By Dr. Esther Kawira
25 May 2011
Abdominal Pain
“My abdomen hurts”.
This is a very common initial complaint. I responded by asking my
common first question to young women of child bearing age.
“Are you pregnant?”
“Yes”, she responded.
She was from Musoma, the district headquarters several hours away, but
had come to Roche to attend a funeral at her brother’s home. She had
taken the opportunity to be examined by me on my one day per week at
the Roche Health Center.
She had been troubled by abdominal pain for months during this, her
third pregnancy. By history she was now about six months along. She
had had an ultrasound a few weeks before, she said, at a private
clinic in Musoma. She said she had been told that the placenta was
high and the baby was low....but nothing that made sense to me. The
report, she said, was on her antenatal card that she left at home.
I examined her, and found that the swelling of pregnancy in the lower
abdomen was not as large as I had expected. I found good fetal heart
tones with the doptone. However, more worrying was a hard mass across
the upper abdomen. Could she be developing some kind of ugly tumor, I
wondered? It didn’t seem to be connected to either the liver or the
spleen. I advised her that we needed to do another ultrasound, to
determine the true age of the baby, and to see what that mass was.
At the end of clinic hours, I found her waiting, requesting a lift
with our vehicle to Shirati, my home base where I do ultrasound. I
agreed that if the power was on when we arrived, I would do the
ultrasound then, though I normally do non-urgent scans just in the
mornings.
When we arrived, we found that the power, after being off all day
(rationing), had just come on again.
I started the scan in the lower abdomen, and was surprised to see that
the uterus was only minimally enlarged, and did not contain a
pregnancy, only thickened endometrium. I could already see an ugly
looking tumor encroaching into the scanning field in the lower
abdomen. Where was the pregnancy? Had I really heard the fetal heart
tones earlier, I wondered, or was the patient’s own heart rate rapid?
I rechecked the patient’s pulse, and it was about 80. Perhaps my
memory was faulty.
I scanned upwards a bit, and the ugly tumor continued into the upper abdomen.
I looked again in the uterus. Still no baby, not even a tiny one!
With a sigh, I decided to look for familiar structures in the upper
abdomen, starting with the spleen and left kidney in the left upper
flank. Moving my probe, I saw clearly....a fetal head!!
I was dumbfounded. Yes, it was definitely a fetal head, it couldn’t
be anything else. It was big. I measured it, giving no visible
reaction to the patient. It was 26 week size.
I scanned across the upper abdomen and found the body, with a beating heart.
This was an advanced ectopic pregnancy, abdominal type, with the baby
still alive, and the ugly tumor was the placenta, plastered among the
intestines no doubt.
I turned off the machine. I was still almost speechless, though I let
out a big sigh, intentionally, to start gently cluing the patient in
that perhaps all was not right with her world.
“Do you have someone here with you?” I inquired.
“Yes, my brothers are outside”, she replied. Sure enough, not one but
two brothers had followed us by motorcycle and were waiting for my
report.
I sat us in a circle and began gently to explain the problem, the
potential disaster that was brewing in the abdomen of their sister.
They listened intently. “Risk to the baby, risk to the mother,
surgery will have to be done, placenta can’t be removed”...some of it
went over their heads, but they got the basic message. It was urgent
to transport their sister to the hands of a specialist surgeon in
Mwanza, five hours away.
As I write this report, they are en route by bus to Mwanza, with my
referral letter. Meanwhile, I have traced the name of an Ob/Gyn
doctor there to receive them, consulted with him by phone, and sent
his name to them by their cell phone, so there is no undue delay or
confusion when they arrive.
According to the Obstetric textbook, this situation of advanced
abdominal pregnancy occurs in about 1 in 10,000 pregnancies. The
baby, if not already dead when the situation is diagnosed, is often
born premature because of danger to the mother of expectant
management, and therefore the decision to operate immediately. The
mother is at risk of death from hemorrhage during the surgery, as the
placenta may separate spontaneously from its anchorage onto other
abdominal organs. Even when the placenta is left in place, its
resorbtion over time can be complicated by abscess or fistula
formation, sometimes with need for subsequent repeat surgery.
I am thankful for my stellar reputation, that led this patient to
seek me out during a funeral visit to our area. I am thankful that I
have a good ultrasound machine. I am thankful that the power was on.
I am thankful for cell phones, that have completely penetrated even
into rural areas of Africa. And I pray that the doctors at the zonal
referral hospital will have the means to save this patient’s life,
even though the risks are greater here than in the country where the
textbook was written and from which the statistics came.
Party Gone Wrong?
Our team was preparing to depart from my weekly visit to Roche Health
Center, when a man carrying a large child was ushered into my room.
He had been running, apparently a long way, to catch us before we
left.
His story came out in confused bursts, partly in Luo and partly in
Swahili. He had gotten a call, he said, that two of his children,
plus his brother’s child, had suddenly become ill and had been taken
to a dispensary near their home. When he arrived, he found his three
year old girl child, Schola, was the one most ill. The dispensary
advice had been that he should take the children to the traditional
healer, as the problem was that they had all begun to act strange
(maybe bewitched?). He decided to race with this child to my clinic.
Schola was indeed acting strange. She was not able to walk on her own
at first, but swayed and staggered when supported on her feet. She
looked around randomly, alternately smiling and appearing afraid. She
staggered erratically here and there, aimlessly. She picked imaginary
things off her clothes, or the floor, or out of the air, and pretended
to eat them. She occasionally talked nonsense to herself.
The only noteworthy thing on physical exam was that she had dilated
pupils that reacted minimally to light. Her heart and lungs sounded
normal.
A visiting student from the US, observing her, commented, “It looks
like a party gone wrong.”
“What happens then, do they all get taken to the emergency room?” I asked.
“Yeah, or if it’s not too serious, they eventually sleep it off and
wake up fine in the morning”, he assured me.
Party drugs not being available here, and certainly not to children
under five, I began to suspect that the children had gotten into some
poisonous substance. Further questioning of the father revealed that
he indeed had toxic chemicals stored at his home, for use in curing
tobacco, general category no doubt being “pesticides”.
About six hours had passed since the “illness” started, and we had no
way to do any toxicology screen. The general advice said that trying
to pump the stomach or induce vomiting often did more harm than good,
but in any case it was too late to consider. So, we all sat and
observed the child, and tried to keep her from injuring herself (and
tried to keep from laughing).
Over the next hour, she improved, was able to walk by herself, though
still unsteadily, and could sensibly answer questions, such as “What
is your name?”. She drank some water without much trouble. She
denied feeling any pain. Her pupils were not dilated very much any
more.
We allowed the father to carry her off again, with advice to lock up
the chemicals. It is amazing, what nasty tasting stuff children will
ingest. But when I think of it, adults also ingest stuff that to me
is like liquid fire!
Under the Same Sun
A young mother, looking anxious, entered my exam room. Tied on her
back was a large child, and an older boy walked after her. Both of
the children were albino.
Of her six children, these two, she said, were affected. She and her
husband were bewildered. They had never heard of albinism, or seen
any albino person. They wondered what kind of curse had appeared in
their family. The mother talked with my nurse, who had encouraged her
to bring the children to be seen by the doctor.
For my part, I had seen albino people in cities, but never in my rural
clinic before. However, a week before, I had seen an interview on
television with some staff of “Under the Same Sun”, an organization
promoting awareness and rights of albinos in Tanzania. It was
mentioned there that the incidence of albinism is higher in Tanzania
than in other countries.
The boy, age seven, had chronically burned skin in sun exposed areas,
especially bad on the face and forearms. The mother had no idea a
person can be burned by the sun, and didn’t know what was causing the
“rash”. The baby sister, due perhaps to being developmentally
delayed, could not yet walk, had been kept in the house, and still had
mostly pristine white skin. Both children had nystagmus, the dancing
eyes typical of the most common form of albinism.
I wondered what the boy thought of seeing, perhaps for the first time,
another “white” person. Many times albino children are teased by
others using the slang “mzungu” yelled at white visitors. I wondered
if he had been called “mzungu”, or if perhaps no other child in his
village had ever seen a white person and had occasion to learn the
word.
The “treatment” consists of sun avoidance, using brimmed hats to
protect face, ears, and neck, sunscreen, and long sleeves. Sunglasses
protect the eyes. To white North Americans, all of this sounds like
routine advice when we go to the tropics. But of course none of this
protective gear is available for children in villages here.
With a promise to ask upcoming visitors to supply clothes, hats, and
sunglasses for the children, I requested photo permission. When they
return in June for another visit, they will meet a very large group of
white people (hopefully none of them sunburned)!
Albinos in Tanzania have been in the international news lately, at
risk for being murdered for their body parts that some witch doctors
use to bring good fortune to their clients. Both children and adult
albinos have been murdered. I shudder to think of such a fate for
these children and their oblivious parents. We will have to gently
clue them in to be vigilant for their children’s safety, even as we
educate them about the condition and let them know their children are
not alone. We will get in touch with “Under the Same Sun”. Perhaps
they have literature in Swahili, or contact with support groups.
Moth Eaten
“My hair is falling out” said the patient.
She had unusually thick and luxuriant hair, I noted, and wore it
natural and loose, not braided down. But sure enough, around in the
back there were patches that looked thin, as if it had been eaten by
moths.
Why did that term come to my mind? I recalled that, under
descriptions of syphilis in the medical textbook, one was that the
hair could fall out, giving a “moth eaten” appearance.
The patient had no other history or symptoms to suggest syphilis. But
syphilis can be sneaky. I heard that it used to be called “the great
masquerader”. It can remain for years without symptoms. And while in
the US it has been reduced by years of screening and prenuptial and
antenatal testing, in Tanzania it is still prevalent, almost forgotten
in an age where HIV overshadows everything. I have had many occasions
to review medical textbook descriptions of syphilis. And recently, I
had come into posession of rapid testing, that can give an answer on a
fingerstick drop of blood in 10 minutes.
This patient agreed to be tested for syphilis, and her result was positive.
After I explained about the treatment, and the advisability for
testing her husband and her co-wife, she had one more question for me.
“After the treatment, will my hair grow in again?”
It doesn’t say in the books, but I recklessly assured her that it would.
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