Dr Girija Wagh, Obstetrician, Gynecologist, IVF expertMD, FICOG, DIP ENDO, FICS
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The case of Mrs SB(39) : a will to live > triumph of motherhood with timely medical assistance !
This is a story of SB a woman who wanted a baby despite all odds and was ready to go an extra mile for the same. SB had several miscarriages and was diagnosed to have SLE (systemic lupus erythematosus) a serious autoimmune disorder which affects the blood vessels and other tissues, consequently major organs. Pregnancy is associated with grave complications to the mother and miscarriages in SLE.
She conceived the fourth time and at 12 weeks was advised termination by her obstetrician as there were intrauterine bands seen and with the presumption that the baby will suffer growth restriction and eventually land in problems. She came for second opinion to me and on careful evaluation, we confirmed that the baby had no chromosomal abnormalities. However, there was a possibility of CTEV (bent ankles) and placenta revealed several sinusoids ( lakes ) making the sonologist suspect a placental developmental abnormality. We discussed the pros and the cons with SB and she with her husband, decided to continue the pregnancy “doc finally it’s my baby …however it is”. The somewhat torrid course continued with SB suffering from gastritis sometimes severe food intolerance with all the pregnancy supporting medications, SLE medications. She had 3 episodes of brisk bleeding during the entire course for which she was hospitalised and given supportive treatments. Finally, at 34 weeks with lung protective and neuroprotective medications for the baby, she was posted for planned caesarean delivery with estimated baby weight of 1200 g.
With due preparation and checklists in place, the caesarean delivery began. The baby was delivered and handed over to the neonatology team and the actual weight was estimated to be 1050 g. SB suffered a massive haemorrhage (post partum haemorrhage : PPH ) to the tune of 3000 ml ( 4/5th of her entire blood volume ). Immediate quick actions by the obstetrics team, the anaesthesiology team and the nursing support massive transfusion protocol ensued. The uterus had to be removed ( obstetric hysterectomy ) as the entire wall was pathologically invaded by the placental tissue and she was pouring blood from the uterus as well as the incision. Quick clamping of major blood vessels, continuous aggressive fluid and blood component therapy helped medicine win the battle of massive post-partum haemorrhage and helped us grant SB her ultimate wish of being a mother. The entire infrastructure of the facility had pitched into, every other medical personnel offered help and we could achieve what we have. Finally SB is now home with her baby girl who is thriving well.
What helped ? retrospective analysis
1.Extremely cooperative patient and her husband amenable to counselling and compliant with a lot of trust in my treatment. ‘madam you are my godsend angel and I trust you. I know you will be successful. I feel nice and confident when I see you and hear you’. Even on the operation table my eyes swelled with tears looking at her trust and she just said “I know you are the best and doing the best for me’ with such a trust comes a huge responsibility !!
2.Fantastic team work : quick decisions by the obstetrician and the anaesthesiologist and the nursing assistance and continuous support from the blood bank and swift initiation of transfusion and resuscitative protocols
3.Prenatal counselling sessions with the entire team of obstetricians, neonatologist , anaesthesiologist and the radiologist
4.Infrastructure: with all the necessary monitoring and supportive gadgets
5.Availability of round the clock support staff, continuous vigilance by duty doctors and guidance and timely interventions by the intensivist
LESSONS LEARNT: SLE and previous uterine surgeries and not only cesarean deliveries predispose the mother to morbidly adherent placenta (MAP ) where a hysterectomy may be necessary and massive blood transfusion and good infrastructure is necessary for delivery
Careful antenatal risk assessment, radiological evaluation can help suspect MAP or adverse outcomes and help to be on guard
All pregnancies are at risk of sudden turn of events and proper evaluation, vigilance and proper patient cooperation help to achieve good results despite all odds.
I wish to thank god for giving me an opportunity to deliver through all challenges and Cloudnine for helping me in doing so . . .
Dr. Girija Wagh, MD (Obstetrics & Gynaecology), FICOG, FICP, Diploma (Endoscopy, Infertility), Fellowship of Indian College of Ob-Gynec, Women health care specialist, Academician, Acclaimed Orator & Researcher, B. J. Medical 1990-1992, Topper University Of Pune 1992
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