you do? They are high risk to the community. 

3. Could we have donated blood from the TPHA positive husband to the TPHA positive wife? We had a bit of difficulty getting blood after the husband was refused as a donor. Crossed my brain only now . . . it could have been done. 

2 Happy Families . . . Could have been tragedies . . .

Over the last week, in addition to the tragedy of 3 members of a single family getting burnt, we did have our moments of joy. . .

The first reason for the same was SD1. SD1 came about 10 days back in a terrible state. It was SD1's first pregnancy. There was no antenatal check up. She had turned up at the neighbouring district hospital after being in labour at home for some time. It was sometime before the people there realised that SD1 looked a high risk case.

SD1 had a hemoglobin of 5 gm%. On per vaginal examination, the cervix was edematous with dilatation of 5 cms and there was meconium pouring out. I was in a fix. The referral letter mentioned that SD1 is being referred to Ranchi. We needed blood. There was only one bystander.

I was thankful when the blood matched. But, one pint was never enough. I was sure that the hemoglobin would be lesser than 5 gm%. However, we had to do the surgery. Otherwise, we risked having a rupture uterus and a dead baby.

We went ahead with the surgery. The baby was sick. But, he somehow pulled through. The bystanders were  quite fast is arranging two more pints of blood. It was quite a relief when SD1 recovered soon to be discharged.

The challenge for us was the bill. Because it involved 5 blood transfusions and neonatal care, the total bill was around 20,000 INR. The family was too poor. It did not need much convincing that they would not be able to afford even half of this bill. They paid about 10,000 INR. The rest went as charity. It is a burden for the hospital. But, considering our vision and mission, we have to make such concessions. . . 

The next patient was SD2. Married for 14 years, the family did not have issues. The interesting aspect was that she had a whopping 8 abortions. And the saddest part was that she did not take much interest to do any antenatal check up during the present pregnancy. The delivery was uneventful. It was a pleasure to watch the joy of the family as they adored the new arrival. 

The last one was 2 days back. SS had come with usual labour pains after an uneventful antenatal period. On arrival in labour room, Dr Johnson diagnosed a breech presentation. Since she was a multi, we did not anticipate much problems. But, as soon as the breech was out, Dr Johnson was sure that there was one more baby inside. And yes, she had a surprise twin delivery to add to her already large family of 3 children. 

All the 3 deliveries, especially the first two could have ended up as tragedies. We are thankful that all the babies and mothers are doing well.

Over the last 2 weeks, the 'marriage season' has started in this region. It is very hilarious. Everything revolves around the weddings. Almost everybody in the ward requests for a discharge citing excuse to attend a wedding or to get married . . . We expect quite complicated cases to come in during this period. In addition, we have students from the Christian Medical College, Vellore visiting us for the next 2 weeks. Do continue to follow the blog . . . there should be interesting posts continuing . . .