I was thinking, if I had one wish whilst being on-call at Gondama Referal Centre (GRC) it would be to have secret door. Hidden round the back of the labour room, a door that would open onto an Intensive Care Unit like the ones back home. The cool dry air conditioning, quiet beeping of machines and the intelligent micromanagement to keep patients stable. I would be able to discuss cases with the anaesthetist, or any specialist I needed, get every clinical test I wanted as a priority and be able to rest knowing the patient had “one to one” care. Needless to say GRC is as far in distance as it is in reality of having such a facility.
The patients continue to come to GRC in little clusters. I might go hours with no new admissions, just sitting around wondering what I should be doing and then three ambulances will roll in together. In the UK pre-eclampsia is a common condition (a disease of pregnancy associated with high blood pressure and internal organ dysfunction), but thankfully eclampsia (the more severe condition diagnosed by the presence of seizures) remains rare.
The opposite is true here, I have seen very few cases of pre-eclampsia but eclampsia is virtually a daily occurrence. I assume that the lack of antenatal care (and therefore no screening) means that the “pre” goes unnoticed till the seizures begin.
My first case was a few weeks ago, a lady at full term transferred mid-way through labour having violent convulsions. By the time she arrived she had been having seizures on & off for several hours. I try to stand back encouraging the national staff to manage the situation, giving cues on what to do next. It is important that the midwives and nurses can manage these emergencies independently, MSF will not be here forever. She was stabilised, then a plan put in place to deliver the baby and keep her on treatment for 24 hours. A pretty standard recipe for eclampsia. A few days later she went home with her baby. A happy ending.
However the last week has brought a flurry of extreme and complicated eclampsia cases, several cases each day. Over three days we admitted a series of eclamptic patients with varying severity, from a couple with sever pre-eclampsia (no seizure) to some who were unresponsive and comatose.
One patient had been admitted over several days, originally with severe pre-eclampsia. She was started on stabilising treatment and delivered (the same recipe as eclampsia), she continued to make excellent post-natal progress and 24 hours after delivery the treatment was stopped, she was walking around and caring for her baby.
A plan was made for a couple more days of observation and discharge home. Another success story. Around 48 hours after delivery she unexpectedly began having seizures, the classic short lived but violent convulsions of eclampsia. She was cold and clammy, becoming increasingly confused. The blood pressure was not high, but she had the tell tale signs of headache, seeing flashing lights and swelling down the legs. Her breathing was rapid, but she had good air entry and clear sounding lungs. The usual recipe of oxygen, magnesium sulphate and strict monitoring of fluid going in & out was restarted.
The patient appeared to settle, her vital normalised and she had a restful night. As I left the hospital the following morning she was lying on her bed talking to her mother (who was nursing the baby). It looked like we were back on the road to recovery. A few hours later she quickly became breathless, the on-call gynaecologist reviewed her, the blood pressure remained stable but the urine output had tailed off. The medication was stopped and an antidote given but she did not improve. On listening to her lungs it was clear that they had become congested with fluid, high flow oxygen was started and drugs to shift the fluid out commenced. She continued to deteriorate. Over a couple of hours she drifted deeper unconscious, fighting to breathe above the water in her lungs. She died.
The thing with eclampsia (so they say) is it is unpredictable. A serious disease that we try to catch early but can creep up unexpectedly and present with or without the classical signs. I thought through this lady’s management over and over again, discussed the case in detail with the other doctors. What did we miss? In truth we found no answer. I think we needed my the secret door to ICU.
The staff see eclampsia so often that they barely raise an eyebrow when these women appear shaking and jerking, one look and the magnesium sulphate is already being drawn up. But I fear that familiarity can also lead to complacency. Yes magnesium treatment is needed, but understanding stabilisation and management is also vital and takes more than a reflex reaction. Over and again I stand-back, watching and commenting… Airway, breathing, circulation, oxygen, recovery position, manage the BP, slow down the fluid, SLOW DOWN THE FLUID. I like an emergency that runs like a well oiled machine, and even with limited resources and personnel I believe it is achievable here.
Saturday’s shift brought three more eclamptic patients. Each presentation having its own challenges, and each time leaving me looking for my secret door. At 8am I took handover from the previous shift. An 18 year old was in labour, trying for a vaginal birth after a previous caesarean. There were no concerns other than her progressing labour. The blood pressure was normal and no protein in the urine (a diagnostic sign of pre-eclampsia).
As I began my ward round I heard a commotion coming from the labour room “Doctor we need you”. I ran round to find a flat pale baby being rushed to the resus table and the mother lying with back arched, arms and legs flexed shaking aggressively. There is a saying in obstetrics when it comes to seizures in pregnancy “eclampsia till proved otherwise”, so the reaction is usually to reach for the magnesium. As the nurses responded to my prompting I went over and began rubbing and bagging the baby with one other nurse, till it began whimpering. I looked at the young woman and asked if the magnesium had been given yet, “no doctor, this is not eclampsia”.
OK, so what is it? I sat and went through the notes with the midwives. In labour for two days and not eaten. Hypoglycaemia? She has malaria (as do many of the women attending). Could it be cerebral malaria? I spoke with the family- no history of epilepsy or anything similar. It was true that her BP was never high, maybe the midwives were right. I conceded and agreed to a period of observation alongside giving some glucose and beginning treatment for severe malaria. But then she had another seizure, this time there was no discussion and much to the disapproval of the staff I commenced the eclampsia recipe. I sat and chatted the reasoning through with them, explaining the possibilities and process of elimination. That though rare, eclampsia can indeed happen without any warning, no raised blood pressure and no protein in the urine. They remained unconvinced but started treatment anyway. As it turned out her blood pressure did slowly creep up and we all agreed that it was eclampsia. She is doing very well, unfortunately the baby died in the neonatal unit several hours later.
In the night another 18 year old arrived, she had delivered her baby 10 days before. I heard her before I saw her. Screaming incoherently, distressing sounds with a blank look on her face. She had been having seizures since the morning before, a long time to be left without treatment. She looked terrible and was completely unresponsive other than the occasional jerks with an agonising scream.
It had been a couple of days since the other patient with postnatal eclampsia had died, still a raw experience, one I was keen to avoid ever seeing again. We went through the usual drill, starting the drugs, ruling out other causes. The girl’s eyes were fixed and not moving, she only responded to being rubbed on the chest (screams only) and her oxygen level was 86% (dangerously low for a young woman). I feared the worse. I racked my brain, what else can we do. We cranked up the oxygen and gave medication to try and offload retained fluid. As I looked upon her I thought about my secret door. How different things would be.
Thankfully I was distracted from staring at her as I tuned into the sound of two more ambulances arriving with patients who urgently needed to go to the operating theatre. When I finally got round to returning to her bedside I was overjoyed to see she was now a different person. Sitting-up trying to feed her baby, she had no recollection of ever seeing me before. Today she too remains well, off the recipe and hopefully to return home soon.
The eclampsia patients will continue to come, often late on as with all other conditions here. Most respond to the standard treatment, but a few take a stormy clinical journey, it’s for them that my secret door is needed the most.