An update from Tim about what has been going on at the hospital over the past few months.
Lori has described a few of the experiences we have had together in earlier posts, but I would like to share some more. Since coming back to Ghana in July, I have been spending most of my time in the Maternity Ward of the hospital, and especially since the beginning of September. I also round on the Isolation Ward each day, but this post will be dedicated to Maternity Ward stories.
The reason that I have been the main person rounding on the Maternity Ward since September is because Dr. Victoria, one of the Ghanaian physicians that I started working with almost 2.5 years ago at BMC and who is interested in obstetrics, has had to take some time off from work for a couple different reasons. Fortunately, in September, there was a fourth year Family Medicine resident, Charlie, from my residency program in Texas that came for the month, and he was a tremendous help. I also hope that he learned a lot from the variety of cases that came in that month.
One patient that we had toward the end of September was a young woman that came in with repetitive seizures. She was found to be pregnant at about 23 weeks, had mildly elevated blood pressures, lots of protein in her urine, and her baby was not alive. In obstetrics, you pretty much assume that anybody that is pregnant and with new onset seizures has eclampsia (a life-threatening condition in pregnancy that requires urgent delivery). She was admitted from our outpatient department one morning at a time when I was somewhere else in the hospital, and she was started on magnesium sulfate (the medicine of choice to control seizures in eclampsia). I came by the ward a little later and saw the woman for the first time, and she was seizing continuously, so we checked her blood sugar (low blood sugar can cause seizures), which was normal; we then gave her two doses of one type of anti-seizure medicine (but it did not help); we then gave a loading dose of another type of anti-seizure medicine (and it also did not help); we also gave Artesunate IV (to treat possible malaria, which is endemic here) as well as Ceftriaxone (an antibiotic to treat possible meningitis, which is also endemic here). I had placed a pulse oximeter on her finger at one point, and it was reading that the oxygen in her blood was around 40-50% (normal is above 90-94%), both on and off oxygen. At this point, I decided that we needed to do a Cesarean section (since delivery is the ultimate treatment for eclampsia, she was not close to delivering on her own, and she was severely hypoxic (low oxygen levels) despite being on maximum oxygen available on our ward (plus the OR had access to a tank of 100% oxygen, which I hoped would help). We took her to the OR, and her oxygen levels went up to the upper 90s on the 100% oxygen with a mask. We then did the Cesarean section and monitored her in the OR for around 6 hours afterwards until her oxygen levels were above 90% on the oxygen concentrator (what we have in the wards for administering oxygen). She even began to wake up some and resist us. We then transferred her back to the ward, and the next morning her blood oxygen levels were in the mid 90s on oxygen. Unfortunately, later that day, they called me back to the ward because she had begun vomiting up green stuff and had stopped breathing. Her heart stopped soon after that, and despite CPR, she then died. This was by far the hardest obstetric situation I have faced since coming back to Ghana.
Our hospital is pretty rural, about a 2.5-3 hour drive away from a larger hospital, which is the teaching hospital in Tamale. Even though that is the case, we are still very blessed to have the possibility to transfer patients to a higher-level of care, even by ambulance if we need it. There have not been very many times where I have needed to transfer obstetric patients to Tamale, but in the last couple of months, there have been several cases that have needed it. Also, there is normally no feedback that I receive about the patients that I transfer, but I will tell you about a few where I have received some word. Dr. Victoria had given me the phone number of one of the OB/Gyn specialists at Tamale Teaching Hospital (TTH), and I have been calling her to discuss difficult cases prior to transfer. It gave me some assurance (in kind of a strange way) that I was not transferring silly cases when I called this specialist about the third transfer for the month, and she told me that she was starting to get palpitations whenever she saw that I was calling (because of the complexity of the cases). To name a few of them:
First, there was a lady that came in with a suspected partial placental abruption (the placenta, or life supply for the baby, was coming off of the inside of the uterus) at 23 weeks, and the baby was not alive. She delivered normally shortly thereafter, but then the rest of her placenta was stuck inside and had to be removed. The next day, she was very anemic (looked pale), had low platelets (in the 30s- low normal is 150), and her eyes looked yellow. I was concerned about HELLP syndrome (acronym for Hemolysis- breaking apart of red blood cells leading to anemia; Elevated Liver enzymes- as shown by the yellow eyes, but we cannot check liver enzymes at BMC; and Low Platelets), a very serious condition in pregnant and postpartum women that usually requires several units of blood and blood products (which is limited at our facility). We transferred her by ambulance to TTH, and I later received word back that she was treated as HELLP and recovered.
Second, there was another lady who was about 29 weeks pregnant who had Hepatitis B, a seizure disorder, and who had been vomiting blood for the past 4 days and was confused and not talking. She was transferred by ambulance to TTH and improved.
Third and Fourth, I sent two ladies so that they would have access to the Neonatal Intensive Care Unit because they were likely going to need to be delivered early. One was at 26 weeks with preeclampsia with severely elevated blood pressures who had persistent spots in her vision. Another one was at 33 weeks by an earlier ultrasound with preeclampsia with severely elevated blood pressures, and her baby was measuring significantly smaller on U/S than it should have (~27 weeks). I have not received any feedback about the first one yet, but just this week I saw the second lady. Unfortunately, she said that her labor was induced about 1 week after being transferred, but the baby died a few hours before she delivered.
Fifth, there was a lady who had a seizure disorder and was undergoing induction of labor. Unfortunately, her baby died during the induction (as a side note, intermittent monitoring of the heart rate of babies during labor is not the same as in the US; instead of being checked every 15-30 minutes or more often, it is usually checked about every 4 hours or so; therefore, babies dying during labor are much more common here than in the US, where we can catch a baby early that is not doing so well and either take for Cesarean section or try other maneuvers to help the baby). She later delivered normally and then had a retained placenta, which needed removal. Prior to removal, we noticed that she was breathing a little fast, so we placed a pulse oximeter and saw that her blood oxygen levels were in the low 80s. We placed her on oxygen, finished the procedure, and started some new medicines to treat the suspected infection. The next day, she began having much more difficulty breathing and her blood oxygen level was in the 70s on maximum oxygen, so we got her set up with an ambulance for transfer to TTH. Then, just this past week, the woman, her husband, and her mother came by our house with one of the pastors of a local church to tell us thank you. I have attached the picture for this lady and her family on this blog.
Even though the outcome for the baby in many of these stories was not good, God was gracious in saving most of the lives of the mothers, and we praise Him for that.
There are many more maternity patient stories that I could tell, but these are some of the ones that stood out and that I wanted to share with you.