Monday, November 5, 2012

Forewarned is Forearmed

Another Ultrasound Story from Roche Health Center
By Dr. Esther Kawira
Nyamusi Magatti helps with vital signs during clinic operations at Roche Health Center.

The patient was presumably 32 weeks into her first pregnancy. But when I examined her, the uterus was only the size of about 24 weeks.  The baby’s heartbeat was normal, however, so I knew she was indeed pregnant rather than having some other kind of tumor.
The usual cause for this, wrongly remembered dates, is easily determined by ultrasound.  Other common causes are late ovulation (which itself has several possible causes) or severe illness in the mother leading to undergrowth of the baby. This young mother appeared totally healthy.
I advised the patient to come for ultrasound, which she did a few days later, along with her interested young husband.
The cause of this problem was easy to see.  There was no (I mean zero) amniotic fluid.  The kidney areas of the baby were replaced by large cysts instead of functioning kidneys.  The baby was not making any urine, therefore the amniotic fluid, mostly made of fetal urine, was in this case not present, and therefore not cushioning the baby’s growing body.  The normally egg shaped fetal head was already flattened into an oblong oval by pressure from the uterine wall, and the fetal lungs, that normally are filled with fluid, could be seen to be “hypoplastic”, meaning underdeveloped.  Though the fetal heart was still beating, I knew that birth would be lethal to this baby, as it would not be able to even draw its first breath.
The husband peered intently over my shoulder at the ultrasound screen.  So I pointed out the head, and the beating heart, that are easily seen even to the untrained eye, even as my heart was sinking as I was putting  together the implications of what I was seeing. 
Knowing that these conditions can be genetic, I extended the scan to the kidneys of the mother.  I found that her left kidney was normal, but her right kidney was filled with about six large cysts. 
“Okay, I’m finished.  You can get up” I said to the mother.
When she and her husband were seated, I said, “There is a bad problem with the baby”.
Slowly I explained to them how a baby normally floats in fluid, how there was no fluid here because of a kidney problem, and how this led to a lung problem that would mean that either the baby would be born dead, or would die at birth.  I also explained that she might not go into labor at the usual time, because part of the trigger is the size of the uterus, and in this case the size would never reach that of a full term baby. 
Then I had to turn to the issue of genetics.  I didn’t know percentages, and anyway they would not have had much meaning for this couple.  So I simply explained that the mother also had cysts in one kidney, but that the other kidney was normal and could handle the job.  I said that the lethal condition of the baby might happen again, but they could also have normal children, just like the mother was normal. 
I wondered to myself later whether forewarning this couple of the lethal condition of the baby, and the possible recurrence, was a good thing.  But I concluded that “forewarned is forearmed”, and that preparing psychologically was better than the shock of giving birth to a malformed and lifeless baby when they were expecting a normal baby.  In this culture, where such things are often attributed to witchcraft, I got my scientific view into their heads first.  “ This condition is known and understood, we know what will happen at birth, and we have means to follow any subsequent pregnancy closely to either confirm recurrence or to be able to see a normal healthy baby.”

NOS 2011 Video featuring Michael Zaretsky and the Roche Health Center

This fabulous video captures the sights and sounds of the construction of Roche Health Center and features Michael Zaretsky reflecting on the history of the building. Enjoy!