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via Swollen Misfortune.
Monthly Archives: May 2012
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.
Early Marriages, Adolescents and Young Pregnancies
(These are curated tweets by WHO during the World Health Assembly 65 at Geneva Switzerland, dated May 25, 2012)
- In 2008, mothers aged 15-19 years gave birth to 16m babies, representing 11% of all births worldwide.
- About 95% of births in 2008 by mothers aged 15-19 years occurred in low- and middle-income countries.
- Progresss has been made: worldwide, the adolescent birth rate has declined from 60 per 1000 in 1990 to 48 per 1000 in 2007.
- Discrepancy between regions in adolescent birth rates is wide, eg 5 per 1000 women in eastern Asia to 121 per 1000 in sub-Saharan Africa.
- What contributes to adolescent pregnancy? Most people initiate sexual activity between 15 and 19 years of age.
- In poorer countries, sexual activity for girls is often initiated in marriage, or due to coercion, frequently with older men.
- Rates of use of contraception by adolescents are often low, hence adolescent girls may become pregnant.
- Early marriage also contributes to adolescent pregnancy. Worldwide, 60m+ women aged 20-24 years were married before age 18.
- Gender norms can also contribute to adolescent pregnancy; eg social norms that condone violence against women, girls put them at risk
- Not knowing much about sex, family planning contributes to early pregnancy. Effective sexuality education is lacking in many countries.
- Education in general is important: the more years of schooling, the fewer early pregnancies.
- All couples should have access to safe, effective, affordable, acceptable methods of family planning.
- Women have the right to access appropriate health-care services that enable them to go safely through pregnancy and childbirth.
- Many countries have laws that prohibit adolescents from accessing sexual and reproductive health services without parental, spousal consent.
- What are the consequences of early pregnancy? A first pregnancy at an early age is risky. It can lead to disease and death.
- Early, unwanted pregnancies can lead to induced abortion which can lead to severe health risks, death when carried out in unsafe conditions.
- Up to 65% of women with obstetric fistula develped this during adolescence, with dire consequences for their lives.
- Adolescent pregnancy is dangerous for the child. The younger the mother, the higher the risk of stillbirth and death of the infant.
- Social consequences of adolescent pregnancy can be severe: school drop out, lack of subsequent income, violence against unmarried girls…
- How can too-early pregnancies be prevented in developing countries? WHO has issued 6 recommendations.
- 1) Reducing marriage prior to age 18; 2) Reducing pregnancy before the age of 20 years.
- 3) Increase the use of contraception by adolescents at risk of unwanted pregnancy
- 4) Reducing coerced sex among adolescents
- 5) Reducing unsafe abortion among adolescents to prevent too-early pregnancies.
- 6) Increasing the use of skilled antenatal, childbirth, postnatal care among adolescents to prevent too-early pregnancies.
For complete copy on the report of the WHO Secretariat on Early Marriages, Adolescents and Young Pregnancies, please feel free to read this article http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_13-en.pdf
Dateline to Impeachment
My poor recall of this part of Philippine History…
Few years ago… GMA was proud to be this…
August 2009:
Former Pres. Corazon Aquino succumbed to colon cancer. During her funeral march, several people have been calling out for Sen. Noynoy Aquino to run as President in the next year’s election.
October 2009:
Sen Noynoy Aquino took some time to reflect whether to accept people’s encouragement.
November 2009:
Sen. Noynoy Aquino filed his certificate of candidacy as President of the Republic of the Philippines under the Liberal Party.
May 2010:
Noynoy Aquino emerged as a popular president with a landslide victory (redundant?).
June 2010:
President Noynoy Aquino announces the creation of TRUTH Commission that shall be responsible for the investigation of misdeeds of the past administration.
(Then I dont remember the dates that followed)
Supreme Court junks the Truth Commission.
Ombudsman Merciditas Gutierrez was impeached.
(BIR and DOJ joint committee conducting investigation on Electoral Sabotage – according to Sec DeLima)
June 2011
PNoy delivered his 2nd SONA. GMA didnt attend the SONA, instead went to her hometown on the same day to inspect. Later in the day she was admitted at St. Lukes Hospital due to nape pains and hypertension? Then GMA attended Sen Miriam’s Wedding.
But during the recessional… look at GMA at the upper left corner of the photo: (Yes, no neck brace!)
As days passed by, GMA was diagnosed to have some bone spurs in her neck. She required wearing neck braces and underwent neck surgery.
Few days after GMA’s admission at St. Luke’s Hospital, this picture was released…
The neck surgery of GMA had complication, either and endocrine problem with calcium imbalance or infection. It was the former later that was the main consideration.
Series of scams have been coming out.
PCSO scandal broke out. Allegedly, a bishop sought a vehicle as a gift from GMA.
PCSO Charity fund was channeled through other purposes, was that about 700M?
PAGCOR 300M also went… where?
Anomalous purchase of helicopters by the PNP where Mike Arroyo’s name was dragged.
One of the Ampatuans testified vs GMA about election rigging in his region during 2007.
Mikey Arroyo and wife slapped with tax evasion charges by BIR.
November 25, 2011:
GMA lawyers prepared a fake medical abstract (based on personal observations of the lawyers, not the doctors) and asks her doctors to sign it, but they refused.
Then GMA’s lawyers petitioned SC to have TRO of the WLO so that GMA can fly and go abroad for treatment because she has apparently a life-death condition.
SC by virtue of 8 justices (all GMA appointees, including CJ Corona) grants the TRO, GMA able to pay 2M bond beyond 5pm, after office hours of SC cashier.
Then GMA entourage headed to airport, staged a drama. They were given VIP access but they instead went to public gate (remember how GMA wants VIP treatment before, when asked to remove shoes at airport and was to be whisked, she asked the guard, “kailangan pa bang gawin to?” irritatedly)
Leila deLima enforced that they not be allowed to leave the country.
Reactions poured out on why did the DOJ secretary defy the SC ruling.
On the other hand, why did the SC hastily issued TRO without hearing govt side.
GMA headed to St Lukes.
On a friday, SC en banc session was held, COMELEC-DOJ joint panel filed Electoral Sabotage vs GMA, Ampatuan, Bodal and Abalos. Pasay RTC Judge Jesus Mupas issued warrant of arrest for everyone.
Saturday, GMA had her booking (finger printing, mugshots taken by the police at SLH).
Saturday, GMA had her booking (finger printing, mugshots taken by the police at SLH).
Tuesday:oral arguments for the SC granting TRO vs WLO
Friday: GMA doctors testified in court; claimed GMA condition getting much better, can go home anytime. GMA’s lawyers motioning that doctors need not testify, now wants a motion for house arrest instead of hospital arrest.
Another photo of GMA after the foiled exodus…
GMA dont want doctors to testify in public because GMA wants her condition in private.
Prosecution moves for GMA transfer to a detention cell.
Prosecution moves for GMA transfer to a detention cell.
GMA got transferred to Veterans Memorial Hospital.
December 2011:
House of Congress by virtue of 188 congressmen, filed impeachment complaint against Renato Corona.
Addendum:
PNoy owned 2% of the shares of Hacienda Luisita, but sold his share before his presidential election. (This I recall from Winnie Monsod’s videos).
(Please feel free to correct me with the chronology of these events by posting your comments, or insert details that I have forgotten to include. Very much appreciated).
My Blue Baby
(Image credit: http://www.lhm.org.uk/info/surgical-treatments-for-right-sided-single-ventricle-conditions-48.aspx)
On that day that I admitted three babies successively, there were two premature babies who immediately presented with respiratory distress (of course, it’s expected & understandable), and a full term. I thought that the full term baby was unremarkable until a few minutes after birth when he himself presented with respiratory distress. Initially, I thought it was because of fluid retention in his lungs that caused him to be breathing fast and appearing “bluish.” Fluid retention is usually a common disorder usually experienced by babies delivered via cesarean section (whose mothers did not undergo labor). To some extent, vaginally born babies may also experience transient tachypnea due for fluid retention especially if the labor was precipitous (shorted period than expected). Fluid retention usually resolves in six hours in most babies, but in few cases, may last up to 2-3 days. Babies presenting with such condition will not usually require antibiotic treatment, and will respond often to mere oxygen administration. I initially started the baby on oxygen inhalation.
On the sixth hour of life, the baby remained with fast respiratory rate (tachypnea). We did an x-ray and did a blood test for a marker of infection. Chest x-ray was suggestive of pneumonia whereas the infection marker was non-reactive. Initially, I did not agree with the x-ray findings because the baby has no risk factor of having an infection so I did not start antibiotics yet. The baby’s respiratory rate actually normalized few hours afterwards, but his oxygen saturation was always low, especially when active and crying. This patient’s status and presentation is not compatible with the classical pneumonia cases. Nevertheless I was forced to start antibiotics (at the back of my mind, it’s better act than be sorry if in the end the baby has also a concomitant infection). On the third day, baby remained comfortable, with normal respiratory rate, however, still bluish especially when the nasal cannula delivering the oxygen gets accidentally dislodged from his nostrils. We also noted that the heart beat was stronger in the right side than in the left (which is the normal location of the heart’s tip or apex, and thus stronger heart beat is supposedly appreciated louder from that side). I was considering now that this might be a heart problem. I requested for a repeat chest x-ray to confirm my suspicion of a dextrocardia. (Dextrocardia means that the heart apex is located in the right side, contrary to the normal).
(Image credit: http://estudandoraras.blogspot.com/2009/05/dextrocardia.html)
Few hours earlier, the baby was evaluated by a cardiologist. A 2D Echocardiography was done and revealed a dreadful finding, it sealed the baby’s fate. The baby indeed has a dextrocardia, but on top of that are more serious findings: situs ambiguous, single atrium, single ventricle, large patent ductus arteriosus, and moderate pulmonary hypertension. This just means, his heart is like that of a fish. I was literally dumbfounded when the cardiologist told me his findings. I dont know how the mother can take it when I will talk to her but I am glad that the burden of telling the mother went to the cardiologist. He would be in a better position than I explaining the baby’s condtion. This would be too heartbreaking on the side of the mother, especially so that she plans to leave for the Middle East after one month to work. Question now is, will she wait for the baby to die before she leaves?
— UPDATE—
Few days after, yesterday to be exact, mother sent me an SMS that baby finally expired. May God bless his soul and take him to His kingdom.
In The Nick of Time
Yesterday I was consulting patients when at 2:00 pm, I received a referral from a hospital where I will be attending to the delivery of a term baby via cesarean section. The procedure was scheduled at 4 pm. Since I don’t have a long queue of patients, I was taking time my time to attend to my outpatients. At 2:45 pm however, with 3 remaining patients, my phone rang again and the caller is the same hospital. I thought the CS was being rescheduled but it was a new referral. A mom who is on her 9th pregnancy, but this would be the 6th live baby, was admitted due to very high blood pressure at 220/120. She was being scheduled for emergency cesarean section. I asked what time, the resident said NOW! I asked for the indication and the resident replied there was a sudden drop of blood pressure from 220/120 to 160/90. It was alarming indeed! With the three remaining patients I haven’t attended to yet, shall I ask them to come back tomorrow or will I finish my consultation before I proceed to the hospital? I decided to consult them all, anyway, they were all for an oral vaccine. I was really telling sorry I had to rush them, but they do understand that I am no regular pediatrician, and they also won’t prefer to come back the next day, so all was well.
I drove as fast as I could to reach the hospital on time. Upon arrival at the parking area, I saw the obstetrician handing her key to the guard so the latter could do the parking for her. I also did the same and ran towards the NICU. I first checked the equipment if they were all prepared and in less than 5 minutes, I was notified that the operation has began. (The NICU is adjacent to the operating room). I then went to the operating room and just as I finished gloving, the baby came out. The baby was limp, no spontaneous breathing, and was bluish in color. The obstetrician immediately cut the cord so I could attend to him. On the resuscitation table, after the initial procedure of drying the baby, wiping off the amniotic fluid, the baby was not reacting. So after clearing the mouth of any secretions, removing the wet towel and covering the baby with a newer one, I immediately did bag-mask ventilation.
Bag-mask ventilation. (Image credit: http://odlarmed.com/wp-content/uploads/2009/02/laerdal_als_baby_rescuer_cpr.jpg)
After few seconds, baby started to grimace, breath regularly, and his color improved. Heart rate was at a normal rate and baby began to cry. I heard then the OB gave a sigh or relief. I give credit to the obstetrician for delivering the baby as fast as possible.
When the baby already seemed alright, I immediately latched her onto the mother. While baby was on mother’s chest, I went to inspect the placenta as the obstetrician noted abruption. I noticed that on the uterine side of the placenta, it was black all over. This means that the placenta completely separated from the uterus prematurely, the black indicates blood has already clotted. (This explains why the blood pressure of the mother suddenly dropped from 220/120 to 160/90 even if the medications for controlling her blood pressure was just started). What is the implication of this? In cases of abruptio placenta (or placental abruption), the blood supply to the baby decreases depending on the placental surface that separated. The more placental surface separates, the more decreased blood flow. If this remains unmanaged, it may go to the extent where baby will become completely devoid of blood flow, loss blood volume and suffer shock. If this will still remain uncorrected, it can lead to the baby’s demise. In the case of this particular baby, the placenta completely separated, meaning, no blood flow was already going to the baby. That’s why when the baby came out, he was bluish, limp, not breathing spontaneously, and heart beat was very slow, almost towards death. The ventilation process that I provided (as illustrated above) reversed this process that’s why baby came back crying.
(Image credit: http://www.moondragon.org/obgyn/pregnancy/placentaabruption.html)
In less than 5 minutes that the baby was on his mother’s chest, I noticed that he was again turning pale to bluish and breathing was getting slow. I immediately took baby to the NICU for further care. After stabilizing him, I took his blood gas and showed a mixed acidosis, and the pH was at 6.9! (A pH below 7 usually is not compatible to life as the cellular enzymes and proteins already begin to coagulate). Glad thing it was reversed immediately.
ABRUPTIO PLACENTA is one of the very serious complications of pregnancy. Depending on how immediate the action is, the baby will eventually turn out normal (if the baby was delivered immediately upon detection of subtle signs, such as a sudden drop of blood pressure on a hypertensive mother at the time of evaluation or presentation), or dead (when the action was delayed, probably due to delay in recognition of symptoms, or no health care provider was able to assess the condition, such as in remote, rural areas, or when the patient is poor enough to afford a physician/hospital). The most common frank manifestation is vaginal bleeding in relation to abdominal pain and/or labor. Subtle sign may be the sudden drop of a blood pressure in a mother who was hypertensive during the course of pregnancy. Management of course would be immediate delivery of the baby or else the baby will die. For mothers who are hypertensive, let it be known and remembered that this elevated blood pressure is able to direct blood flow to the baby. Since it is not also good for the mother to be having a very high blood pressure, as it may also cause sudden rupture of blood vessel in the brain causing stroke, they are usually admitted for it to be controlled to a satisfactory level. The control is done gradually hence the titration of the anti-hypertensive drugs. If the blood pressure immediately drops, this will cause minimal to nil blood flow to the baby, and the baby will suffer shock, and eventual death.
This is one complication of pregnancy that we are wary of as babies often are the ones who suffer the complication, from ending normal, premature, with cerebral palsy, or dead. My baby was indeed premature at 32 weeks. This is facet of the reproductive health of the mother. If the bill get’s passed and enacted, health care providers may be able to reach pregnant mothers in the remote areas, those who cannot afford private obstetrician care. Once the health care provider is able to assess a mother at risk, then they can be referred to a higher institution capable of taking care of such cases. Luckily, my patient’s family can afford private physician’s attendance. But what of those poor mothers?
