Swollen Misfortune

Few weeks ago, someone sent me an SMS seeking an appointment. She is a first-time pregnant woman who wants to discuss the results of her second ultrasound findings. She told me her baby was found out to have hydrops and she wants to hear my opinion. Well, that was kinda flattering, but the person she really needed to see is a perinatologist (an obstetrician who subspecialized on very problematic pregnancies, and this pregnancy is one example). Nevertheless, being a neonatologist myself, I may also be able to give her my piece, though on a limited span.

I saw her after few days, together with her mother, and before they sat, she handed me the ultrasound findings. It’s true, the baby was visualized to be hydropic (generalized swelling) on ultrasound. As I shifted my eyes from the ultrasound result to her face, she was already on the verge of tears. You can see there the longing to hear a different opinion, that perhaps the ultrasound result was erroneous, that the baby will still become normal eventually. But I am not someone who will nurture that false hopes she was brewing. I told her that a single ultrasound finding is not definitive. The baby has to be serially monitored and the best person to do this better be a perinatologist. She heeded and went straight to the perinatologist immediately after we ended our conversation.

Few days ago, while attending to the delivery of a baby whose placenta separated totally from the uterus, I was notified that the mother with a hydropic baby was scheduled for cesarean delivery at seven in the evening of the same day. I asked why the preterm termination of pregnancy, the resident reckoned the mother already began to have abdominal cramps (labor pains). This was the 26th week of pregnancy (panic mode alerted! Baby is extremely premature). If baby was premature, then there’s not much problem; if hydropic, there’s not much problem. But if you combine both prematurity and hydrops, that’s too much of a trouble. I almost swallowed my testicles that rushed up my throat upon hearing the news of imminent delivery later in the day.

The operation commenced. Upon opening the uterus, the amniotic fluid was so voluminous. This must be stretching the uterus beyond limits that prompted it to contract and expel the baby. After almost four liters of amniotic fluid was siphoned, the baby was next. The baby’s feet was first to be delivered. It looks big for a 26 weeks old baby, more like that of a 34 weeks. Then the body followed. There was almost difficulty of delivering the baby as the abdomen was too distended and tense, and so was the head. The skin was so taut from abdomen to the face, his lips were almost like a fish mouth in appearance. Generally, the baby looks like a victim of drowning. She was gasping for air. I immediately intubated her to assist her breathing as her chest will have difficulty in rising.

I took picture of the baby and showed it to the mother as I can’t let baby have skin-to-skin contact with the mother, while the nurse rushed baby to the incubator at the adjacent nursery. I provided mechanical ventilatory support but the baby wasn’t improving much. I showed baby after attending to her immediate needs to her lola. I asked them to provide surfactant that may help baby get better, but they were reluctant as they think it is an extraordinary measure anymore to do heroic measures. They were already resigned that the baby will not make it; and if ever, will grow up impaired.

Maybe I was wrong to ever ask them to procure some medicine, or they were right all along not to continue providing baby’s needs. I did some work-ups to help me identify the probable cause of baby’s hydrops. Hydrops is usually called by a problematic baby’s heart. Because of it’s inability to pump blood well, the fluid gets retained and thus explains why the baby’s entire body swells, including body cavities damming up with fluids. Another most common cause of hydrops is anemia of severe degree. Because of anemia, the body lacks adequate oxygen delivery. Baby’s heart now have to work more than double time to cope up with the body’s demand (just like in a congestive heart failure), and likewise ending up generally swollen. For this particular baby, her blood work-up showed a very, marked anemia. I wish I could do further test and identify what could be the cause of the anemia but then I was limited. I could transfuse blood to reverse the condition, it could have been easy. But there was a major road block. Parents are Jehovah’s Witnesses. (Oh, I was doomed.., nothing further).

Five hours from birth, baby’s condition still never improved. Her heart already showed declining function… The heartbeat and oxygen saturation keeps on falling… her color started to turn darker… I asked them if they have some practice of baptizing baby or a minor before death, they said it was up to them to pray for the baby. I respected their religious view. Six hours from birth, baby finally succumbed.