Monday and Tuesday were relatively quiet, the calm before the storm. We had a lot of deliveries and a lot of admissions for malaria and dysentery but I didn’t have to go to the operating room (OR). All that changed on Wednesday.
A patient came in in labor. She had previously delivered two children, one by C-section and one vaginally. Her baby had a heartbeat when it arrived but during the time when she was pushing the midwife lost the heartbeat and the baby’s death was confirmed by an ultrasound.
Like the patient from just a few days before, her abdomen was extremely tender and there appeared to be a lot of fluid in her abdomen. The baby’s head was wedged in the birth canal but was still too high to even try to remove. I again thought she had probably ruptured her uterus along the old C-section scar and explained to her and her husband that we needed to go to the OR to deliver the baby by repeat C-section. I also told them that there was a possibility that if the uterus was indeed ruptured it might not be able to be repaired and might need to be removed.
Her husband didn’t take well to that news. He was adamant that we deliver the baby vaginally. His exact words, translated, were “give her a pill or something”. I explained that even if we could deliver the baby vaginally my biggest concern was that the uterus might be ruptured and needed surgical attention. He became more and more insistent and finally just stalked off. The patient signed her consent form with a thumbprint after a discussion of what I expected to find. The family members who were with her, her mother and some other women, were in agreement.
Her uterus was ruptured and badly. It took a while just to figure out where the various pieces were from but it was apparent early on that there was no way to salvage the uterus. After delivering the fetus and the placenta I did a hysterectomy on her because that was the only option. She also received blood during the procedure and postoperatively has done well. She is still in the hospital but should be able to go home within a few days.
I saw her husband today for the first time since the day we took her to surgery. He is still angry and still believes that we should have left her uterus inside. He also feels that we should have asked his permission before we removed it. I’ve explained to him as calmly as I can that saving her uterus just wasn’t an option but he’s not really listening. I worry that he is going to make her life a misery once she is discharged.
Later that same afternoon a patient came in who had delivered her previous five children at home. She came to the hospital this time because she couldn’t push the baby out. When I examined her it was immediately obvious that she had torn badly, perhaps with her last delivery, and the vaginal opening admitted only a single finger. The baby’s head was pushed hard against the membrane of scar tissue that closed the canal. When I tried to put a catheter in her bladder it went in just a few centimeters and then exited into the vagina.
Upon questioning she said that she constantly urinated on herself since her last delivery. She must have had a massive vaginal and urethral tear and had healed badly. Now she had a direct communication between the urethra and the vagina. The bladder emptied any time the pressure inside of the bladder became strong enough. She had absolutely no control over the flow.
The baby was still alive and was delivered by C-section, healthy and kicking. There was nothing we could do about the mother’s injuries right now but I’ve put her on the fistula list, a list of patients with similar injuries who will hopefully be contacted when a surgeon who specialized in repairing those injuries comes through the area.
Still later that day a patient came in on referral from MSF Spanish section, who has a project in a town relatively close to Aweil. They were concerned that the patient had a placenta previa. What she actually had was the largest molar pregnancy I’ve ever seen. A molar pregnancy is the result of two sperm fertilizing an empty egg, an egg without any maternal genetic material, or from one sperm fertilizing an empty egg and then reproducing its own genetic material. All the genetic material in a molar pregnancy comes from the father.
Rarely there can be a fetus combined with a molar pregnancy but usually there is no fetus, just a cluster of material that looks like a cluster of grapes on ultrasound and on pathology. When it is caught early it can usually be treated by doing a dilatation and curettage (D&C), removing all the tissue from inside of the uterus. However the longer the molar pregnancy continues, the higher the risk to the mother of a massive hemorrhage. I’ve done d&c’s for these pregnancies before and even at eight or nine weeks size they can bleed tremendously, even requiring transfusions.
This woman’s molar pregnancy was the size of an eight month pregnancy. Her uterus was huge, an invitation for a massive hemorrhage, and a D&C was not an option in this setting where the entire blood bank might have only 15 to 20 units of blood available for all patients. Fortunately she had already had several children and agreed to a hysterectomy, the only option I was comfortable with since it gave us control over the amount of blood she was likely to lose.
The hysterectomy went well and she will go home in another few days. Because molar pregnancies can persist or even metastasize to other parts of the body, sometimes even developing into a cancer called choriocarcinoma, she will need to be followed closely for the next year. The beta-HCG urine test that we use to detect a pregnancy is also useful for following the markers for these particular types of growths.
If she still had her uterus we would put her on birth control pills and advise her to avoid pregnancy for a year just so we could know that if her HCG levels began to rise it was due to the tumor and not a new pregnancy. Since she can’t become pregnant there’s no need for birth control. We’ll just follow her monthly with HCG tests. If, however, they should come back positive we really don’t have a treatment option here. The drugs used to treat these growths are not available at the hospital nor in town and probably not in the entire country. So I’m wondering if there’s a point in ordering a test to check for something that we can’t actually treat.
That gets us to Thursday which was, hands down, the roughest day here so far...
Stephen wrote this post in March 2015