Lessons in High Risk Obstetrics

My life has started to look a lot like Residency Part II recently: Work, Eat, Sleep, Rinse and Repeat.

This is an ultrasound I did for a patient who presented with bleeding at 26 weeks.  I have been spending a lot of time on trying to improve my ability to diagnose IUGR (IntraUterine Growth Restriction), because women here often present with pregnancy complications and unsure dating.  While I was scanning this feisty baby, he decided to start sucking his thumb - so I snapped this pic with my camera!  This Mom delivered (Chronic Abruption and Preterm Labor) at ~ 27 weeks and baby is in the Nursery.

This baby's mom presented with severe IUGR and ITP (Idiopathic Thrombocytopenic Purpura - a disease where the immune system destroys platelets, necessary for blood clotting).  One challenge here at Tenwek is that I don't have access to packed platelets - only whole blood.  The patient's Hb was quite good, though her platelets were 32,000.  I tried steroid administration and blood transfusion on the day of CS, but at the time of surgery her platelet count was 28,000!  Thankfully, everything went well.  I was only able to give her one unit of blood because post-op her Hb was 18!  Again, the steroids did not help in the absence of platelets and on discharge, her platelets wer ~34,000.  The baby is doing well in the nursery, just gaining weight.  The patient has had 3 other fetal deaths, so this is her first liveborn baby!  She still cannot believe that she has a live, healthy baby.  Postop, when she was waking up from the general anesthesia (necessary due to her low platelets) - she kept asking: "Where is my baby?  Is it alive?  Are you sure she is okay?"

Another patient came in with a "BOH," or Bad Obstetrical History.  Her last baby was a postdates induction of labor, complicated by meconium stained fluid.  Now, remember that we do not have continuous fetal monitoring here at Tenwek - only Dopplers and fetoscopes.  So, meconium presents a problem for us in regards to vaginal deliveries.  I have definitely seen the truth of a "normal" fetal heart tone does not ensure a good baby.  I am sure many of our babies have horrible variabilty with decelerations - I just can't see it.  So, typically, if I have a patient with meconium who is remote from delivery, I usually just do a CS.  Sounds extreme, I know, but otherwise the risk can be too high.

Back to my patient - her baby delivered with meconium and seemed to be doing well, but then died within a few hours of birth.  When she came to see me she was 40 weeks and 3 days with the second baby and was very nervous about the idea of being induced again.  We discussed her options, all the associated risks, and she decided she wanted an elective primary CS.  Oh - and did I mention she is the relative of a staff member?  No pressure.  On the morning of her CS - everyone was excited. 

Unfortunately, one of the aforementioned risks occurred - she got a high spinal.  She became profoundly hypotensive, developed respiratory distress and needed to be intubated.  Needless to say, it was a much faster CS than anyone had planned.  The baby did well and weighed 8lbs 9 oz!   

Many of our patients here are Kipsigis - the local tribe.  Their children are given traditional names based on their sex and the circumstances surrounding their birth; ie... what time of day it was, if vistitors were around, etc...  So, this baby was named: Kipchirchir.....Kip (for boy) and chirchir (for entering the world very FAST!)  I felt very complimented! 

Now, one might think that I am all work and no play these days.....but I am very, very happy to announce that I will be getting a vacation!  I am going to be visiting my family in Kentucky for a short time!  Please pray for my travel and my adjustment in the US as I leave later this month. 

And no, Teddy will not be traveling...he has opted to stay at Tenwek with his friends here.....!