Tuesday, 23 July 2013

Babies and more babies

Well, it's official! The English royal family has a new prince. In other news...

1. Primigravida with ruptured ectopic pregnancy
A 23-year-old primip presented to our hospital mid last week with severe lower abdominal pain on a background of 6 weeks of amenorrhoea. My colleagues did a quick ultrasound scan of her belly before admitting her and saw a possible right adnexal mass; however, it also looked like there was an intrauterine gestational sac (?heterotopic pregnancy) without any signs of peritonism or guarding. I saw her on the ward in the evening and she was haemodynamically stable, smiling and appeared comfortable. The next morning was a whole different scenario; she was on her knees in obvious pain and a repeat scan showed a definite fetal pole in her right fallopian tube with an empty uterus.

Rushed to theatre, we were waiting for induction when my colleague took a peek around the drape, saw her suddenly turn pale and made the (correct) call that the ectopic had ruptured. Proceeding to laparotomy, we found massive haemoperitoneum. It was rather scary as she continued to bleed profusely even after the ectopic was removed; there was a question of whether the blood was tracking down from other parts of the intraperitoneal cavity following the initial rupture or whether it was from another source (she also had smear-proven malaria and the possibility of splenic rupture was considered). Ultimately, we decided to close the abdomen, estimating blood loss of at least 1.5 litres. Thankfully, she recovered very nicely. Her postoperative Hb did drop to 6.6 from an admission Hb of 12+ despite intraoperative transfusion (with just one unit of whole blood - this is South Sudan, after all) but she remained clinically stable and was discharged home after three days with a discharge Hb of 7.8.

2. Yet another case of postpartum haemorrhage
Another of our patients, this one pregnant with twins at 36 weeks gestation, represented one day after discharge in active labour. The first one delivered fine but CTG showed fetal distress with the second bub (known to be breech and smaller in size - 500g difference from memory). Thank God, he delivered soon after; Apgar score at 1 minute was 4/9 and he was initially bradycardic and floppy but a couple of minutes with positive pressure ventilation quickly fixed that.

Everything seemed hunky dory in the next few hours until I did a quick evening ward round and the mother told me that she was concerned that there was more lochia (vaginal bleeding and discharge after birth) than expected. Alarm bells went off in my head since she had a multiple pregnancy and a second-degree perineal tear that was left unrepaired, both risk factors for PPH. Say what you will, I think it was the Holy Spirit that prompted me to take her back to the labour ward to properly examine her, and I am so grateful to God that I did. There was quite a bit of ooze from the perineal laceration, which we repaired without further ado. What was more concerning was how we subsequently uncovered large amounts of clots coming from further up (i.e. the womb). In fact, we had to then sedate her with ketamine to manually evacuate the uterus.

This time, the haemorrhage was managed in a more or less controlled fashion, and better still, we had a satisfactory outcome for both the mother and her twin babies. In other words, the stark opposite of the case of PPH we had just a short two weeks ago!

Psalm 127:3-5 Behold, children are a heritage from the Lord, the fruit of the womb is His reward. Like arrows in the hand of a warrior, so are the children of one's youth. Happy is the man who has his quiver full of them...

No comments:

Post a Comment