Ectopic in the Tropics, with Icky Photos

Hanging out with the curios sellers, buying jewellery. Only three working days left to this rotation, in Embangweni which is in the Northern Region.

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An eventful month for me. Twins. Triplets. Breech deliveries. Cord prolapse. Uterine rupture. Ovarian cancer. Cervical cancer. Ectopic pregnancy. Tuberculous pleural effusion, tuberculous osteomyelitis, tuberculous cystic abscess, pulmonary tuberculosis. HIV positive, HIV negative. Kaposi sarcoma. Cerebral malaria, neonatal malaria, malaria with anemia, or just ordinary malungo. Kwashiorkor. Septic abortion.....

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Ectopic pregancy in Canada presents in a particular way: pain, positive pregnancy test, ultrasound showing no intrauterine pregnancy but not necessarily locating the ectopic, and not necessarily showing blood in the abdomen. But this is the fear: a ruptured tube and exsanguination (bleeding to death in the abdomen).

It is managed urgently or emergently depending on the level of pregnancy hormone and the presence of fluid in the abdomen. Either methotrexate to cause the pregnancy to abort and resolve, or if it is too late for that, surgery to remove the pregnancy and the source of bleeding.

In Malawi, women put up with incredible amounts of pain before coming to medical attention. And sometimes the results are surprising.

The doctor I have spent this month with tells a story of a lady who presented to Zomba Central Hospital because she was overdue. They confirmed her dates and tried to induce her labour, but nothing happened. They gave her repeated doses of drugs but her cervix stayed as tight as Fort Knox.

Eventually she left this hospital, because she felt she was not being helped, and presented to MMH. There, they performed an ultrasound and found that the baby was outside the uterus. The placenta had implanted on the outer wall of the uterus, and the amniotic sac was intact in the abdominal cavity. They performed a laparotomy to remove a live post-term female infant with apgars of 8 and 9.

Mother and baby did fine and went home after a week.

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Of course, this is unusual. I saw a lady who was sent to us by the prenatal clinic, known as sikelu or scale. She was sent for failing to gain weight normally. Her last menstrual period had been in April, but her uterus was 22 weeks, and felt, well, weird. There was a hard lump that felt subcutaneous in the epigastrium.

We did an ultrasound and what we saw led us to schedule a laparotomy for the next day.

The hard lump turned out to be a calcified fetus, which had died months previously, presumably when the placenta could no longer get enough blood from where it was attached to keep up with the fetal growth needs. It was largely resorbing and only some fetal parts were identifiable.

The placenta was attached to the woman's right fallopian tube, and had destroyed the tube. It had developed into a large vascular ball instead of the flat leafy shape we are used to. The lady had, on history, had a lot of pain in May and througout the pregnancy, really, but had thought it normal and never complained.

Her uterus and other tube were normal, and in all likelihood, she will be able to complete her family. She recovered without incident and went home a week later.

Missing Home

Well, sometimes.

I'm on the traveller's weight loss programme. More effective than Jenny Craig, faster than Weight Watchers. *sigh*

But my sister sent me this photo, and you know what? It makes me really grateful to be here.

Mangoes

How much does a mango cost? You know, the fat red creamy ones?

The ladies are selling them for under 5 Kwacha each. There are 275 kwacha to the British pound. It's highway robbery to take them away for that, but they are so plentiful, none of the locals are buying for more.

I love mangoes, and to help out the ladies I am buying tons of them. I expect to be orange and sweet by the time I go home.

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The hospital had a busy weekend. Two uterine ruptures: one baby survived, the other came in too late.

But both mothers survived. And you know what? That's a damn miracle.

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This morning's entertainment: Young girl from Mozambique, from Villa Milanje. Hello. Oh, you're due this week. Having abdominal pain and that's why you came in. Okay.

Who came with you? (Every patient has a guardian to cook for them, wash their clothes, advocate for them.) Your mother and your sister? Alowetsani (bring them in).

And so in comes sis. Also pregnant, with a notebook which serves as a medical chart here in Malawi. Hm. A load of help YOU'RE going to be. Also due this week. No abdominal pain.

You're sisters? Yes.

Same mother and father? Ah, no.

Same mother? No.

Oh. Same HUSBAND. Not sisters, co-wives.

Both doing fine, both around 19 years old, both due this week. I hope he's faithful to both of you, because if not he's putting a lot of people at risk.

Tragedy

Woman presents in labour. Ominous past history: five pregnancies with two micarriages, one stillbirth and one live baby. But all seems well.

Baby's heart recorded at 9am as 150 beats a minute, normal for a fetus. Mother progressed slowly but steadily.

At 1340, the nursing notes say that the baby's heart rate was 122, still normal; and on vaginal exam they say the mother had reached 6cm, but they thought they felt placenta, so they sent for the clinical officer.

I showed up by chance. Nobody had called for the doc yet as the iCO was still examining the patient. He looked up with that nervous African smile that it takes people forever to understand does not mean happy, and said two of the most dreaded words in obstetrics: "Cord prolapse." I turned and ran for the doctor, who grabbed her dopplex and came.

Cord prolapse is when the baby's blood and oxygen supply, the umbilical cord, slips ahead of the baby's head into the mother's pelvis. When mum has a contraction, the force of the baby's head compresses the cord, cutting off baby's oxygen. You have very little time, minutes to get a baby out in that situation. It's hairy in the best of hospitals.

She handed me the dopplex, and ran to grab her ultrasound, ordering everyone to get ready for an emergency cesarean. I searched frantically for a heartbeat. I could hear placenta. I could hear mum's vessels.

But nothing. Nothing.

The doctor returned with the ultrasound and quickly visualised the heart. We were too late.

The intern clinical officer explained to the mother in Chichewa that her baby had died. She began to cry. The commotion around her stopped.

In Malawi, to respect the family's grief, only the immediate family are allowed to cry when someone dies. Imagine holding the hand of a woman who has just had her baby die, watching her cry and offering her words of sympathy while keeping dry eyes. Because to do otherwise would be to take something away from her.

And there was more pain to come. She still had to deliver the dead baby.

But there was no urgency now. We let her rest. The nurses didn't comfort her, and I had little to offer in her language.

A beautiful baby girl.

Happy Dance

CaRMS is finished!!!!

Nguludi

Another of Malawi's pretty little secrets, Nguludi is tucked away in the hills outside Limbe. It's a verdant valley with an unexpected mission hospital and church.

At the hospital, seeing patients: primary amenorrhea in a 22-year old. Would you believe Mayer-Rokitansky-Kuster-Hauser Syndrome? (oh, yes, of course) Blind vagina, likely no uterus, to be confirmed by laparoscopy because we are not convinced by the (very expensive but notoriously unreliable) radiologist's report that he "located" her uterus on ultrasound.

Update: A visiting gynecologist brought his old-school laparoscope. One generation removed from a magnifying glass in a tube, fabulous to see how it was done. So we got to see directly that there was in fact no uterus but only rudimentary fallopian tubes attached to normal-looking ovaries. So diagnosis confirmed.

Have we done the patient any good? Well, probably not. We could tell her that sadly, there is no chance of children here in Malawi. The technology for surrogates exists elsewhere, but not here.

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Blantyre: The Celtel tower was the latest casualty of the lightning, so my planned couple of hours at the internet cafe to finish up CaRMS didn't happen. Hi-speed in Blantyre vs dial-up in MJ is the difference between 2 hours and 8 hours, and my blogging, it should be noted, has been done whilst waiting for my pages to load. Yup, still loading. Dial-up=no photos, sorry.

Anyhow, did you know the University of Toronto has an Office of International Surgery? Does this sound like it was made for me? And they are here! Believe it or not, providing access to the UofT Libraries to African surgeons! How amazing is that? Given how hard it is to get your hands on up to date print materials in this part of the world, and even if it wasn't, this is an incredible resource, which can only improve patient care.

(no applause, just throw money)

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Sinterklaas. No, I don't speak Dutch either, but who cares. It was a fun Christmas party for the little kids and I won an elephant!

More Dispatches from Malawi

The postpartum ward is nearly empty. People are either not having complications, or they are not coming to the hospital. It is the planting season, the rains have begun, and everybody is needed in the fields. There is nobody to take a woman to hospital, nobody to stay with her once she arrives, and no money for transport besides.

So who is here?

An older lady, a Jehova's Witness. We removed a mass from her abdomen last Thursday. I will have to learn to bring a camera (but I know you would strangle me, Sari), because it was HUGE. Harder to deliver than a baby. She's currently doing well.

We don't have the path report yet, nor will we until the College of Medicine reopens after the holiday (remember THAT next time you are grumbling about how long they are taking with the frozen section), but the tumour looks very like ovarian cancer. We have de-bulked the tumour and omental cake, and done a TAH-BSO, but she had peritoneal seeding and studding over her liver. She had ascites, and this is already collecting again.

In Canada, she would get chemo, molecular analysis, maybe hormonal therapy.

Here, she will be sent home with painkillers.

This is my patient. This is killing me.

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We had a lady come in, in labour.

Not unusual.

Ok, but she had already delivered on the way to the hospital; the baby, tragically, was born dead.

Twins, you say.

Well, that's what we were thinking. Push. Oh, there's the second baby, born alive. So small. Here comes the placenta. WTF?

Another head? Triplets!

Two babies born alive. 1.1 and 1.5 kg.

If you're religious, pray for them. If you're a scientist, courier us some BLES. Either way, they need help.


Update: The bigger of the two babies died the next day, of respiratory failure. There is no respirator, and the supplemental O2 only works when we have electricity, which we don't on Tuesdays.