Eclampsia.

There are three big things that kill mothers around the world: infection, hemorrhage, and preeclampsia (pregnancy induced hypertension). In Somaliland, for some unknown reason, preeclampsia and its associated complications are far and away the most common cause of maternal mortality. In the 8 years Edna's hospital has been open, 40 women have died [with about 10,000 women having delivered here, that's about a 0.4% mortality rate, remarkable for this country and continent]. Of these 40 women, 32 have died of preeclampsia or complications of preeclampsia (pulmonary embolism, organ failure, etc.)

So why? No one really knows what causes preeclampsia, and the only cure is delivery, though there are some palliative measures to bring blood pressure down. Preeclampsia becomes eclampsia as soon as a woman has a seizure. In the United States, preeclampsia is usually identified at prenatal visits in its fairly early stages and monitored and/or aggressively treated. In Somaliland, the vast majority of women receive little or no prenatal care. Thus, they don't tend to present until they have very severe preeclampsia or are actively seizing.

At about 3:30 this afternoon, a woman expecting her third child was admitted (accompanied by the requisite 15+ family members) having full blown seizures with loss of consciousness since that morning. The family had come from a very rural area, perhaps explaining the delay between her reported loss of consciousness and her arrival. Her aunt said she was 9 months pregnant. Another aunt said she was 32 weeks pregnant. Her fundal height suggested she was about 28 weeks pregnant. In a hospital where the age of viability is about 32 weeks (it's 24 weeks at many hospitals in the US, now), these inconsistencies made choosing a course of action very difficult, since an immediate c-section or augmenting to speed labor quite possibly meant choosing mother over child. She was given one drug to bring down her sky-high blood pressure, one to stop her seizures, and a third to mature the baby's lungs to improve its chances of survival should it be delivered, not unlikely since her family said she had been having labor pains and she was several centimeters dilated.

The drug to stop her seizures is one widely used in the US (magnesium sulfate), but here it is regarded as prohibitively expensive at $40/vial and must be imported from Djibouti or the Middle East, so it is doled out carefully. About an hour after the first dose was given by a student midwife, Lauren and I discovered that the vials were a different, much lower concentration than had previously been stocked and that the patient had received was totally insufficient. Since the muscles in your butt (where the drug is injected) can only hold so much fluid, it was out of the question to just inject more of the lower concentration meds. Some creative thinking and internet searching revealed a solution and she got the increased dose, but it only sort of worked. She continued to dilate and was moved to labor and delivery, and I went to eat dinner upstairs.

At about 9 pm, I went back downstairs to check on her and found she was about the same as before. But an elective c-section was about to start, so Lauren and Harrison and I stuck around to go over neonatal resuscitation with the students again, though it was an elective repeat c-section and complications didn't seem likely. The GIANT c-section baby was delivered just after 10 pm and didn't look great. We were just starting to give it oxygen when someone banged on the door and asked us to come. We were like, sorry, going to have to wait, when the student said, there's another baby. Lauren and I rushed out and discovered that the woman with eclampsia had abruptly delivered a very tiny, very limp, very blue baby girl in her bed. No heart beat, no respirations. We immediately started CPR, doing two rounds before hustling the baby into the neonatal resuc room and putting the baby on the single warmer table, already occupied by the first baby. After another round of CPR and lots of ventilation, the baby had a solid heartbeat and was breathing on her own, but still totally limp and silent. The first baby perked right up and was taken out to its family, but Lauren and I worked on the tiny baby, about 4.5 lbs., for almost half an hour, suctioning and rubbing and drying and giving oxygen before moving her to the incubator.

I spent almost two hours with her, monitoring her vital signs every 15 minutes and keeping a close eye on her. She's still not stable, but she's closer, and she's under the close watch of a carefully chosen community midwifery student for the night. She's warmer, but still not breathing great--the steroid that Somaliland has access to to mature the lungs takes twice as long to work as the one available in the US, so this baby probably didn't feel the effects of it (12 hours vs. more than 24 hours). This baby's life is at the very limits of what technology in this country can sustain. Her mother, though, is doing quite well, resting comfortably and if all goes well, tomorrow she'll meet her new baby. Fingers crossed.

Other than that I find it very interesting, there's not really a point of this story other than that working here is a big back and forth of, look at what we can do! oh, but look at what we can't. But look what we can! But if only we could do that too...Constantly caught between being relieved about the increased access to care you are part of and the occasionally heartbreaking reality of what all more could be done, if only, if only. You just never know which side of it you're going to come out on. Here's hoping that both mother and baby come out of this story on the side of the beauty of increased access to care.