Friday, March 18, 2011

A Puzzle.

Athong on her first prenatal.
This week brought many new and strange cases to my door. Cases ranging from possible placental abruptio, to ectopic pregnancy, to placenta previa. None of which, could I properly diagnose (no ultrasound machine), so I quickly referred them to Wau.

Why my brain goes to all these worst-case scenarios eludes me. I must be tired. Perhaps, they were just having normal bleeding.... but when is bleeding and sharp pain ever normal in pregnancy? My point.

Plus, I had to tell, not one but three women, that their babies had died in utero. Definitely low points this week. 

But of all the women, who lay on my prenatal bed, one stands out. Her name is Athong.

(For the midwifery minded out there, she is a G6 P3 L0 A2. Not good.)

Her first baby died during delivery after a 3 hour shoulder dystocia. (Yes. Read that again. 3 hours.) Her second baby was born prematurely (at 6 months), and died a few hours after the birth. Her third baby also died within hours of his premature birth (also at 6 months). The fourth baby miscarried at 3 months. The fifth miscarried at 2 months.

She was now on my bed telling me she was 5 months pregnant... or maybe less. There was no baby bump and no fetal heart tones, so I ordered a pregnancy test. Honestly, I was leaning toward her NOT even being pregnant.

When it came back positive, I got hopeful.

What her history screamed to me was an incompetent cervix due to her traumatic first delivery. But that would only explain the two premature births, not the two miscarriages. Sigh.

Differential diagnosis made me think syphilis or some other kind of STD; but perhaps she had a Rh-negative blood type and became sensitized somehow. Wouldn’t that explain her history better?

She was a puzzle-- a sad puzzle where each piece brought tears and dashed hopes.

Fortunately, our lab can test for blood typing and syphilis, so I sent her for an evaluation. Her blood was Rh-positive and she didn’t have syphilis. (Both results pointed toward incompetent cervix.)

I asked if I could do a speculum exam to see if her cervix had any noticeable tearing or scarring. She agreed happily, saying, “Whatever you need! I will live here at the clinic if you tell me to, so long as this baby lives!” We laughed jovially. There was hope in her voice.

During the exam, I didn’t see any tears, but I did see extensive signs of STDs, which explained the last two miscarriages.

What that means is, if she is really 3 months pregnant now, then there’s time to do a cervical cerclage to help her maintain this pregnancy. Whoohooo!

(For those who don’t know, cerclage is when you sow the cervix closed to reinforce the pregnancy, until it’s term. The sutures are removed in the third trimester, so labor can progress naturally.)

I don’t know how to do this procedure, but I’m told Dr. Tom does. All we have to do is treat her STDs, make sure the pregnancy is viable, stitch her closed, then watch her like a hawk.

When I explained this possibility to her, she jokingly promised: “If you help me have this baby, and it’s a girl, I will name her Akuac! And if it’s a boy, I’ll still name him Akuac!”

We laughed heartily at the idea of a boy walking around named after a female cow, but I’m pretty sure she’s serious. Ha!

I warned her that I was not guaranteeing her anything. I was only promising to do everything possible to help, and pray like mad!

Will you join me? 

May this baby be the one that lives!