2.1 equals 1.1

Yesterday a young girl came for help. Reported to be early in her third trimester, she complained of malaria symptoms. Fever. Chills. Pain.

Margaret saw her and called Dr. Tom to help evaluate. I’m told she was severely pale so they asked our new lab technician, Caroline, to check her hemoglobin.

She had a hb reading of 2.1 g/dl.
    --Yes. You read that right. A hemoglobin of 2.1

(For those who don’t know, that reading is crazy low! Normal hb in pregnancy is 11-12 g/dl if you are moderately healthy.)

She needed a blood transfusion.

Remarkably, her baby was still alive. I was told Margaret and Tom were preparing to refer her to Wau for a transfusion while starting aggressive treatment of the cause --malaria.

Since church was starting soon, I decided to visit her after church. But once service ended, Margaret approached me saying she’d delivered.

What? I thought she wasn’t having contractions. When did she deliver?

Apparently in an effort to save her life, her body expelled the child spontaneously. He was born alive but severely preterm weighing just 1.1 kg (or 2.4 lbs).

Once I heard the news I went to check on him. He was breathing well but starting to show signs of distress. His mother looked sad and exhausted.

She explained that all her family was far away or in prison. There was no one left to help her get to Wau for the blood she needs.

Sigh.

With time Dennis was able to start an IV on this precious munchkin and we gave formula through an NG tube. He looked like he wanted to live.

After doing a Ballard’s score (a rating to help determine the gestational age of a newborn), we guess him to be around 31-32 weeks gestation. This explains his ability to breath well but not his size. I believe him to be small for gestational age (SGA) as well. Long term anemia will do that in a pregnancy.

Please pray for them. Her name is Ayen. She is family-less, severely anemic, with a tiny preterm baby. Please pray for God to keep them both healthy and alive. Thanks.

Jaundice: The Color of Kernicterus

I never got to hold him --my day was too busy-- but I did get to pray for him. And as I lay my hand on his chest to pray, his gaped-jaw expression and labored breathing jarred me.

Would he live?

By the time I saw him, Dennis and Margaret had already completed a Ballard’s score on his tiny frame. A Ballard’s score helps determine how old the newborn is in terms of weeks. This is particularly useful when the child is preterm, like he was. He was roughly 32 weeks gestation.

His parents said he was born 4 days earlier but refused to breastfeed. Margaret was able to help his mother manually express, then fed him with a syringe --the first time in four days!  But ultimately it made no difference.

He died.

I’m told his mother came once for prenatal care. She delivered prematurely at home and then for four full days stayed there watching her child become progressively weaker and yellow.

Did she not know we could help?

However by the time she came, there was little we could do. He was lethargic, dehydrated and yellow. Pathological jaundice --or possibly Kernicterus-- had already set in.

For those who don’t know, jaundice is caused by the build up of the levels of unconjugated bilirubin in the blood.

It is more common in preterm babies and was perhaps caused or compounded by the fact she was not able to breastfeed. Treatment for it is helping to establish breastfeeding and exposing the baby to sunlight (or bilirubin lights).

When bilirubin levels are high for too long, it leads to Kernicterus which is when bilirubin is deposited in the brain, causing brain damage.

Had he lived, he would have been severely brain damaged.

Please pray for the family that lost this precious child. Pray also I’m able to teach these women about breastfeeding better. Frankly, I don’t know where to start on this one. Thanks.

IUGR or Pre-term?

This morning one of my prenatal girls proudly brought in her precious little girl for me to meet. She was beaming! When I looked beneath the blankets though, my breath caught in my throat. She was tiny! So small in fact, I had to touch her briefly to make sure she was alive.

“When was your baby born, honey?” She certainly didn’t look like she just gave birth. She was too rested and relaxed.
“Last Sunday.” She said with a smile.
“Oh, you had her yesterday?” I offered.
“No. The Sunday before.” I must have looked confused, so she repeated herself. “You know, a week ago.”

I had to marvel at this little package of estrogen. Could she really be a week old, already?
“She is so small. Why didn’t you come before now?” I asked.
“Oh... we have a tradition in our culture. You cannot take babies out of the home for several days. If it’s a girl you must wait 4 days. But if it’s a boy then you wait only 3 days.”
“I see. Can I do a exam on your baby to see how old she is?”
“Of course you can. I’m here for a check-up anyway.”

I smiled and held back my concern. She certainly didn’t act like she was fighting to live... but she was so small. When I got her on the scale, flash backs of last weeks premature births blasted through my brain. In fact, the second premature baby weighed more than she did! She only weighed 1500 grams (3.3 lbs!).

But as I checked her out... all her vitals were stable and she seemed healthy in every way. So I did a Ballard’s Score on her. This is a test done on newborns to help determine if they are premature and, if so, how much. It tests reflexes, neurological development and physical maturity attributes. It’s only meant to give a general range but it can help differentiate between a small but term baby and a premature newborn.

When I checked her reflexes, postures and muscle tone, she passed with flying colors. Her neurological development was spot on. In fact, I didn’t see anything amiss except her size. At the end of the exam, it was clear to me I was dealing with a severely IUGR baby and not a preterm one.

For those who don’t know, IUGR stands for Intra-uterine Growth Restriction. It means the baby was unable to develop and grow at a normal rate in utero. Something hindered her. It could have been from placental insufficiency or maternal life-style (alcohol, drugs, cigarettes). It is also caused by poor nutrition and illness (chronic or infectious).

I’m not sure what caused hers... but it’s the most severe case I’ve seen to date.

Fortunately, she is fine and eating fairly well. I asked her mom to bring her in regularly so we can monitor her growth. She said she’ll come. I have a feeling she will.

Preterm Sadness.

Another preterm baby came in today. His mom was in a lot of pain but didn’t look anywhere near as bad as her baby did. We did a Ballard’s score (to tell how preterm the baby is) which placed her at about 27 weeks gestation. She only weighed 1.8 kg.

It seems prematurity is epidemic around here.

The baby had a number of problems. Her breathing wasn’t good-- nasal flaring, chest retractions, apnea. Plus, she wouldn’t suck. She looked like she was barely hanging on. My heart went out to her. But I had hope.

Then something changed. As Denis was doing the physical exam, he couldn’t find an anus. He called me over for a second opinion. Nada. The baby had an imperferate
anus (in short: the anus is missing). In the states, this requires surgery and pretty quick.

But here?

Denis referred them to Wau but they didn’t look even remotely interested in going. Lord, may this tiny treasure find her way to Your precious arms soon. May her suffering cease.

Namesake.

Regina holding her little girl.

This week’s theme seems to be prematurity. Twice already we’ve had two mom’s deliver  preterm at home and then come in because of complications. Each time the baby died. Both moms were referred for different things-- One for a blood transfusion due to massive hemorrhage postpartum, the other because she was in a coma for some unknown reason and wasn’t improving. So when a young girl come into the clinic today in premature labor, I wasn’t sure what to think.

She was acting pretty melodramatic. I admit I thought she was exaggerating a bit... or I did until I saw the contractions. There was no doubt something was going on, but could it be labor? Maybe it was just Braxton-hicks contractions? She was 7 months pregnant by LMP and only measured 27 cm. Not good. Her belly was way too small.

The last time this happened, we tried to refer the mom to Wau, but she never made it. She just ended up having the baby at home. Fortunately, all went well. But we weren’t there for them in their need. I didn’t like that. So, this time, I decided to keep her at the clinic.

I thought keeping her here would be a no brainer but her family wanted to take her home. I cautioned them that if the baby was really  7 months gestation, it was better to have our help. To my relief, they agreed.

Baby Stephanie Akac, weighing in at 1.5 kg.

So when Regina started pushing, we were ready. We had resuscitation equipment set up and mentally, I was ready for another anything -- even another death. I know that’s pessimistic of me, but I had to steel myself for the possibility at least. Not one baby born that early has survived here in my (short) experience.

I prayed over her and left it up to God. The Creator of all life certainly knows how to preserve it. I prayed for His will to be done. Besides, He knows what I can handle. I’ve mourned these children all week. If I am meant to mourn another... He’ll walk me through it.

The birth went smoothly. Regina only pushed a couple of minutes -- surprising for a first time mom. And as the head passed the perineum, I was surprised to see a tiny face looking up at me. :- ) (She was born completely posterior!)

Although she was minuscule in stature, you wouldn’t have guessed it from her lungs. She screamed and wailed and made such a ruckus that Margaret and I couldn’t help but laugh... and sigh in relief. No resuscitation necessary.

But would you believe she is only 1.5 kgs and (by Ballard’s score) only 28 wks gestation. That is how old the baby boy brought into our clinic on Monday was as well. But he weighed half of that (only 600g). Dennis and I were so confused we did the test twice but the results were the same. This little one is only 7 months old.

The good news is that... by God’s abundant mercy and grace.... this little girl is doing great. She is vigorous and very interested in breastfeeding. Pray that continues.

Her father was so happy with the good news, he asked if he could name her after me. So I have my first namesake. Rejoice with me as I’ve discharged little Stephanie Akac this afternoon. Both mom and baby are doing great. But they need prayer... lots of it. The risk of complications and infections are higher with prematurity. Thanks.