Hello all,
The young woman's eyes are swollen almost completely shut. Her face is puffy and deformed. Her pregnant belly bulges out as if it wants to explode. She is unconscious. I turn to the family standing by to learn more. She has been having seizures since the morning. I check her blood pressure. It's 176/132...unbelievably high. The diagnosis is sure: eclampsia. I check the fetus' heartbeat. It's normal. David goes to call Samedi. Hortance has already given Diazepam. She finds the vein while I run to the pharmacy to bring back an old bag of Magnesium.
As Hortance inserts a urinary catheter I watch the Magnesium drip in drop by drop. She's still having occasional seizures. Samedi arrives, we transfer her to a gurney and we wheel her towards the Bloc Operatoire. I fumble with the code on the lock in the dark and finally yank it open. We creak open the doors, flip on the lights and pull the patient into the OR. A quick scrub and drape and the patient is ready, the knife is in my hand.
We pause, Samedi prays and I quickly slash down to fascia, dissect up, and cut, pull apart the muscles and peritoneum to reveal the glistening lower uterine segment. A small incision, a push with a clamp and the amniotic fluid sprays up into the wound. Fingers in to guide the scissors, cut, cut, and a shock of wet, black hair is revealed. Hand reach in, bend the head forward, Samedi pushes on the uterus from the belly side and the baby pops out and starts to gasp for air as its arms and legs jerk upward. Clamp, clamp, and cut between and the baby is in Sarah's hands to be dried, stimulated, and revived. A cry soon pierces the air and I clamp the bleeding edges of the uterus and start suturing in close. There are no complications and the skin is soon sewed shut with a subcuticular suture, a dressing placed, and we unscrub to go back and sleep.
Early the next morning I'm in morning worship and a commotion starts up outside the door. Sarah goes out and soon comes back to whisper in my ear that I should go see this patient. I quietly get up and go to the exam room. An young Arab women wrapped in brightly colored clothes and vail is lying unconscious on the bed having seizures. She is obviously pregnant.
D�j� vu? You bet. Her blood pressure is also elevated at 162/130 but this time the baby's heart beat is absent. She has been like this since yesterday. The same process is repeated until I get my hand in the uterus to bring out the dead baby. Samedi pushes and a limp fetus plops out. I start to clamp, clamp and cut between and he gives a faint gasp! I quickly cut and hand the baby to Sarah who begins to breathe for her with a bag-valve-mask as she checks and finds a faint heartbeat. Samedi and I continue our work on the mother and we soon are rewarded with a small cry followed by a hearty yelp from the now vigorous little girl!
A woman comes to see me that morning after the surgery. She has had abdominal pain for a month now and was seen at our hospital in April for the same pain plus some vaginal bleeding. She was treated, the bleeding and pain stopped and she was sent home. Now she is referred from the Hospital in Lai for an ultrasound. Unfortunately, the ultrasound is temporarily out of order. On exam the only thing remarkable is tenderness in her lower abdomen. I suspect pelvic inflammatory disease and hospitalize her. The next day she is no better and her pregnancy test comes back positive. I decide to operate.
She is prepped and draped and the anesthesia is given. I hold the scalpel again as I pray for God's help during this surgery. I slice open the abdomen from belly button to pelvis and dark blood surges out of the wound.
Samedi quickly starts suctioning as I jam lap sponges into the four quadrants of the abdomen. We finally get enough of the blood sopped up to see that there is a large ectopic pregnancy in the pelvis but it is so advanced that everything is inflamed and stuck together so that I can't even identify the uterus much less the other anatomy. I start at the left abdominal wall and incise through the peritoneum. Blood continues to ooze as Samedi suctions and blots and I try to be methodical while at the same time hurried as I want to stop the bleeding. Finally I identify some of the blood vessels feeding the ectopic pregnancy from the side and am able to tie them off. After what seems like another eternity of mopping and aspirating up blood I finally have a breakthrough as suddenly the ectopic pops out of the pelvis and I can know identify the uterus and where the mass is attached. I clamp and tie off the blood vessels and suddenly the whole thing is out. I rinse out the belly and dap carefully all around. There is no bleeding anywhere. I close up and breath a prayer of relief.
Four days later, the woman is doing well when another woman comes in with almost the exact same problem. This time I don't waste a day but operate immediately and there is less blood and less inflammation. It's always scary though when that surge of blood rises towards you as you open up the abdomen. There's that brief moment of panic when you wonder if you'll be able to stop it. Then, somehow you find, or God finds for you, the courage to calm yourself and proceed with persistence until it is finished, one way or another.
James
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