THE STORY OF KHADIJA L(myself) AND ALEXIS - FIBROIDS IN PREGNANCY

Alexis , 42 year old approached me one fine clinic . She had recurrent fibroids (Atleast 6 in number) and badly wanted a third baby; her first two had also been born through C/S after a rigorous fibroid-removing surgery . The biological clock was ticking fast . She wanted to know her options . If we could avoid a surgery before the pregnancy the better . I looked at the scans , the fibroids didn’t look too big at the time and the cavity was clear - we are always warned that the ultrasound isn’t the best tool for fibroid mapping - MRI is better but is costly and mostly unavoidable. I warned her that with my fertility drug prescription, she could conceive on month one of our fertility treatment so she needed to be sure . I don’t know if I’m allowed to go all African and say that niko na mkono ya fertility 😇 - many get pregnant through my hands even in difficult circumstances 🥸; I’m grateful though for any positive outcomes of course through science, correct prescriptions and God’s grace  . I’m told my late great-grandmother Bi. Khadija Mbeneka was a serious herbalist and people would come all the way from Congo and beyond for her fertility concoctions and many a times they worked . Back to Alexis, she was very certain that the time to have her last born had come , she reminded me that her mother went into menopause at age 44 so indeed the clock was at tik-tok. Power of the tongue 😀; she conceived pronto and in 6 weeks time she was back with a positive pregnancy test . I promised her that tutapambana till she holds her baby . I had personally walked that journey when I was pregnant with my son Q - I was pregnant and with a few fibroids ; zilinisumbua wacha tu . I was in severe uterine pains (worse than labour pains) and my cervix literally funneled(opened at the top) at 22 weeks and I had to be on mandatory bed  and pelvic rest for 9 weeks . Thankfully I had finished my curriculum in my final 4th year postgraduate study and was only working on my theses and a few weeks of just one clinical rotation . My Gynaecologist at that time Dr. Pallavi was very particular that I couldn’t work during that time ; she never got tired of filling out my sick forms because she knew how bad things could potentially get ; she literally asked me to go home each time she saw me sneaking into school - my colleague a senior doctor in Fetomaternal Medicine warned me that school could wait but my pregnancy was a  once in a lifetime shot for that particular baby and a loss could shatter me. 

So back to Alexis ; I don’t know if we under-estimated the fibroids or if they simply grew with the pregnancy hormones . Let me tell you Maina , it’s like we had new recruits of fibroids . By 16 weeks she looked like she was 28 weeks pregnant . Then the pains and contractions started. I had put her on natural micronized progesterone tablets since the beginning to get ahead of the fibroids but with time I had to max to highest doses( these drugs cause uterine quiescence ; the uterus to remain relaxed to avoid contractions).!The pains were bad ; every phone call from her and I wondered if she was reporting a miscarriage . I admitted her so many times , the hospital literally had a corner bed designated for her . We celebrated every milestone . I kept asking myself , ‘shit what have I done ?’ Maybe I should have removed the fibroids first but time wasn’t on her side - removing fibroids would mean waiting another 12 months after surgery at earliest  before she could try conceiving to give the uterus time to heal . She would be 44 going to 45 years by then . We cheered to every milestone . At 28 weeks we thanked God . At 30 weeks I gave her steroids ready for the preterm baby anytime . At 33 weeks we repeated the steroids and procured surfactant for the expected baby . Our fingers  were tightly crossed . At 35 weeks the pains disappeared but she developed hypertension of pregnancy - man, she was still an over-40 woman and with a risk of pregnancy induced hypertension - we had focused too much on the fibroids and almost forgot that she an over-40s pregnant woman 😅 with other age-related risk factors to worry about. 

In my case with Q’s pregnancy , my pains continued but disappeared fully by 32-33 weeks and I was back to cat-walking on university corridors with my big bump  trying to finish school on time . Still, no one dared to put me back on work rota in the teaching hospital, but I was certain that the pains and risk of preterm labour were behind me . Sijui nilikuwa natoa nguvu wapi !! But with my case , Q and myself worn . The fibroids degenerated and started calcifying ( a phenomenon in which fibroids die off and are covered in calcium and become like stone) . The pain happens as the fibroids grow fast and outgrow their blood supply and start struggling for blood susteinance, degenerating (kuoza) and sometimes die off as was in my case . The pain is from the uterine irritation from the struggling  degenerating fibroids and this can potentially provoke preterm labor or a miscarriage. 

My instructions to Alexis were clear . No work , no straining , no sex till delivery . Prostaglandin in semen can cause mini contractions and catapult things in a patient with an ‘irritable uterus ’ with fibroids . Contractions from orgasm can also worsen contractions from degenerating fibroids and potentially cause a miscarriage or preterm birth . I had also been on these strict instructions during my time . The uterus was to remain un-provoked as much as possible. 

So we struggled with Alexis . Pains were minimal but the blood pressure effects were real but soon we got things under control . Every week after this 35 week gestation was a bonus for me and Alexis . This pregnancy had tried by all means . At this time most  of her  fibroids were bigger than the baby’s head 🙃. I rehearsed her caesarean section in my head a million times even in sleep . I was just waiting for the phone call . Blood was at all times at standby for her and I kept re-checking.  

Believe it or not we reached 38 weeks . The night before the surgery I didn’t sleep . I kept wondering if she could potentially go into labour the night before and rupture her uterus  🙁. Weh nightmares for me . I also slept knowing very well that she had two huge fibroids about 10 by 10cm at the lower uterine segment where I was supposed to cut to remove the baby . I said a dua for her as  I left the house . 

Surgery was tough ; we did it under general anesthesia just to give me room if I needed to do another surgery like the dreaded removal of uterus during C/S . I had to make a classical incision - this is opening the uterus longitudinally like an open book to remove the baby . The fibroids were pouring out blood . Baby boy got born safely and cried - much to my joy . The inside of the uterine cavity was littered with so many fibroids such that I had to remove the placenta piece-meal as it was embedded in the many caves and corners of the   affected uterine cavity - I don’t know where and how the baby stayed there for 9 months . How did we miss out the submucosal fibroids on all scans we did?Suturing the uterus was a tall order . There were fibroids everywhere and I literally had to remove the fibroids that were on my way as I repaired the uterus . Crazy !!! We bled lots but we were well prepared . 

I know most of you are wondering if it’s possible to concurrently remove fibroids during a C/S . Is it possible in very few selected cases but it’s extremely dangerous . The bleeding that can happen can be life threatening. I don’t pull those stands myself unless it’s a very superficial and pedunculated fibroid or on my way during suturing . It can be very very dangerous . Infact I generally don’t remove fibroids during C/S. Kwa muoga huenda kicheko , kwa shujaa……

Fibroids in pregnancy can also cause other dangers like early separation of the placenta especially if overlying the fibroids causing bleeding that not only causes risk of preterm labour but can cause significant bleeding risk to mother and baby . This remains a high risk pregnancy that has to be followed closely and following all instructions. 

So dear Alexis is so grateful. Her baby is growing and and thriving ; she still looks very pregnant 😆. She had asked me to remove the uterus during the C/S but I warned her to ‘tema hiyo mate chini’ . Getting to that would mean that she she is in serious danger during the C/S . We don’t remove other things during C/S due to the increased blood supply during pregnancy which can potentially make additional surgeries very risky. The anatomy is also usually a bit distorted due to pregnancy changes and can lead to damage of other organs such as the ureters (tubes from the kidneys to the bladder) . I had to promise her that when the time is ripe , that I will do her much needed hysterectomy(removal of uterus). She needs to recover from the C/S first and take care of her little one . She reminds me that her menses are usually crazy heavy and getting another pregnancy would be very risky for her . 

So back to my story . My uterus went quiet in the last leg of the journey with Q . I defended my theses successfully, finished my few weeks of a rotation and did my finals very confidently passing with some distinctions. Heck the pregnancy even prolonged after that to almost 41 weeks; I delivered a week after my finals . Q remains my miracle baby . My fibroids froze to date and  I’m yet to get any new ones - my 2nd pregnancy was easy cos the fibroids were long calcified . Many of my clients remember me doing major surgeries and caesarean sections past 38 weeks of my 2nd pregnancy with R . I was that strong . I knew what it feels like to be bed bound so the good health during the  tiny sweet healthy 2nd pregnancy was a blessing and i maximized my activities at work and beyond . My daughter walks and dashes very fast and she reminds me how I used to dash theatre to theatre; hospital to hospital working during most of her pregnancy . 

I hope the story of Alexis gives women with fibroids hope that they can hold their babies even before fibroid removal but it’s a journey that requires very close follow-up . For those with crazy fibroids or infertility due to fibroids should make  plans in good time to remove the fibroids quite early and give them time (6months to ideally a year) to heal before they try another pregnancy . We also have a few blessed ones whose fibroids remain calm and quiet throughout most of their pregnancies . I hope the post was educative!!

(Written with permission from Alexis (not her real name) 

GENITAL WARTS - A MENACE AMONGST COLLEGE STUDENTS AND PREGNANT WOMEN

Common summarized scenario at clinic (most present like this almost identically ) ; Patient A- a young late teens-early 20s storms in and looks at me not knowing where to start. ‘I have itchy , smelly velvety things growing on my privates and my mum shouldn’t know about this ; figure out what to write at the insurance forms because she will find out.’ It clicks to me immediately this is definitely HPV Genital Warts . I calm her down , take a detailed history and request to review then I’ll advise further . The are indeed warts . I take a further focused history including sexual partners , HIV history etc. You can imagine the shock on the early 20s girl when you tell her that you needed to screen for HIV among other tests first then we embark on a treatment plan . How do you lie about warts in the insurance forms ? Is it even legal ? You can call malaria a febrile illness but what do you ‘baptize’ warts now that the treatment is very particular, very expensive and longterm ? The cost of treatment cannot be handled by a student’s pocket money . How do you maneuver that the mother knows that the girl is innocent and working hard in school and possibly a virgin ? Mother is well connected and will get the insurance alerts in detail . You shock her further that when she gets to age 25, she needs timely cervical cancer screenings done. She looks at you bewildered - cancer ? She also wonders if she should avoid sex with her Brayo and for how long ? Could Brayo be responsible for this ? What if he is the shedder of the virus ?

2nd scenario ; Patient B- A young beautiful pregnant lady walks in . (This is hypothetical covering how most present and worry about). Let’s say 28year old , first pregnancy , freshly into a ‘come-we-stay’ arrangement . Storms in very angry because the fiancé refuses to take responsibility for the itchy velvety lesions in her private parts. She wants you to confirm that indeed this is from John and he needs to be called to come in for checks ; he must be cheating according to her. She also worries because she has googled that pregnant women with warts are not allowed to ‘push’ and caesarean section is recommended . She looks at you with teary eyes ‘see what John has done , imagine a C/S because he probably cheated.’ You calm her down and shock her that ‘there is a chance that this is not from John , could be a sub-clinical infection from way back ; maybe an ex-boyfriend  , provoked by the changes of pregnancy ‘. She looks at you very shocked and wonders if you know John and have plans with him to protect him . You shock her further that even if it’s from John , there are no tests to test men for HPV , they are mostly carriers of the virus. 

Genital Warts  also known as CONDYLOMA ACUMINATA are non-cancerous lesions that can appear in the genital areas of both male and female but are more prevalent in the females who carry about 70% of the burden clinically . They are caused by the Human Papilloma Virus (HPV) variant 6 and 11 . Warts can appear in other parts of the body including  inner thighs, anus and mouth and main mode of transmission is sexual ; with a high rise in homosexuality in Kenya, we expect to see more male clients . Transmission can also occur via contact to infected formites such as towels (Watu wa AirBnB are we together?). Heterosexual male rarely exhibit symptoms and are mainly silent carriers . Sadly there is no test to test men unless the few ones with lesions on penis, pubic region or anus etc . 

So why college students ? These are young girls, late teens to early 20s. Potentially exposed to multiple strains of HPV by their potentially highly sexually active college boyfriends or by themselves being highly sexually active - or a frequent change in boyfriends with a higher turnover than your average busy working-class Mary. HPV spreads fast , almost like a family-tree with a potential build up on multiple variants in one individual - you sleep with Alex who has variant 6,11, 45, 31 then sleep with Joseph who got variant 16,18 ,33, 72 etc from Jane and you end up with total variants 6,11,45,31,16,18,33,72 and the build up continues  . Some of these variants such as HPV 16,18, 31,33 are responsible for future cervical cancer in 10-15 years or less if the body doesn’t clear the virus . The more risky the sexual behavior is , the more risk of low immunity and HPV persistent in the body . But college students use condoms so why the high virus load ? Condoms are not 100% protective against HPV virus - this is a virus that is contagious through touch;skin-to-skin - the condom only covers the penis shaft upto 3/4 , what about the other penile skin and the testicles and inner thing ; any shedding virus in these areas will definitely transmit the virus to the female during the act of intercourse . Oral sex leads to susceptibility to oral warts . Persistence of HPV 6 and 11 leads to clinical manifestation of warts which are raised , velvety , lesions that can be itchy and that can grow very fast and become fungating(rotting away)  especially in immunocompromised individuals . Any new HIV infection in an individual or non-adherence to ARVs compromises immunity leading to fresh symptoms and manifestation of warts . Take note that not all patients with warts have HIV (actually most of them are HIV negative) but being one of the opportunistic infections for HIV, HIV screening is mandatory at first contact with a doctor and 3 months later. 

Why pregnant females ? In pregnancy , immunity goes down significantly due to pregnancy changes and there is  increased blood supply especially in the pelvic and genital organs. These two factors increase activity of a dormant past asymptomatic HPV virus leading to symptoms . This dormant infection could have been ‘hiding’ for years; maybe from a prior exposure from a different partner  . Due to increased blood flow and skin sensitivity in pregnancy , the warts become larger, very friable and itchy during pregnancy. What’s the rumor about C/S in women with warts? Well, in my earlier training as younger doctor , the practise was to take all mothers with warts for planned caesarean sections. This is to minimize HPV transmission to the baby which may cause symptoms to the newborns eyes - conjunctiva , mouth and genitalia . The riskier transmission is to baby’s respiratory system leading to respiratory pappilomatosis which are basically HPV lesions in the trachea and lungs ; this is however very rare 1 in 200 newborns in mothers with warts but can potentially be deadly . Some

Warts can be so large as to block the birth canal all together leading to bleeding and tears during birth . The current practice now is to try and manage the lesions as much as possible before delivery and give the mother the autonomy to consent for vaginal birth of the lesions are treated or significantly reduced but they must understand that infection to the baby can occur and can potentially be deadly . 

How are warts treated ? For the larger ones , we aim for excision ( cutting the off ) using a few medical techniques e.g cautery ( use of heat), cold knife(usual surgical blade excision) or clinical procedures that break off the warts such as cryotherapy(freezing technique) and use of laser . This can be done the office or in theatre  depending on how big the procedure is- I collaborate with the dermatologist for trickier small multiple lesions . Thereafter there is application of immune modifying creams that burn off small lesions and prevent recurrence. For smaller lesions we go straight for the creams without requiring excision .Such creams include Imiquimod(Aldara) which are applied on alternative days for weeks till a week after complete cessation of lesions. Cream for 3 days( a week’s dose) costs about 30 dollars - Kshs. 4000 ; per month totals to about 14000 to 15,000 shillings  . The creams burn and can affect sorrounding skin and mucosa - advice is to apply some Vaseline on normal skin around the lesion then apply the aldara . These creams also interfere with integrity of condoms  and make vagina mucosa so friable and sensitive so sexual contact should be avoided while on treatment . So I tell my girls to avoid Brayo till they are fully recovered and done with treatment; some worry that Brayo will leave - I ask them to choose their battles . There are other creams and treatment formulations such as podophyllotoxin which are not readily available in our Kenyan market. I once had a student who was on Aldara only and wondered how she was going to afford till around 12 weeks ; she couldn’t dare inform her parents about her struggle with warts . 

One day , about  5 years ago , I participated in total removal of a patients pubic area(vulva) leaving only the urethra and clitoris because the lesions were very very big completely obliterating any normal skin - this is called a total simple vulvectomy - removing all labia and approximating skin from the edges . 

In pregnancy , Aldara is very toxic to pregnancy . Some lesions clear on their own as immunity build up but for the larger ones , excision is recommended . Otherwise we mostly treat symptoms such as itchness , pain etc using lidocaine creams(numbing creams) , sit baths etc and hope that the body clears the infection or we cut off the lesions . Our hands are usually tied in pregnancy due to potential toxicity to pregnancy of the known treatments for warts .  Lesions that block the birth canal or distort the vagina significantly risking a bleed lead to automatic caesarean section . 

Sadly even after best treatment , warts can recur so long term follow-up is recommended . I always advise my patients to eat well , avoid stress and avoid risky sexual behavior to help in boosting immunity hence enhancing quicker recovery and reduction in recurrences. Is college academic stress , junky diet , social stress a contributing factor in us seeing these lesions more in college students ?

Recurrent lesions must always be biopsied for histology to rule out the rare incidence of concurrent cancer in these lesions . 

We believe that once exposed to the HPV that causes warts could mean possible concurrent exposure to the HPV that causes cervical cancer.  Generally in the population , all sexually actively women must be screened for cervical cancer lesions from age 25 every three years and annually if HIV positive . We only test high risk  HPV variants at age 30 and above to give the body time to clear the exposure so that we only focus on persistent infection . THE RULE CANNOT BE IGNORED ESPECIALLY IN THOSE WHO HAVE HAD HPV WARTS hence more risk for possible multiple HPV types exposure . So dear Njeri, when was the last time you had  a pap-smear or VIA for screening done ? (VIA is a cheaper screening modality that gives instant results and being embraced widely). 

Warts are associated with a lot of stigma but let’s remember that most people have been at risk of the symptoms  if we look back deep into our histories and that of our partners . Just because you never got caught doesn’t  mean that you were never exposed to HPV 6 & 11; you are only lucky that your body cleared it before you could ever notice it . So don’t judge a sister with warts ✅. 

One prevention modality is HPV vaccination of our children( both boys and girls but mostly girls) before they ever begin sexual life ; best age is age 9-14 or older if they are yet to be sexually active. This way we protect them against not only warts but also future cervical cancer. The vaccine is available for free in all government vaccination clinics ; the rule for 9-14 years is more of a budgetary policy issue but in essence all persons who have never been sexually exposed are eligible for the vaccine.

Let us also maintain faithfulness in our relationships and marriages . Please men kindly protect us ; you are carriers and spreaders and hardly ever face the wrath of the stigmatizing symptoms of HPV. Sadly there are not tests to test you . How unfair !!! Let us also vaccinate our boys to protect their future girlfriends and wives . 

College girls  , abstinence seems like an old fashioned boring terminology but it protects you against so much including HIV, cervical cancer , STIs, possible tubal infertility , unwarranted pregnancies etc . The boys have nothing much to lose . Let us also embrace and open up to our mothers, aunties , sisters, spiritual-mothers Gyanecologists etc for guidance and advice. 

WHEN I FOLLOWED MY HUNCH AND SAVED A PATIENT

 Just before Christmas, a daughter to a patient I had treated in 2022 looked for me . She came carrying a huge banana(that my family enjoyed thoroughly over Xmas week) . She wondered if I could remember her mother's history because she needed some reports and pre-authorization forms for a follow-up MRI written. I had seen them back when I worked in a public facility in Imenti South so all their documents were at the facility . How can I forget Madam Zulekha's history(not her real name) ? It was fresh in my mind to the finer details. She was surprised and reminded me that their mother will forever be grateful to me for diagnosing her rare cancer in Stage 1A and for a timely focused referral and care . She was currently in remission and living her life fully.

Zulekha and her daughter Hawa came to my then busy Wednesday public clinic.  A Clinical Officer in our facility had told them that the facility had since acquired a passionate gynaecologist. They had come in all the way from Embu. She was then 69 years old , had an abnormal pap smear report with a high risk precancerous lesion and wanted to know the way forward - a simple hysterectomy(uterus removal ) had been rightfully recommended by another gyanecologist . I examined her ; the cervix looked quite flushed up into the uterus due to menopause and it had some mild inflammation changes .A simple uterus-saving procedure called LEEP wasn’t an option for her due to the nature of the cervix with age. Removal of the uterus was the way to go.  Before I booked them for surgery , I noticed that their latest ultrasound had commented on a small vascular area on her uterine lining on colour doppler ; the lesion was about 4mm in size. It was an otherwise normal ultrasound but this small microscopic lesion was noted in the body of the report . The images showed a tiny drop of a bright part of the uterus lining . A very vascular area means a small part with an abnormally high blood supply that brightens up on an ultrasound setting called doppler. The sonographer who did the ultrasound my friend Enid swears that she couldn't remember doing the colour study and doesn't know what prompted her to do it ; possibly a small irregularity or lack of smoothness on the lining . I decided that I wasn't going to ignore this .  A colleague told me that I was overthinking; the lesion was so tiny and she didn't have any endometrial cancer signs and symptoms . My made was made up ; I wasn't going to do her hysterectomy before confirming what that 4mm lesion was - imagine 4mm  -how small ? I didn't have access to a pipelle instrument that can be used to biopsy the uterus lining in the clinic . I booked them for a D&C for biopsy purposes . We did the procedure the following day and sent the samples for histopathology . Thankfully her daughter Hawa was very supportive and respected my decision to take the long route. I promised them that I would proactively follow-up the case . It’s notoriously common for tissue samples to be lost in most government facilities- patients wait for months for reports , others die before they can have a diagnosis . I killed this bureaucracy during my time at the public facility by creating public-private partnerships with two top pathology centers. The patients would pay up directly to these centres , they would pick the well preserved samples every Thursday and they would relay the results within 6 days before the following Wednesday clinic .Due to numbers , I also negotiated favorable prices matching GOK rates . I was stoned a bit for this but the system worked and we never lost any patient to follow-up. Imagine first contact with a client on a Wednesday and discussion  of confirmed diagnosis and treatment options by the next clinic? Oh , I miss that facility and the pathology systems I set up . I believe that a patient in public is not inferior to a top client in the private sector - we are all equal . 

6 days later I get the results on my email . Zulekha had a very rare form of uterine cancer - a squamous cell carcinoma  - of the uterus . A very rare incidence of that type of cancer being seen on the uterine lining- it’s mostly seen elsewhere like the cervix or the skin. Imagine a 4mm spot ending up to be a 1 in 100,000 diagnosis ; what were the chances ? By 1996, only 58 cases had been reported of the cancer world wide - probably one of less than 5 known cases in Kenya to date . I quickly called Hawa and asked her to bring the mum we talk . The type of surgery she needed was beyond my scope because it would involve deeper dissection of lymph-nodes. It’s a cancer that can be extremely aggressive if not managed properly from the beginning . This would require a skilled Gyane-Oncologist to perform the surgery. My mentors tell me that one of the attributes of a good surgeon it to know when NOT to operate. I ordered an MRI and Chest CT-Scan to stage her and gladly she was STAGE 1A disease ; right at the beginning of the illness . I made some calls to Kenyatta National Hospital(KNH) and the team was enthusiastic to have her ; this was a rare disease type . They kept asking me how I picked it . Who are you daktari? I was tempted to answer them how my namesake and owner of my name , my late great-grandmother used to answer; 'I AM KHADIJA MBENEKA; DAUGHTER AND QUEEN OF THE MOUNTAINS! 😀😀😀'. A doctor there encouraged me to apply and join their Fellowship in GyaneOncology training program; he was impressed by my keen eye and interest . 

Zulekha was attended to promptly, she didn’t have to wait for the notorious KNH queue m, her surgery and follow-up oncology care was successfully done and she was fully confirmed to be Stage 1A disease of the exact type of cancer we had diagnosed. She made a full recovery and was due for her 2 year review this time when I was seeing them in 2024.

Had I not followed my hunch , I would have done a simple hysterectomy on Zulekha for the cervix pre-cancerous lesion and in the process potentially upstage her endometrial cancer . I can't thank Enid enough for picking up the microscopic lesion on ultrasound though she can't remember it . I'm reminded to always follow my gut and re-confirm any science deviations above all things to give my patients best care . There is no need to rush and in the end cause more harm than good . The daughter remains a star in my eyes , she has walked the journey with her mother without complaining and following all steps as directed without delays . 

We wish Zulekha a long and fruitful life with zero recurrences. Amen