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!

Mastectomy!

Yesterday I participated in my first mastectomy!

(For those who have been following this blog for some time, you will probably guess who got the procedure. Yep. Mary!)

I first met Mary a few months back when she came in for a prenatal check. (Read her story here.) She explained that her right breast got really big after one of her births, and she had not been able to breastfeed from it since. As she sat on my consultation table, it sat beside her. It was big. It was cantaloupe-sized big.

Fast forward a few months, during which time I spoke about her case with the doctors. Tom seemed optimistic that he and a surgeon friend might be able to do the procedure when he (the surgeon) comes in May. But when Tom saw her breast this week, he said it would be easier than he thought. Why not do it now?

I couldn’t see any reason to wait; sure there were possible complications (pregnancy, no operating room, minimal staff, etc.), but doing the procedure now would give her time to heal before the birth.

When I shared this news with her, hope danced in her eyes. Twelve years is a long time to live with a dangling appendage.

Asking her to come back on Friday afternoon, Tom and I looked into what it would take and discussed the details. Tom was confident it would be a simple procedure, but didn’t down play the risks either. Using local anesthetics, we’d cut; if any bleeders occurred, we’d just ligate them and move on.

Nervous and excited, she returned yesterday afternoon. The clinic was (blissfully) quiet as we prepped the room and explained the procedure in detail (once again). She said she understood and was happy to do it now, adding that it was extra bothersome in the heat and it’s hard to sleep. (I can only imagine!)

I won’t bore you with the details. Suffice it to say, it was all about meticulous cutting, ligating arteries, and suturing everything back up. The hour it took to cut it off was long and grueling, but the blood loss was minimal.

When I showed her the removed portion, weighing in at 2.3 kg (or 5lbs), she smiled gleefully. I must admit, I didn’t expect such joy. But then again, if a part of my body had haunted me for 12 long years, I think I’d be ecstatic to see it go, too!

Long story short, we stitched her up and watched her through the night. We plan on daily wound dressings over the next few weeks and I’ll be sure to update you on the progress. Please pray for a quick recovery and that no infection sets in.  Thanks.

The breast before surgery.

The tissue after it was removed, weighing 2.3 kg.

Two Broken Legs and a Baby.

Last night I was called to the clinic to help with an emergency. Two women were in critical condition after being hit by a truck. To get to them, I had to walk through a dozen somber looking men gathered on the clinic porch. They pressed in to see but our staff barricaded the doors; the doctors needed space to work.

My patient was named Adong. She looked to be in her twenties and had a severe fracture of her left femur; it lay unnaturally swollen and twisted. When I lifted it back in place, I could see where her bones were no longer connected. It was a clean break -- No doubt a painful one.

While irrigating a deep gash on her foot and removing mud and sand from various wounds, I was able to piece together her story. She and her sister-wife, were walking alongside a road when a land cruiser hit them, sending them flying. The driver stopped, abandoned the vehicle and ran for his life. They knew both the driver and the vehicle well. There was no doubt who was responsible. 

Only then did she ask me if her baby was okay. What? She’s pregnant? I made her repeat herself. She explained she was five months along.
-- “My stomach hurts a lot. Is my baby okay?” She groaned in delirium as I palpated her belly.  “It hurts everywhere.” I could feel the well formed baby beneath her skin, perhaps she was more than five months.
-- “Can you feel your baby moving?” I asked. But she seemed not to hear... or understand. Instead she repeated how she was in pain and wanted to turn on her side.
-- “Your leg can’t be moved right now. Why do you want to turn?”
-- “I have to turn because my baby is uncomfortable in this position. I have to lie on my side.”
-- “Please don’t move. I’ll check on your baby. Just don’t move.”

Adong with Dr. Tom

As I got the doppler and ultrasound gel, I couldn’t help but wonder if we’d have a third victim on our hands. Relief rushed through me when I immediately found a solid heartbeat.
-- “Adong, your baby is fine.” I reassured her. “He’s fine. Meth Apoul. He’s doing well. ”

The room sighed in relief with me... but she moaned. The pain was intense. I took her hand and prayed. I couldn’t thank Him enough that they were all alive. It could have been much worse. I then went to pray with Amer, her sister-wife in the next room. Amer sustained a fractured right leg and several facial lacerations. She was stable and despite the blinding pain, would live.

The crowds continued to come and go. Among those pressing to get into the clinic were newspaper reporters and police investigators. Everything had to be documented. The man who hit them was a foreigner, an Ugandan. He worked for a Christian relief organization. Worse still, he attends our church and once worked with our ministry. We know him well.

As the reality of this news became clear, each face grew heavy in question marks and concern. Would their family retaliate? Would he be killed? Would he flee to Uganda? How will any good come of this? Answers would come in time. So we turned in for the night.

Amer after being stabilized.

This morning’s light brought more officials, commissioners and looky-loos. It took some time for the women to be moved to our vehicle. But by mid-morning all was arranged and they left for Wau.

I also learned that the driver was arrested (mostly for his protection) and is now being held in custody. Since no one died, his life is not in jeopardy but he will have to pay several fines. 

Please pray with me Romans 8:28 for our Ugandan brother. Pray for wisdom, peace, protection and grace. Pray for these women and their families; healing, life, forgiveness and mercy. May this little baby grow healthy and strong. Amen.

15 going on... pregnant.

Just as the day was winding to an end, I was called in by Margaret to counsel a young girl who was crying inconsolably. She was crying so hard, I couldn’t tell what was wrong. So I looked at her file. She was pregnant.

I brought her to a quiet place and asked her a bit more about it. Poor Natali (my translator) acted like he didn’t know what to do. Apparently, a crying woman is just as perplexing to Dinka men as they are to men back in the States.

It took a while but eventually she started opening up. She was 15 years old. Her father was dead. Her mother lived far away and her brother took care of her. She was beside herself with fear thinking what he would do to her when he found out. The father of the child would probably marry her. But what upset her most was, she would have to drop out of school.

As I watched her shoulders heave and sigh with each new sob, I tried to imagine myself in her shoes. If I had gotten pregnant out of wedlock at 15, I would have thought my world had ended too. Perhaps it has. No doubt her world as she knows it is over. But a new world can begin.

I encouraged her to be truthful with her brother soon because she wouldn’t be able to hide the belly for long. I also told her to return for prenatal care next month so we can help her have the best pregnancy possible. Then I prayed for her.

I prayed for the fear and dread she felt at the possible beating she might receive. I prayed for the father of the child to be honorable and marry her. I prayed that no harm would come to her or her baby and reminded her that God has a purpose for each and every life-- even unexpected ones.

Please join me in prayer. Her name is Veronica.