Even more Puzzling...

Today, Athong came in for a prenatal. (For those unfamiliar with her case, please read here first.)

Thrilled to see her in my prenatal line, I asked her quickly if her baby was doing well. She nodded excitedly and handed me her book.         --Hallelujah!

Since she hadn’t come the month before, I thought perhaps she had miscarried. I can’t tell you how relieved I was to see her. I kept thinking, “May this be the baby that lives, Lord!”

She positively glowed when I called her in to be checked. We exchanged pleasantries as she lay down and lifted up her shirt, exposing a perfectly round belly bump.             --Adorable.

Before I left on R&R, Athong had faithfully come for several weekly check-ups in order to get the full arsenal of our STD-fighting meds! She was eager to do whatever it took to keep this child.

Each visit, I expectantly searched for fetal heart tones but found none. I did find a growing belly, however, and so assumed either she was off on her dates or ... she’d miscarry very soon. We prayed it would be the former. but steeled ourselves for the latter, just in case.

So when she reported ‘no bleeding’ at all this morning, I was hopeful.

Already measuring 11 cms, her belly was firm but tender to the touch. She winced a bit while cautioning me to be careful; she didn’t want to lose the child.

Laughing lightheartedly, I continued to check her in.

My doppler picked up a number of blood vessels and whooshing sounds, but nothing resembling a heartbeat could be found.                         -- Not good.

Searching for much longer than I normally do, I sent for Dennis to consult. This was looking oddly familiar. As we waited for him to arrive, I reviewed all the basics with her again.

-- So, Athong. Tell me again when you think you got pregnant.
-- Well, it actually stopped bleeding in June of last year, but then it continued each month until February of this year. Then it stopped for good.
-- Oh, I see. So, you think you are only 3 months pregnant now. Right?
-- Yes.
-- But last time you told me that you got pregnant in December of last year.
-- No. I got pregnant in March.
-- Huh? So your last menses was in February and you got pregnant in March?
-- Yes.

Here’s the trouble: If she is only 3 months pregnant, why then this colossal belly-bump? What’s more.... why is it so hard? If she is 5 months pregnant, why can’t I hear the sweet toc-toc-toc of her child inside. Even at 3 months, there should be something... anything. But all I can hear is the soft wooshing of nothingness.

Palpating once again, I made mental notes: “It’s definitely a pelvic mass. Her ovaries are tender but not enlarged. Although no reported bleeding, her menses have been irregular. Plus there are no fetal heart tones. The fundus is growing (it grew 2 cms since last month), but it’s woody and hard. Could it be...?”

My brain trailed off as Dennis came in. Catching him up to speed, he nodded and palpated it all for himself.

Conclusion: She needed an ultrasound.

I can only think of three reasons for this state of being. One: she has a baby that is astute at hiding its heartbeat (unlikely); Two: she is only 2.5 months pregnant with large fibroids or some kind of uterine mass; Or three: she has a hydatidiform mole.

Personally, I suspect the hydatidiform mole. Horrified as I am to admit it, it just fits the symptoms best.

Unusual bleeding. HCG in her urine. Lots of nausea. Woody hard fundus. No fetal heartbeat.

Would someone please tell me I’m wrong? I would LOVE to be wrong.

I don’t want another hydatidiform mole. You all remember what happened with the last one. (If not, please read these stories. Story one. Story two.) Plus, she DESPERATELY wants a child.

Taking the news in stride, she nodded with possible INcomprehension as I explained the details over and over again.
-- “What you need is an ultrasound. We need to know what we are dealing with,” I said.
-- “No. I will go to the witch-doctor. I’m sure I have been cursed. The witch-doctor will fix it.”
-- “Actually... the witch-doctor will not be able to help. What you need is a picture on the inside which will tell us what is in there. Please don’t waste your money on a witch-doctor. Please get an ultrasound instead.” I almost begged. 
-- “Okay. I will go.”

Was she just telling me what I wanted to hear? I couldn’t tell. Please pray for her. If she has a hydatidiform mole and doesn’t seek help, she will start bleeding soon.

I’m very concerned for her.

Also... please pray that God would bless our clinic with an ultrasound machine. We need one desperately. It would be so great to not have to guess all the time.

Does anyone have one they want to donate to us? Does anyone have connections for a cheap retailer? I’m semi-desperate! ha ha.

Please pray for an ultrasound machine.... and a place for me to train how to use it. Thanks.

Hydatidiform Mercy.

(Updated Information at the end)

A week after Awen’s hydatidiform mole was removed, she came in for a check up. She had almost no bleeding and her hemoglobin was on the rise. She was doing well, and promised to come regularly for reviews. 

She promised not to get pregnant for as long as possible, so that the tissues would be less likely to reoccur. I was looking good; I was hopeful.

However, today she came back. She looked so dejected and morose, I almost didn’t recognize her.

Dread. That’s it. Dread. She looked like a woman awaiting the firing squad. She looked like death had visited her and rattled her chain.

Dread.

Downcast eyes hid her fear, as she explained the bleeding started again two days ago. It kept coming. No clots. Could I help?

My heart sank.

Her uterus (that had involuted nicely last visit) was palpable again. Rubbing it firmly, no clots were expelled, but it didn’t look good. Her clothes were stained with blood- both fresh and old.

Oh, no.

It’s been about a month since her procedure. That’s not too soon for a menstruation, but this was too much blood if so. What was going on? The only thing that made sense was if her hydatidiform mole had re-grown.

To be sure, I did a pregnancy test.

If the abnormal tissues had started growing again, she’d have excessive amounts of HCG (Human Chorionic Gonadotropin) hormones in her system, giving a positive pregnancy test.

I held my breath as the first line -- and then the second line appeared.     --It was positive.

I wanted to swear.

I conferred with Dennis, and he agreed. She needed more care than we could provide. Doing another manual vacuum aspiration (MVA) could cause her uterine scarring or possibly perforate it. It wasn’t safe. She needed a D&C or a hysterectomy.

Trying to explain this to her family wasn’t easy.

-- “Can’t you just give her some drugs to make her stop bleeding?” they asked.

-- “No. It doesn’t work that way. This problem cannot be fixed with pills. She needs surgery and soon.” 

Shaking their heads in dejection, they said they’d take her home, and discuss it with her husband.

At the thought... my heart shrieked ‘Noooooooo!’ but it didn’t reach my lips.

The problem is: I’ve met her husband. He’s a scary, monster of a man. He left her here for three days, with no money and practically no food, after her last procedure. When he arrived, he told her she was not sick, and was just pretending.

When I told him that she almost died and was very sick, he argued with me in loud octaves that shook the walls.

This belligerent beast of a man reminded me of a pirate; one of his eyes, white with scarring, stared vacantly at me during his tirade. He scared me at a level that I’ve rarely experienced, so I quickly got Dennis involved. 

At that time, she told me that he was a hard husband to live with. She was at his mercy, and he was not a merciful man.

So when her family chose to take her home, my heart screamed itself hoarse. It’s screaming still.

He doesn’t strike me as a man willing to spend money to keep this wife alive when he could just buy a newer one that wouldn’t be sick all the time.

I’ll be shocked if he makes any effort to keep her alive.

Her family took her home before I got a chance to say goodbye, but I did pray for her.

Without surgery or at least a D&C, I’m not sure she’ll live.

Please pray for her. I’m sick. I’m sick thinking her life might be in her husband’s hands. Yes, I know ultimately she is in God’s hands. I know this in my every fiber and cell!

Honestly, her death might be God’s mercy toward her. It might be better for her to die than live another month with such a hard man.

I don’t know how to pray.

Lord, You know! Please, show mercy -- however that might be best! Amen.

March 29, 2011 ~
She and her husband came in today for another review. Thank you so much for praying! The husband was a completely different person. He was worried, and willing to take her to Wau. They left this morning, and promised to come back after the procedure. Praise the Lord!!!

Also, a few wonderful nursing friends reminded me that we could start her on Methotrexate or actinomycin D to prevent it from regrowing. Does anyone know how I can get my hands on some?

Hydatidiform Mole~

Awen came for a prenatal yesterday morning, saying she’d been bleeding non-stop for 9 days. She was pale and worried and scared -- she had a right to be.

As I measured her belly and reviewed her vitals, the best conclusion I could come up with was a missed abortion and/or intrauterine fetal demise (IUFD).

For those who don’t know, a missed abortion is when a child dies in utero before 20 weeks gestation, (whereas a IUFD is after the 20 week mark), and the child is not expelled.

She had no idea when she got pregnant, but I thought she might be more than 20 weeks since her fundal height was 20 cm and she reported fetal movements before the bleeding began. If so, she had an intrauterine fetal demise (IUFD) which wasn’t being expelled.

The abdominal mass was alternately soft and mushy, then hard and rigid. There were no heart tones and no clots passed, and the bleeding was strange-- slightly foul smelling, and thin.

I conferred with Dennis and he agreed that the best course of action would be to induce her, lest the pregnancy become septic. I asked her if she had family to help her through this, but she didn’t. She spoke, however, of a sister in town who could help her with food, and she’d send word for her husband to come.

Once, the prenatals were through, I started her on an oxytocin drip. I titrated the dosage, bumping it up regularly to help the contractions take off. A few hours into it, I did a vaginal exam. She was completely closed, so I bumped it up some more.

Four hours later, she was still only 1 1/2 cm dilated, 50% effaced. I wasn’t sure if this was normal as I’ve never done it before. The books never said how long such things would take. But Dennis had done this numerous times before, so he was my reference.

However, several hours later, she started passing large clots. I called Dennis in because clots in ‘labor’ don’t make sense. He assured me it wasn’t normal and suggested we were wrong about the gestation age.

I agreed. Perhaps we were dealing with an early pregnancy (missed abortion) after all, and/or incarcerated clots. We were guessing, but they were our best guesses.

Dennis decided to do a manual vacuum aspiration (MVA) to remove the missed abortion and clots and I happily handed her case over. Margaret was taking over the shift, so I left them to it.

About an hour later, I was called to help them again; Tom was called as well. When we arrived, the room was full of IV fluids, bowls of blood and a pile of clots mixed with strange looking tissue that Dennis had removed during the procedure.

He had called us because she wouldn’t stop bleeding. He had completed the MVA and removed as much  tissue as he could get, but he couldn’t get the bleeding to stop. He also wanted us to weigh in on the tissues extracted.

The white, vesicled tissue was distinct and immediately apparent; what he removed was not a fetus but a hydatidiform mole. (For those who don’t know, a H. Mole is a rare mass or growth that forms in the uterus. It develops early in pregnancy, as a tissue that is suppose to become the placenta, goes rogue. What develops is a grape-like vesicle tissue that is NOT a baby but still produces pregnancy hormones.)

We discussed how to manage her case as she lay there bleeding. What should we do to stop the bleeding? To look at the amount of blood lost and the amount that kept pouring out, I was shocked Awen was even conscious! Afterward, we conservatively estimated her to have lost 3000cc. That’s about half a person's blood volume!

She was going into shock despite massive fluid replacement, but was still coherent. A miracle!

After discussing her case, I suggested I do an internal manual extraction of clots, since the MVA was not getting it out. Frankly, there was too much blood to even see the cervix. How Dennis was able to do it at all was/is a mystery.

An internal manual exploration is not something you normally do for miscarriages, but if you recall I did it on a incomplete abortion last year and it worked. I explained my reasoning to Dennis and he agreed.

So, I donned gloves and explained what and why to Awen; she agreed, and I reached in to extract what I could. It was painful-- there is no doubt. But once the clots were removed from her vaginal vault, I was able to extract a large piece of vesicles and tissue trapped in her cervix.

Instantly, her bleeding stopped as her uterus clamped down, and the room heaved a collective sigh of relief.

Wow.

Of the four of us in the room, only Dennis had ever seen a hydatidiform mole before -- just once. What a miracle we were able to get it out, keep her alive and stop the bleeding! What excellent team work!

She has been resting all day and is still dizzy for all the blood loss, but that is to be expected.
Pray for a full recovery and that this mole wouldn’t reoccur her next pregnancy. Thanks!