26.03.2020 Challenging Day

Just after 5 am and my phone tears me out of deep sleep.  A patient, not one we have taken care of during the pregnancy, has just been brought in on a truck with strong vaginal bleeding.  Her papers she brought suggested she was somewhere near term.  Closer analysis showed that the baby had been measured small so the delivery date had been moved back (this is one way to just pretend that the baby does not have an intrauterine growth restriction or is small for gestational age). She was more than two weeks past her due date.  While this was being sorted I was doing an ultrasound and I find a placenta praevia totalis (reason for the bleeding) and no fetal heartbeat.  We break the news and are quickly on our way to surgery. Case #14. We see this didn’t happen just yesterday.  The sonographer who saw her last week made no comment to placenta location.  Speechless.  The placenta was accrete too and it took some time and curettage to remove it.  Thankfully it was not worse than this as I have no interdisciplinary team here to help out.  The mother was stable but very weak after an unknown presumable large blood loss prior to arrival at the hospital.  A quick scan hemoglobin (recently acquired) showed 7 g/dl, low but manageable without transfusion.  The baby was beautiful and peaceful, dressed lovingly with hand and footprints made as a memento for the family.  Sad that this could have so easily been avoided with right diagnostic and a timely scheduled c-section. 

After a coffee its back to work.  More early pregnancy diagnostics and a patient presenting with potential early onset HELLP Syndrome.  Clinically though more of an epigastric pain with no further signs of HELLP.  Normal blood pressure and normal urine test.  Doppler also no abnormal findings.  Finally to wrap up diagnostics, I was just preparing to take blood when I was told that because of Coronavirus precautions the lab is only opened until noon (current time).  No lab available.  And I was so happy recently over finally having managed to get a blood analysis organized.  So we gave her some Omeprazol and told her to come back if she felt worse.  Back in labor and delivery I was called to help with a pathologic birth situation following an attempted vacuum delivery using KIWI. Head was still high and my pulse quickly rose.  It was her second child, the first came spontaneous but also slowly I was told.  Carefully I placed the 55 mm bell and was able to deliver (no maternal injuries!) in 3 tractions the baby which showed signs of amnion infection syndrome (something that seems to happen more frequently during the rainy season here).  While taking care of providing oxygen, CPAP and antibiotics to the newborn the mother started bleeding profusely.  Emergency curettage.  Placenta rest.  Therapeutic oxytocin, tranexamic acid and Cytotec finally stabilized the bleeding.  Mother and baby both on antibiotics.  Baby still in critical condition but stable in our intensive care unit.

This day was mentally and physically quite the challenge and I am a bit exhausted.  I realize too how much more challenging these situations are knowing there isn’t a back up there.  However, thank you to all of my senior doctors back home for teaching me so I could handle these situations today!

Our baby incubator with self constructed oxygen supply (tube running at the left side of the picture into the incubator and taped to the inside top near the baby's head)

 The oxygen saturation was finally stable some hours after the vacuum delivery that mom and baby got some one on one time.  

Three days later we are out of intensive care but have noticed a rise in bilirubin (jaundice).  Luckily, we have a bili bed.  Note though as we only have solar energy we are limited to operate it between 7 am and 3 pm.  Before and after we cannot use it as it would use up all of our energy we need for other essential tasks in the hospital.  So thankful for this even if operating times are limited!