Sunday, September 11, 2011

BLEEDING

"Doctor, I don't know if you will see her?" my nurse, Christiane began. "She says she is bleeding a lot."

It is late in the afternoon and I have already finished consulting and am working on an order for our pharmacy medications. "Bleeding a lot" does not sound good though!

"She's one of our pregnant patients." Christiane says.

The situation does not sound good. I ask Christiane to go back and begin taking the patients vital signs and getting a little more of the story.

"I'm coming," I tell Christiane.

When I get down to the clinic, I see that our patient is a 30 year old lady with an expected due date next month. Her first child was delivered via cesarean but her next two children were born naturally. Up till now, her pregnancy has been uneventful. She has come to a couple antenatal (prenatal) check ups and everything has seemed fine.

Christiane has our patient lying down on the waiting room bench. She is readjusting our automatic blood pressure cuff. The patient is behaving in the typical Cameroonian "sick role". When a person is sick, they are very expressive! Moans, occasionally loud exclamations of "O, my God!", and complete generalized weakness is the norm. This kind of drama is attended by caring family members who support the sick person, usually one person on each side of him or her, and who give her great empathy and soothing words.

"She has no blood," Christiane clucks her tongue in dismay as she removes the blood pressure cuff without it registering a value.

"Bring her into my office," I tell Christiane.

Between the two of us, we manage to get our patient on the exam table. It is no easy task as she is moaning and staggering in both mental and physical agony.
Once on the table, I try to ascertain a little bit more about what happened.

"When I get up from bed this morning, I just see blood," Eva, our patient, says.

"What time did you get up?" I ask.

"Seven." she replies.

"How much blood come out?"

"A lot of blood, doctor."

"Did any water come out?" I inquire. I want to know whether her amniotic membranes that surround the baby inside the womb and cushion the infant by encasing him in a sac of water, have ruptured. (aka, water broke).


"Yes. Water come out then blood," Eva confirms.
"What happened since this morning? Why did you wait until this afternoon?" I inquire.

Eva just lets out several moans as she has another obvious contraction. I finally give up my questioning. I suspect she really doesn't have an answer as to why she has waited all day. I am pretty sure she has delayed coming until things got painful enough that she was finally compelled to come. She is not a wealthy woman and money is a big concern for her and the family.

call for Christiane to bring in the ultrasound machine. While she gets the machine, I examine our patient. Her conjunctiva are white, a sign of severe anemia or blood loss. She has a steady but fast pulse. Her blood pressure was too low to register on our automatic blood pressure cuff.

Christiane returns with the ultrasound machine. As I place the probe on her abdomen, I do not see the reassuring movement of the infant heart. In fact, there is not movement whatsoever. The fetus is eerily motionless. Given her bleeding, I try to determine the exact position of the placenta. Is the placenta covering up the cervix (the exit door of the womb) giving a condition called placenta previa? I am not certain. I think so, but honestly, I've never diagnosed a previa under these less than ideal conditions. I wish desperately that I had more training in ultrasounds! Finally, I do a careful speculum exam and note a little placental tissue peaking out of the cervix.

I go out into the waiting room. There is the young man, a relative, who accompanied her.

"You need to take Eva to the general hospital. She needs a blood transfusion and surgery. The baby is not doing well. You need to go there right away." I try to stress the urgency of the situation. I'm afraid the family might go home first otherwise.

Already, there has been a delay of at least 9 hours since things first started going wrong. Further delay could easily lead to Eva's death. I watch them leave in a taxi and head up the road to the general hospital where there are blood transfusion facilities and an operating room. It is only a mile up to the hospital.

I say a prayer for Eva and her family. I know the baby is dead and it will be a sad delivery. I can only hope that the mother will survive to care for her other three children. I don't sleep well that night wondering and worrying about what happened.

The next day, after work, I pay a visit to the general hospital. I know a few of the doctors that work up there. I finally find one of the gynecologists. He gives me the rest of the story. When Eva arrived, she was diagnosed with marginal placenta previa. The placenta was at the edge of the cervix. She did not have money for a cesarean. Since she was not bleeding too much, she eventually gave birth vaginally. She was still waiting for a blood transfusion, since again, there was no money. But, she was alive! I am praying God will comfort her through the loss of the baby and give her strength to recover.

"All praise to God, the Father of our Lord Jesus Christ. God is our merciful Father and the source of all comfort. He comforts us in all our troubles so that we can comfort others. When they are troubled, we will be able to give them the same comfort God has given us."
2 Corinthians 1:3,4