When you work in a maternity hospital that does nearly 2000 deliveries per month (upwards of 60 per day), even on an average day you are bound to come across some interesting and memorable cases.
In 2012, Medecins Sans Frontieres / Doctors Without Borders (MSF) opened a maternity hospital in Khost, eastern Afghanistan, to address the lack of obstetric care in the area. The hospital helps reduce maternal morbidity and mortality by offering a safe environment for women to deliver their babies, free of charge. The community has embraced the services offered at the hospital. There has been a 40% increase in the number of deliveries from 2014 to 2016.
Map of Afghanistan and the surrounding countries. Drawing by Aurélie Neyret.
Khost is a bustling city of 160,000. It is the capital of Khost province, a mountainous region with snow-capped peaks upwards of 2,500 metres, just thirty kilometers from the Pakistani border. Over one million people live in the province, a population that is a patchwork of Pashtun Sunni Muslims belonging to different tribes and traditional nomadic people known as the Kuchi.
City of Khost from the rooftop of a building.
Mornings in Khost start with making rounds of the patients in the pre-delivery, labouring, and post-delivery unit. The midwives manage the large volume of patients and involve the gynecologist when complications arise. The majority of women have no access to prenatal care, so when they present to our facility with concerns, it is often the first health care encounter of their pregnancy.
One morning I was asked to see a patient about 2 months pregnant with bleeding and abdominal pain. This was her second pregnancy, the last one having delivered 3 years prior. As I examine her she nearly jumps off the bed when I touch her belly. On ultrasound I see a small fetus, about 8 weeks in size, with a strong heartbeat. The patient smiles as I explain this to her through the Pashtu translator.
I continue scanning with the ultrasound to determine the source of her pain and see what appears to be a large amount of blood in her abdomen and a mass near her ovary. Something has burst, and I cannot be sure exactly what it is. It could be a bleeding ovarian cyst but it has a certain appearance that makes me worry it is in fact a second pregnancy outside the uterus, an ectopic pregnancy (likely in the fallopian tube). Fallopian tubes are thinner than one’s pinky finger and if a pregnancy lodges wrongfully inside they eventually outgrow the space and rupture. This causes bleeding which can be life threatening to the mother.
Médecins Sans Frontières Hospital in Khost at night.
Ectopic pregnancies are relatively common but a heterotopic pregnancy – one inside the uterus and one outside the uterus at the same time – now that’s pretty rare!
We quickly obtain consent and prepare her for the operating theatre to perform a laparotomy. We suction out the blood that has collected in her abdominal cavity and quickly identify the bleeding culprit – the left fallopian tube, which has been destroyed by the growing ectopic pregnancy. We remove the tube. The bleeding stops and the patient is eventually transferred to the recovery area.
In the coming days she recovers from surgery. Prior to discharge we perform another bedside ultrasound. The young intrauterine pregnancy is alive and well.
Labour room – a rare moment when it was empty!
Seeing patients during the early stages of pregnancy is so valuable to maternal health. Fortunately, this young woman presented in time for us to deal with an exceptional circumstance and give her the best chance for a healthy pregnancy. With growing numbers of patients, every day brings the chance of unique cases for the Khost maternity hospital.