3 MONTHLY INJECTABLE CONTRACEPTION VS. IMPLANTS

It’s been exactly 30 months since I last blogged. I joined school for my specialization and this being my first time in a public Kenyan university, I wasn’t certain how the idea of blogging would be perceived; my original plan was to remain unnoticed and to keep a low-profile as much as possible. I guess I had so many myths running through my mind about treatment of students in Kenyan Universities; that you are there to be seen and not heard - I later learned that all that was not true; no teacher would punish their student for wanting to disseminate knowledge and for exploring their talents. I also had a total change in setting from rural Meru where I experienced firsthand unique situations in a rural setting which was more or less a Primary Health Care set-up where I was the first contact with a diverse pool of patients. In the 30 months I underwent self-discovery, a lot of growing up, understanding my new group of friends and acquaintances; had a slight brush with depression at some point and generally life happened. I decided to wait for the writing bug to attack me naturally and spontaneously. I tried writing at some point last year but the write-up turned out so plastic and therefore I kept a draft unpublished copy.

One week back, a relative approached me and wanted a quick prescription for her usual ‘Depo’contraception injection which she could easily get from a local Chemist without having to queue at a hospital or clinic. I got into doctor-mode and asked her if she was aware that there were better more reliable methods of contraception. She unleashed all these myths about the methods I was advising her about and even pulled a ‘IUCD is Haram in Islam’ statement. What worried me more was that she had used injectable progestin for more than 24 months straight and was already exhibiting some of the side-effects associated with its prolonged use.

DISCLAIMER : For purpose of this blog post, we will not use Depo or  Depo-Provera brand name , we will use the chemical name of 3monthly injectable progestin -  Depot Medroxyprogesterone Acetate (DMPA). This post is not about a brand but the chemical components of the mentioned drugs.

DMPA is among many progestin only contraceptives. This group of contraception contains an analogue of the hormone progesterone; this is in comparison to combined contraceptive methods that contain derivative of both progesterone and estrogen in combination (will write about combined contraceptive methods in subsequent blog posts). Other progestin only contraceptive methods include the mini-pill that is taken daily especially in breastfeeding women, implants such as Implanon and Jadelle (implants are more reliable methods) and the progestin-containing intra-uterine devices - Mirena (very reliable!!!).

DMPA is an injectable method that is given every 3 months . It is a very popular method in Kenya with a use of 15%. It is administered as an intramuscular injection every 90 days; we have other formulations that are given once every 2 months. Its actual mode of action is by thickening cervical mucus making it non-penetrable to sperm and by making the lining of the uterus unsuitable for implantation. It may have an effect in suppressing ovulation (ovum release).

Most notable advantages of DMPA include;

• ·        It is suitable for patients who may forget the daily pill
• ·        It is suitable for breastfeeding women (after 4 weeks of delivery) because it doesn’t suppress milk production
• ·        Is suitable for patients who may have contraindications to combined hormonal contraceptives use such as smokers, patients with hypertension, patients with risk of developing deep venous clots, patients with history or risk of (uterine)cancers.
• ·        It is reliable with a failure rate of only 7 % in typical use (perfect use has a failure rate of 0.3%)
• ·        Less likelihood of anemia especially in women who get decreased or total lack of menses
• ·        Confidentiality – there is no evidence that anyone can use to figure out that you are on dmpa. It is an injection; no rods that can be felt e.t.c. This is particularly important in clients whose spouses are opposed to contraceptives, or unmarried women wanting to avoid stigma
• ·        No complicated process during uptake ; no unnecessary vaginal examination
• ·        Has been shown to reduce the symptoms of endometriosis
• 
  
• ·        It’s cheaper - although when you calculate the number of 3 monthly injections you will have in 3-5 years , implants are definitely cheaper in the long-run

Disadvantages include,

·        May cause irregular menstrual bleeding – some women report heavy irregular bleeding, some women may have light irregular spotting, while some women have a total lack of menses especially after extended use

·        Prolonged ovulation suppression may cause difficulty in return to fertility. Some cases may take up to 18 months to 2 years to conceive after cessation of use of DMPA

·        Prolonged use for more than 2 years continuously causes loss of bone mineral density (due to lowered estrogen levels). This is particularly of concern in adolescents who should be undergoing a growth spurt and in women approaching menopause (these women will soon be in menopause which is associated with a further accelerated bone loss). The return of normal bone density has been postulated to take around 5 years after stoppage of use

·        Depression and mood swings has been noted in women on prolonged DMPA use

·        Weight gain due to fluid overload. Women who gain weight in the first 6 months of DMPA use are more likely to have increased weight gain in the long-term

·        Headaches and migraines

·        Doesn’t protect against STI or HIV (condom-up!!!!!)

·        Others – e.g bloating, breast tenderness

Contraindications include,

·        Pregnancy (obviously!!!!)

·        Uterine bleeding of unexplained cause

·        Breast cancer or abnormal breast masses

·        Active or history of thromboembolic disease e.g deep venous clots, strokes etc

·        Cerebrovascular disease

·        Significant liver disease or liver masses

·        Not advisable in the first 4 weeks of breastfeeding (highly controversial issue)

The main point I wanted to drive home with this post is about the side-effects of DMPA on prolonged use. Of main concern is the issue of decreased bone mineral density and prolonged return to fertility with DMPA. There are definitely better progestin methods such as Implanon (three year implant) and Jadelle (5 year implant).

Implants have the same mode of action as DMPA because they have they have the same componenet ; progesterone although in different formulations. 

Advantages of Implants over injectable progestins include;

·        Long term method hence reliable (you only have to remember after the years have lapsed!!!)

·        Highly efficient family planning method (failure rate less than 1%)

·        These are not associated with decreased bone mineral density,

·        The return to fertility is quicker, rapid. This is of importance in women who have not started their families yet and in women who have not achieved their ideal family size

·        Although they may be associated with decreased menstruation or total lack of menses, they are mostly not associated with heavy bleeding

·        Have decreased prevalence of weight gain, headaches, mood swings, acne

·        Can be inserted immediately after delivery and doesn’t affect breastfeeding at any point

NB: Some of the effects of DMPA like headache, breast tenderness etc may be felt with implants but to a lesser intensity

I hope this read was helpful in clearing things up. I tried to make it as layman’s as possible and avoided jargon use. Feel free to email or comment below for any queries, criticism, corrections or more information.

Next blog will be on IUCDs and there will be a special segment on its use in Islam ; demystifying any myths.

Have a blessed weekend!

Dr. K

MORALITY VS. LEGALITY.

I remember attending a APOC (Adolescent Package of Care) training last year and was surprised to learn that the law allows for teenagers to use contraception no matter the method requested (as long as it's reversible). There seems to be a very thin line between morality and legality.  The over-18 limit no longer applies in this current day and age. A 10 year old requesting for Norplant cannot be denied the service as long as informed consent has been given . I didn't think much about it until I saw 15 year olds with Norplant implants , Intrauterine Copper Devices etc, most of which had been forcefully organised by their mothers. Maybe I have been raised up in a rather traditional set-up where 'abstinence' was the only measure talked about and successfully instilled. I still don't get it why a mother would rather protect their daughter from pregnancy and not worry about S.T.Is or infertility. I have seen countless times young girls coming in with irregular menses, total lack of menses or heavy bleeding and on further enquiry learn that they are on hormonal contraceptives. If a teenager is not married and has no boyfriend, I still don't understand why long-term contraception is important.

There are times in the office when I get stuck. I can't have a rather 'adult-talk' with a child and expect them to make a life-changing decision. I also aim at zero-prejudice and let them make the decisions on their own without being judgmental. When I tell them about probable infertility in the future , most of them confidently state that they would tackle it when they grew up and get married. When I tell them about abstinence or Barrier methods of contraception (condoms) , most of them sneer that I'm old-fashioned and don't understand 'these things'. As a young doctor in her twenties,I try hard to come down to their level and reason as one of them , but I just can't seem to get used to this century's shocks.

A teenager can be expected to make some stupid mistakes , but as a mother, why would you make some of these  decisions for your child. Have we become so westernized, liberal and 'digital' in a manner that can only be harmful to the upcoming generation ?

Looking at it from the other 'digital' view, I guess that we must face the fact that our teens are sexually active. As much as we are aiming at protecting them from pregnancies, we should also balance the equation and protect them from diseases too. It pains me when I see 14 year olds diagnosed with S.T.Is and H.I.V during their antenatal check-ups. Others are diagnosed during their pre-operative check-ups after illegal abortions gone wrong.  Would you rather protect your daughter from pregnancy now and have her suffer from infertility in the future or deadly diseases?

Shouldn't a law be passed regulating contraception use among teenagers? Shouldn't we have parent's consent and some legal framework followed before these kids are allowed to use family planning methods
? Let's ponder about it.

MALE INFERTILITY

MALE INFERTILITY

About 2 weekends ago , I was 'thoroughly' bored in Chaaria on a Saturday evening . I decided to go to Meru Town for company and joined some friends watching football( I know nothing about the game). As they sipped their beer and I continued with my delmonte, they kept making fun of my 'blondness' and total ignorance on matters football; they made it their business to teach me about the game . In the course of conversation, a topic on male infertility somehow arose. They are non-medics so they were very inquisitive about it all. The guys kept on challenging me with questions and giving suggestions on probable treatment . I must say they were very accurate on their suggestions to my amusement . The topic got so intense such that I noted other people in the restaurant starting to pull their chairs towards us and listening keenly to the interesting talk. One of my friends is extremely loud hence the added attention. I was also careful to keep my professionalism and talk only about the theory of the condition without giving any statistics.

I had also written about this topic a while back in my blog about the intense dilemma I go through telling patients about this condition. To most African men it becomes a source of ridicule in society and others even commit suicide. Confidentiality is key in managing this condition , sometimes to the extent of keeping it secret away from the female spouse and letting her continue being branded as the 'problem' by society as we try to find a solution to the husband's condition. This is an extremely chauvinistic way of handling it but hey, this is Africa. A woman can take the ridicule and remain hopeful. That is the general mindset here. Medically it is also easier to treat female infertility compared to male infertility.

Male subfertility or infertility is the inability of a man to make a woman conceive through the natural process. It can be due to a genetic, physiological, pathological or mechanical problem in the production or transport of spermatozoa. About 1 in 20 men are subfertile.

The process of sperm formation starts at puberty and continues throughout life. It takes a total of 74 days for sperm formation to be complete and a further ten days for it to be transported to the epididymis for storage for use during ejaculation. The head of the epididymis stores 70% of mature sperm and during ejaculation it exists through the vas-deferens to the urethra.

The real cause of the infertility could be due to total inability to produce mature viable sperms(AZOOSPERMIA), production of abnormal forms of sperm without the ability to move or penetrate an ovum, production of normal sperm but in low quantity (OLIGOSPERMIA), production of normal sperm in quality and quantity but blockage anywhere in the transport system from production to ejaculation , impotence e.t.c. Other factors like getting infected with Mumps in a male child can also cause male sub-fertility later in life due to destruction of the testicular cells.

This condition is first investigated by doing a SPERM-ANALYSIS. This is done after 3-7 days of total abstinence and studying the quantity and quality of the sperms. A normal quantity is more than 20million sperms per one milliliter , with atleast 40 million per ejaculate, atleast 60% normal motility and atleast 30%normal morphology and a pH of above 7.2. Severe acidity can destroy normal sperms.

The next step is doing hormone analysis to rule out production impairment.  This can be managed using hormonal treatment.

If hormone analysis is normal, the next step would be doing more intense studies to rule out  any mechanical obstruction in sperm transport or even absence of the transport mechanism e.g total lack of vas deferens. Unfortunately this can only be done in very specialized fertility centers and we only have one of such in the  country somewhere in Nairobi.

My loud friend kept on giving suggestions on treatment modalities based of above causes and he was absolutely correct and gave all treatment modalities. If a man has normal spermatozoa but in abnormally small quantities, IN-VITRO FERTILIZATION can be done and this involves harvesting the sperm , harvesting ovum , 'fusing' them and doing insemination into the uterus of a fertilized product for implantation.

If the problem is normal production but mechanical blockage in transport, SURGICAL SPERM RETRIEVAL(SSR) can be done. This is a surgical procedure done in theatre in which sperms are extracted directly from the testicles or epidydimis using a fine needle and then used for IVF.

The above treatment modalities are only done in very specialised centres and outcomes vary from individual to individual.

In the case hormonal treatment fails for total lack of sperm production , a DONOR SPERM can be used and injected into the uterus from a chosen donor or from a sperm-bank.

Other couples agree on having the woman conceive naturally and secretly using a selected 'Donor'. This is a cheaper way out but the legal,ethical, religious, cultural,
and emotional implications associated with this method discourages it's use especially in this era of diseases. It was however wildly practised in ancient African Communities mostly using blood relative 'donors'.

They asked me if Miraa (Khat) can cause male subfertility but I don't know about this. The problem could be due to impotence. Research is needed.

We looked at our watches and we were shocked to realise it was well past midnight. The conversation had been so intense. It's a topic that is very extensive but also very sensitive . I hope the post is educative. Any suggestions or questions are welcome.

SUDDEN DEATH IN YOUNG DIABETICS

On one Monday morning last month, I was doing my usual hospital rounds. I noticed a young man who had just arrived, he was writhing in abdominal pain, breathing so fast and aggressively, he was semi-conscious and his extremities were cold. He also looked severely dehydrated , had a low blood pressure with a rapid heart rate. He also looked like he had a rapid weight loss recently; he was wasted. I quickly stopped all that I was doing and went to him. A nurse, Mr. Ambani, abandoned his 'wound-dressing' duties  and quickly followed me. We positioned our patient properly and both of us couldn't help but notice a sweet smell emitting from his mouth (acetone breath due a waste called ketones).  He was in a very critical condition. I made a quick working diagnosis of Diabetic Keto-Acidosis (DKA) and asked the nurse to dash and get a glucometer( gadget for measuring blood sugar levels) and resuscitation tray with. I.V branulas and fluids. We were aware that the patient had no history of diabetes but we knew that he could be a new case of the disease . The sugars were unrecordably high ; my diagnosis of Diabetic KetoAcidosis was right . We needed to act in seconds or end up losing the patient . His veins were collapsed so I quickly went for the jugular and was in on the first jab. Meanwhile the nurse had given three shots of insulin and I started giving Fluids intravenously (Normal Saline) as soon as possible. Potassium Chloride and Sodium Bicarbonate was also ready. Another nurse joined us and assisted in putting a urinary catheter and getting a urine sample for the labs. He also helped as we struggled to get another I.V line to keep the fluids running fast. After two hours, the condition was still critical and the sugars were still unrecordably high. We put in a continuous insulin infusion as the fluids ran as we monitored and recorded the sugars every 30 minutes . Still after 4 hours, the sugars were very high but we kept on. His condition was better though not stable. There was a ray of hope soon and the sugars started dropping. The young man's breathing also improved significantly and within hours he was awake and responding to commands. By 10.00pm that evening he was walking around. I ended up not completing my ward rounds because I spent hours on the patient but I was glad that a life had been saved.

This case reminded me of an Autopsy I watched on TV  being done by the world renowned pathologist DR.G (Channel 171 Dstv).  A Diabetic patient had just collapsed suddenly after a usual day of work. The patient had sensed that she was feeling weak and mistook her situation as a case of low blood sugars so she quickly took a glass of juice, only for her to collapse and die. Her autopsy was unremarkable but he blood analysis confirmed a serious case of Diabetic Keto-Acidosis, a condition caused by high blood sugars. She was strictly adherent to her drugs and diabetic diet so her family could not fathom how the condition could have attacked her. It was later learned that she had travelled a week earlier by bus with her drugs safely carried in her back-pack. The drugs were not stored in the refrigerator as required so their potency was gone. She was injecting herself during the week with insulin that was not working  due to high temperatures in the bag and bus hence the high blood sugars .


Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but it is not uncommon in some patients with type 2 diabetes. In layman terms, I tell my patients that Diabetes Type 1 is mainly In those who were diagnosed with Diabetes before the age of ~35years. There usually a total lack or very low production of insulin by the pancreas in this type of Diabetes, hence the need of the patients to be on insulin and not oral drugs.

DKA is a complex disordered metabolic state characterized by high blood sugars, dehydration , ketoacidosis, and ketonuria. ( presence of a metabolic waste called Ketone in the blood and urine).

Signs and symptoms

The most common early symptoms of DKA are the insidious increase in thirst and frequency of urination.

The following are other signs and symptoms of DKA:

Malaise, generalized weakness, and fatigability
Nausea and vomiting; may be associated with diffuse abdominal pain, decreased appetite, and anorexia
Rapid weight loss in patients newly diagnosed with type 1 diabetes.
History of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons.
Decreased perspiration
Altered consciousness (eg, mild disorientation, confusion); frank coma is uncommon but may occur when the condition is neglected or with severe dehydration/acidosis

Signs and symptoms of DKA associated with possible intercurrent infection are as follows:

Fever
Coughing
Chills
Chest pain
Difficulty in breathing
Joint pains

Patients having these symptoms must rush to hospital for check up and proper management. This is for all people irregardless of whether or not they are diabetic. In the case of my patient above, he was not a known diabetic and this was his first time to be diagnosed).
DKA is a condition that is is deadly but at the same time very easy to treat and reverse if diagnosed on time.

It's sad, but I have heard and witnessed stories of diabetic patients found collapsed and dead in their houses. This year alone I have certified deaths of 2 young diabetic patients  who collapsed suddenly after a normal working day. We highly suspected DKA.

We doctors also over-emphasize to our patients on the dangers of low blood sugar (hypoglycemia) and forget that High Blood sugar is also similarly dangerous. Public education on this matter is needed.  Patients should also be advised to own blood sugar measuring machines so that they can properly diagnose themselves for emergency first-aid as they rush to hospital.


I hope this post will help us to prevent sudden deaths in Diabetes .

My patient hopes that his story can help inspire others.

P.S....let us not forget HYPOGLYCEMIA(Low blood sugar) which can also kill in seconds. It is the opposite of this condition I have written about and life can be saved by taking sugar. This requires a whole new post for discussion. I hope to write about it soon. Have a wonderful March 2016.

A SPECIAL PATIENT

A few months back a patient walked into my office frail and weak. He had come to pick his biopsy results for a suspicious growth. He had come in with his relatives; son, daughter and handsome grandson. I don't know why I took a liking to these strangers. Either it was the charisma and high spirit of the mzee or the non-Sumbua (non-fussy) nature of the relatives. We clicked !! I talked to them for a while, made them comfortable then slowly broke the news of the diagnoses. It was unfortunately the 'C' word. The 'disease' was at an operable location and I immediately knew that a trial of surgery was a viable option.

I never really get very involved with patients but for this special man, I went all the way. I privately talked to the surgeon (a visiting surgeon from Italy) and we agreed that there was no harm in trying as long as the tumor was localized. Again I gave it my all in doing the labs and the necessary radiological examinations. To cut the story short, a decision to try the surgery was made but there was that risk of local involvement of local structures by the tumor which was difficult to visualize on radiological examinations. I explained this to the relatives and they agreed to try it instead of doing nothing.

Surgery was unfortunately 'short' (lasted for only 20minutes) because we discovered that it was unfortunately too late. There was extensive local spread. Nothing could be done!! It was a matter of 'open, see and close'.

I met with the family the same day post-op and broke the news to them and again they were very understanding. I discharged the old man 4 days later and referred him for hospice palliative care. It was too late to even try chemotherapy or radiotherapy. The days we had him at the hospital were happy days because he would crack the other patients with jokes and stories.

I kept tabs on how the old man was doing and this past weekend, I did what I never do. I decided to pay him a home visit. I learned that he had to get weekly intravenous fluids due to dehydration episodes and I decided to spare him a hospital visit by buying I.V fluids, branula etc and do it for him at home.

He was extremely happy to see me and we had a chit-chat as the fluids run into his veins.  He was having some brief episodes of confusion but I went a long with the mildly confused talk. He got very energetic and even stood and walked outside later that evening. I left him a content man with a big smile and he blessed me just as I was about to leave. I promised to visit often but little did I know that this would be my first and unfortunately last visit with 'Mr. Charisma'.

His grandson did call me today and informed me the Mzee had gone to be with the Lord. I said a short prayer for him and I'm so glad that I gave him the best  care. I'm happy I went for the home visit. I learned a lot about remaining positive from this man and I pray that his soul rests in perfect peace. AMEN!!

MY EXPERIENCE AS A BIRTH COMPANION.

This past month I literally  got a chance to be on the other side of the table. My cousin had chosen me to be her birth companion( if you are pregnant and you haven't decided on who will be your  birth companion then you are not serious with your birth plan). I know that in most public hospitals, patients are not allowed to have companions in the labour room but it's something that should be allowed to some extent. I was excited about the honour that she had bestowed on me and I looked forward to it very much. When my entire family left the house to spend the weekend back home in Machakos like it always happens, I was a bit reluctant because I had given her my word to be around during the days approaching her E.D.D. (Note,a mkamba doesn't sleep in Nairobi on a Friday, this is a known fact; afterall Masaku NOO VAA!!)

I am an avid fan of all pregnancy related shows on TV like 'One born every Minute', 'I Didn't Know I Was Pregnant', 'Adventurous Deliveries' e.t.c mostly on TLC Dstv Channel 172 ; so I had an idea what birth companions go through.

The much anticipated phone call came in on Saturday at 8.00a.m and I was super excited. As a medical doctor, I get very irritated when patients come in with their 'medic relatives' who know it all and want to control everything so I knew that I had to play this very cautiously without crossing other medics  borders.

In the hospital where she was delivering, only the spouse is allowed into the delivery room but I gladly convinced them that I was stepping in on behalf of the spouse. Ofcourse I was a bit anxious not to let anything go wrong because I'm not sure if I would ever forgive myself, there's a sense of responsibility that kicks in when you are watching over your relative. We were in the company of her amazing friends but unfortunately they wouldn't be allowed in for as many hours as I, the 'spouse.'

I humbly introduced myself to the midwives and the 'Intern' (he was either a doctor intern or a very experienced nurse). I played it dumb and cool ; back in my mind I kept wondering if they knew that I practically run the maternity in my hospital and all decisions during working hours fall on me. They must have thought that I was meek and docile ; and that was excellent because I didn't want to intimidate anyone.

I noticed a few mishaps here and there that I would ordinary ignore but not with my cousin.  I literally kept bugging them in a friendly and flattering  manner until they did the correct things but without feeling pushed and intimated.

Again, my hand was sore from all the lower back massaging. At one point I would be told I wasn't rubbing the back adequately and at the other time I would be told I'm rubbing it too much; they are called women in labour, they are allowed to command the moment, haha! I also forgot to eat or drink anything till around 5.00pm when my cousin's friends brought me something to eat and I devoured it irregardless of the maternity environment. I thought I looked mean eating infront of an exhausted labouring woman but I reminded myself that I needed the energy to focus on the task ahead.

I was also very keen to feed her often and give her energy drinks so that she would have adequate energy when the time for pushing out the baby would come.


There are moments she caught me laughing at her but hey, the dramatics of a labouring woman can be comical. I'm sure every woman smiles over some of these memories. I also assigned myself the role of chief-photographer. I thought that she would want these life changing moments captured . I made sure I only took photos and videos with her phone and never mine to maintain privacy. I believe these are very intimate moments that only belong to her and her soon-to-be-born child.


When I felt like she wasn't being monitored adequately as need be, I would call the pretty nurse and request her to politely do what was needed, and we bonded well. I refused to enter the examination room as they did invasive examination because I didn't want to cross into another doctor's territory and I also respected her privacy.

Of course I have dealt with many pregnant women and I know when they are psychologically feeling things. When my cousin would tell me that she was at the point of pushing the baby, I would just sneak out and come back pretending that I have alerted the doctor. Of course you don't bear down so early until you reach a certain dilatation. This happens to us doctors a million times so when you tell your doctor that you feel like pushing and he ignores you, trust me he has your best interest at heart.

We laboured till evening and we reached a point where action (caesarean section ) was needed. I being a staunch supporter of Vaginal Delivery made sure we tried it fully but of course without putting the baby at risk. I would hate it to go home thinking that I contributed in unnecessarily rushing to a Caesarean Section. I had literally forewarned her not to mention the word Caesarean-Section infront of me because I was hoping that she had it the 'normal way.'  I had a partogram( a graphical monitor of labour) in my head, literally and I knew it when it was time to go to theatre. I anticipated a malpresentation, but behold it was a big baby coming out of what looked like a very small pregnancy bump; that caught me off guard literally. How could we have missed out on a Big Baby diagnosis? We had all relied too much on a scan done the previous week which had estimated a fairly small size baby.

In the labour room, I was able to calm down a husband who was very tense. He sensed that I was abnormally calm and he approached me for moral support. I did open up to him that  I am  a medic and with that, gave him the avenue to ask as many questions as he wanted to calm him down. They had lost their first baby at birth and were still traumatized and hoping they would be successful this time round. He managed to calm down finally and be strong for his wife who was clearly going through a difficult delivery. I realised that probably God was using me to wipe off fears from this family in my capacity as my cousin's 'spouse.'


I exited the birth companion role and entered the 'grandmother' role. I was alone at the bedside at the Post-Operative ward waiting for mother and child to come back from theatre. Those were long, tension packed hours. I expected them out in 45 minutes to 1 hour but they took a whole two hours. I kept re-assuring myself but as a medic, I kept going round and round on all things that could go wrong. Soon, I had the pleasure of being the first to hold and clothe the big baby together with the nurse as we waited for the mother to be 'sewed up'.

I would have jumped in to help if anything went wrong, whether with permission or not; I'm I not a licensed doctor in the country? This reminds me of a doctor friend whose child developed breathing complications immediately post delivery and she hastily jumped out of bed with placenta dangling in between her legs and resuscitated her child. By the time the doctor arrived, her child was sorted.

I left the hospital late in darkness but went home a very satisfied woman. Of course I carried home lots of my cousin's DNA, in form of amniotic fluid,  blood, tears etc in my clothes but those were marks of success and victory.

This task made me give a lot of respect to spouses who go through it all in the labour rooms. It's not easy sitting on that bed for more than 12 hours observing a loved one suffer. It's for the persistent, patient and strong at heart.

It also made me appreciate the importance of having a birth companion. I'm a medic and I know that patients who are accompanied are usually taken more seriously.

I also learned the importance of respecting colleagues when in their territories. The midwives loved me to the point of sneaking a joke or two when I went to enquire anything. The maternity guard(Askari) also liked me and praised me for my persistence till I had seen the end of the delivery.

I also learned to treat patients with utmost care because for us, it's an everyday job with 'objects' to treat, but to a patient, this is the first time in their lifetime to ever go through an unforgettable experience. When a doctor spoke harshy to my cousin, I was hurt, yet I do use such words frequently in maternity. For example, I don't like being touched by a labouring woman when doing a vaginal examination yet it's a painful procedure that they have probably never encountered in their lives. With this, I have become a more compassionate doctor especially in maternity.

I pray that my cousin Jacinta and her beautiful daughter have an amazing life together, full of wonderful memories and friendship.

'Dear Jacinta, should you require a birth companion for another pregnancy, I'm all yours. Thanks for trusting me with this very important role.'

BLIGHTED OVUM

             BLIGHTED OVUM
I have been spending so much time with pregnant women of late such that my body, soul and spirit is in pregnancy-mode, I'm actually awaiting my 'first delivery' 3 days from today.  2 close relatives and a best friend are pregnant so I have been bombarded with lots of pregnancy questions. One of the questions that has always come up is about a formed pregnancy with no baby (embryo). This might sound very impossible but it’s a frequent phenomenon. My patients look at me in disbelief when I tell them that they are indeed pregnant but with no baby forming. I have had to take them step by step on the ultrasound till they get it. In the hospital I work in, I see at least two cases weekly. For those who don’t believe the diagnosis, we always advice them to repeat the ultrasound after a week or so, or get a second opinion for the sake of psychological satisfaction.



WHAT IS A BLIGHTED OVUM?

A blighted ovum occurs when a fertilized egg implants in the uterus but doesn't develop into an embryo. It is also referred to as an anembryonic (no embryo) pregnancy and is a leading cause of early pregnancy failure or miscarriage. Often it occurs so early that you don't even know you are pregnant. The pregnancy appears normal on an ultrasound scan in its early stages, but as the pregnancy progresses a visible embryo never develops or develops and is reabsorbed. In a normal pregnancy, an embryo would be visible on an ultrasound by six weeks after the woman's last menstrual period.

WHAT ARE THE CAUSES?
The causes of a blighted ovum are often due to problems with chromosomes, the structures that carry genes. This may be from a poor-quality sperm or egg. Or, it may occur due to abnormal cell division. Regardless, your body stops the pregnancy because it recognizes this abnormality.

 For most women, a blighted ovum occurs only once in their lifetime but I have seen a few women getting it twice or thrice. It becomes very depressing for some.

WHAT ARE THE SIGNS?
With a blighted ovum, you may have experienced signs of pregnancy. For example, you may have had a positive pregnancy test or a missed period.
Then you may have signs of a miscarriage, such as:
• Abdominal cramps
• Vaginal spotting or bleeding
• A period that is heavier than usual.
If you're experiencing any of these signs or symptoms, you may be having a miscarriage. But not all bleeding in the first trimester ends in miscarriage. So be sure to see your doctor right away if you have any of these signs.

HOW IS IT DIAGNOSED?
An ultrasound test is usually needed to diagnose a blighted ovum -- to confirm that the pregnancy sac is empty. For diagnosis, the sac must be of sufficient size that the absence of normal embryonic elements is established. In case the doctor is doubtful, he can recommend one extra week of observation followed by a repeat scan to be sure of the diagnosis once a sufficient size of sac is achieved.

HOW TO TREAT IT

If you have received a diagnosis of a blighted ovum, discuss with your doctor what to do next. Some women have a dilation and curettage (D and C). This surgical procedure involves dilating the cervix and removing the contents of the uterus by curetting. Because a D and C immediately removes any remaining tissue, it may help you with immediate mental and physical closure. It may also be helpful if you want a pathologist to examine tissues to confirm the reason for the miscarriage.

Using a medication such as misoprostol ('the white tablet') to stimulate the uterus to expel the contents may be another option but this must be strictly done as an inpatient in case bleeding complications arise. However, it may take several days for your body to expel all tissue. With this medication, you may have more bleeding and side effects. With both options, you may have pain or cramping that can be treated.

Other women prefer to forego medical management or surgery. They choose to let their body pass the tissue by itself. This is mainly a personal decision, but it must be discussed with a doctor. I remember almost losing a patient who decided to wait for the body to expel but ended up getting life threatening bleeding and ended up being rushed to theatre for an emergency D&C and had to have urgent transfusion.

HAVE I EVER SEEN A NON-DEVELOPING EMBRYO??

I remember doing a D&C and of course after almost rupturing the amniotic sac on my face, the small embryo came out. It was so small, about 3 cm long, I put it aside to study it after the D&C but of course it had melted into a white matter by the time I was done. This fascinated me.

I hope this post was educative enough and I hope that Doctors also stop telling patients 'mimba imeharibika na lazima uoshwe' (pregnancy is spoilt) instead of explaining the exact nature of the condition that made them miscarry and telling them all the options available for them.

Have a fruitful week!!!