Seee time on facebook can be constructive!
(Apologies in advance for this post containing lots of textbook style medical detail, its quite difficult to explain the situation without it!)
After being in delivery ward very late for two days running (yesterday we left at gone 2 am and the day before was gone 1 am) and still being in for the 8am ward round I was very very tired this morning. To be honest I was planning on going home after the morning meeting for a few extra hours sleep as otherwise I felt I would be too tired to be useful - not skiving really considering how many extra hours I have done in the evening I figured. However in the end I did not because I actually felt I was too needed/ could genuinely alter a patients outcome quite drastically by suggesting a form of management that wasn't currently being done (not something you ever really feel as a med. student in England!)
Basically there was another lady with eclampsia in labour room (2 in 2 days :S) but unfortunately this lady was not term, she was only 30 weeks pregnant. Eclampsia is very dangerous for both the mother and the baby (maternal mortality of 2% and fetal mortality of 15%), and the baby has to be delivered as soon as the mothers condition is stable enough regardless of how premature the baby will be. The patients condition was being controlled reasonably well (At this point anyway.. A few days later the mother still had very high blood pressure and was supposed to have half hourly checks and instead the doctor discovered her blood pressure hadn't been checked for over 2 days! She had a go at the nurses about this which was kind of fai
r enough but at the same she should really have done a ward round on these two days or at least have reviewed the serious cases like this lady then she would have noticed the lack of monitoring sooner.) The management of the baby however was basically being ignored and apart from fetal heart sounds being checked I felt the baby was pretty much being viewed as a write off.
Even in England 30 weeks is pretty premature but not so pr
emature that the baby doesn't have a reasonably good chance of surviving with the help of all the high tech neonatal treatments that are available. I have been on a neonatal ward round in third year and saw extremely premature babies (from about 24/25 weeks) and all the incredibly sophisticated technology that is available to give them the best possible chance of survival. Here however there are no ventilators, no incubators, no UV light treatments for neonatal jaundice, no pulse oximeters and no machines that bleep warnings if the babies condition deteriorates even slightly; it is very different. In short if a baby is not strong enough to survive with the aid of a bit of (usually badly done) CPR, some antibiotics and a warm room then there is nothing else that can be done for the baby here and it will die :(. This doesn't mean there is nothing that can be done for the baby at this stage however; in England if there is threatened preterm birth before 32 weeks then the mother is given two doses of corticosteroids over a 24 hour period.
At 30 weeks a baby has not yet usually produced surfact
ant. Surfactant is a liquid produced in the lungs that reduces surface tension and so stops the air sacs of the lungs from collapsing. In premature babies that have not yet produced enough of this liquid, the surface tension is too great so the baby develops respiratory distress syndrome. This often needs treating with oxygen for about 5-10 days and sometimes a positive pressure respirator.... Hard enough to treat in England but here in Tanzania where there is only 1 oxygen machine for the whole hospital and no positive pressure respirator, I doubt any premature babies with this condition survive. However if the mum receives corticosteroids like in England as soon as there are signs that premature birth may occur then the condition can be prevented from arising in the first place. Corticosteroids increase synthesis of surfactant over 1-4 days and therefor
e effectively mature the babies lungs so that they have better chance of being able to breathe independently if the pre term delivery does occur. The type of steroids that are needed are available at this hospital so technically this is one easy thing that the doctors can do to reduce the number of premature babies that die (I think though I'm not sure that at 30 weeks like this baby with corticosteroid treatment and then after birth a warm room then the baby would stand a reasonable chance of surviving and not having any long term consequences. Maybe I am being optimistic though, I'm not a neonatologist!). All very well in theory...
In practice when I asked the doctor if she had given the lady corticosteroids for the babies lungs (I figured if they were not going to deliver the baby yet anyway then there may be enough time for the steroids to have a positive effect on the babies lungs), she didn't even seem to know anything about using steroids in threatened premature labours... This is quite shocking when its one of the few things they could do here to improve the outcome for premature babies (and I've seen them try to delay births using drugs that can
slow the labour down by only a day or two - virtually pointless if they are not using that extra day or so to give the steroids time to work!). So I explained the concept of using steroids in this situation as best I could (bearing in mind I hadn't done any research at this stage so was based on very foggy memories of what I learnt in 3rd year!). She seemed to understand the general idea though but asked if steroid were contraindicated at all in eclampsia/ would make the patient even more unstable. Hadn't a clue about this - only had a 4 week ob/gynae placement so although eclampsia is also common in England I haven't seen a case of it let alone a case similar to this one so I could know whether or not they would give the mother steroids. So in order to persuade the doctor to give the steroids I needed to research and find out for sure if steroids are safe in Eclampsia. Sounds easy but this is Tanzania and nothing is straightforward! The problems are that:
1. I only have a limited amount of textbooks with me and there i
s no library here and just a few very outdated textbooks. In my textbooks I could find information on giving steroids in threatened premature labour and information on how to manage eclampsia but nothing that linked the two.
2. The internet here is so slow that I'm pretty sure its being powered by a hamster running on a wheel. And the hamster probably only has 2 or 3 legs. It often takes over 10 minutes to load a page in the morning (quicker in evening) so not exactly speedy research.
3. The webpages I was finding kept talking about giving s
teroids in pre eclampsia in case delivery has to be done and didn't refer to eclampsia at all. I think this may be because A) Patients are monitored very regularly in the western world so the condition is more likely to be picked up and managed when it is pre eclampsia rather than presenting as full blown eclampsia and B) I think they might be a bit better at managing eclampsia in England so maybe the patient is stabilised more quickly/ the surgeons are better at recognising when the patient is stable enough to perform an emergency c section. If this is true then the baby may be delivered too quickly for the steroids to have a chance to take effect.
4. The clock is ticking! To be effective the mum needs to be given the steroids at least 24 hours before delivery and as I did not know when the mother would be induced/ have a c section (as this would happen as soon as she was stable enough), it felt like every minute was counting.
The solution? Facebook! Seeing as the internet was taking so long I decided to ask whether any of my medical student friends knew whether you could give steroids to woman with eclampsia / could any of them research this for me! Cheeky request but it worked much quicker than my research on the antique internet was, soon I had printed out info saying that giving steroids in eclampsia was ok. So turns out facebook is not just for procrastinating!
I rushed to labour ward to give the printouts to the do
ctor only to find out that although they had been trying for some time they had not been able to find a fetal heart beat. Oh. AJ and me tried again for some time because they only have Doppler machines here (and a rubbish old one at that - one of the other medical students had donated a nice new Doppler machine that had been one of her wedding present requests and just 4 weeks later it has now gone missing and is suspected to be stolen - who steals a Doppler machine from a poor hospital?!) and unless you listen in the right place you can easily miss a present heart beat. However having listened in lots of areas in case we had misinterpreted the babies position (the best place to listen is the babies anterior shoulder), we were forced to concede it really did look like this baby was one of the unfortunate 15% that die :(.
Gave the notes on eclampsia and steroids to the doctor anyway and explained them. Won't help this baby anymore but maybe she will remember them next time there is a pre term lady with eclampsia or just a threatened pre term labour in general. Probably not, but can always hope!
So bit of a stressful and sad morning in the end. Afternoon however I slept, and it was good (and actually well deserved I think!).