Sunday 28 September 2008
Saturday 20 September 2008
Postpartum hemorrhage
Death in Birth
HOW CAN THE INCIDENCE OF MATERNAL MORTALITY BE REDUCED?
In a hospital ward in Freetown, the capital of Sierra Leone, Fatmata Conteh, 26, lay on a bed, having just given birth to her second child. She had started bleeding from a tear in her cervix, the blood forming a pool on the floor below. Two doctors ran in and stitched her up, relatives found blood supplies, and nurses struggled to connect a generator to the oxygen tank. One nurse jammed an intravenous needle into Conteh's arm, while another hooked a bag of blood to a rusted stand, and a third slapped an oxygen mask over her face. In the corner of the room, a tiny baby--3 hours old--lay on a bed, wailing, swaddled in bright-colored African fabric. "Listen! You must feel happy to hear your baby cry," said a nurse, pleading with Conteh to find strength. Three visiting members of a neighborhood church began chanting over Conteh: "Jesus, put blood into this woman! Thank you, Lord!" But as their chants grew louder, the nurses stepped back from the bed. Conteh was dead.
Some version of that scene is repeated around the world about once a minute. Death in childbirth is not just something you find in a Victorian novel. Every year, about 536,000 women die giving birth. In some poor nations, dying in childbirth is so common that almost everyone has known a victim. Take Sierra Leone, a West African nation with just 6.3 million people: women there have a 1 in 8 chance of dying in childbirth during their lifetime. The same miserable odds apply in Afghanistan. In the U.S., by contrast, the lifetime chance that a woman will die in childbirth is about 1 in 4,800; in Britain, 1 in 8,200; and in Sweden, 1 in 17,400. Deaths are heavily weighted to the poorest and most isolated in each country, which means that many politicians remain largely ignorant of the scale of the tragedy. "Often the people in the cities do not know what is happening in their own rural areas," says Sarah Brown, wife of British Prime Minister Gordon Brown and patron of the White Ribbon Alliance, a global advocacy organization that works with governments to lower maternal mortality rates. Brown--who lost a baby 10 days after giving birth in 2001--says that when she tells heads of state and their spouses how many women die in childbirth, "they are aghast."
The Gains Not Made
They have reason to be. For here is the truly ghastly reality of maternal mortality: in 20 years--two decades that have seen spectacular medical breakthroughs--the ratio of maternal deaths to babies born has barely budged in poor countries. To be sure, maternal health has seen advances, with new drugs to treat deadly postpartum bleeding and pregnancy-related anemia. But in many places, such gains are dwarfed by a multitude of problems: scattershot care, low pay for health workers and a scarcity of midwives and doctors. In Mozambique, where women have a 1 in 45 lifetime chance of dying in childbirth, there are just 3 doctors per 100,000 people; in all of Sierra Leone, there are 64 government doctors, only five of whom are gynecologists. Millions of families have never seen a doctor or nurse and give birth at home with traditional birthing helpers, while those who make it to a clinic--some being carried on bicycles or in hammocks--often find patchy electricity, dirty water and few drugs or nurses. Explaining the task of reducing maternal deaths, Sierra Leone's Minister of Health, Saccoh Alex Kabia, who returned home last year after decades of working as a surgeon in Atlanta, says, "The whole health sector is in a shambles."
Many hope that maternal death rates in poor nations will naturally fall over time, as they did in much of the world in the 20th century. They well might. But international officials say governments often lack the political will--as well as the money--to tackle the issue, perhaps because there are too few women politicians to push it. Monir Islam, director of the maternal-health program of the World Health Organization in Geneva, calls governments' low level of investment in reducing deaths in childbirth a "sinful neglect."
In an attempt to jolt officials into action, governments at the U.N. General Assembly in 2000 chose to make a drastic reduction in maternal mortality one of the eight Millennium Development Goals (MDGS)--a series of targets in a program that channels aid to key issues, including education and clean water--to be met by 2015. The MDGS hold people "to a golden standard for progress," says Jamie Drummond, executive director of the antipoverty organization DATA. When world leaders gather in New York City this month to take stock of the MDGS, their speeches are likely to tout the many achievements since 2000: millions more African children now attend school and sleep under mosquito nets; thousands of new water wells have been dug. Yet though maternal health care underpins many other development goals (healthy mothers are more likely to ensure that their children are well fed and educated), the total number of women dying in childbirth has remained virtually unchanged in eight years.
Why? Health officials are clear in their answers. Aside from lack of money and political will, they also face entrenched traditions and fatalistic attitudes to maternal mortality, especially in very poor communities. "People think that dying in childbirth is not preventable," says Nadira Hayat, Afghanistan's Deputy Minister of Health. "They say it is up to God."
So it seemed before dawn one Sunday in August in Kora Olia, a remote village in Afghanistan's northeastern province of Badakhshan, where maternal mortality is about four times the country's already high rate. Nine months pregnant, Harakatmo, 19, began bleeding heavily. Her husband and mother-in-law were concerned, but the local doctor was far away, and expensive, so they waited. When Harakatmo was still bleeding the next morning, they sent a horseman to fetch a village health worker, but Harakatmo's bleeding continued. Panicked, her husband strapped her to a makeshift stretcher and carried her down the steep track from their home until he found a police truck to take them to a clinic several miles away. The doctor there urged the family to rush Harakatmo to Badakhshan's only hospital, in Faizabad, the provincial capital. Harakatmo's husband hired a ramshackle minivan for the journey--a five-hour ride along rutted dirt roads. On the way, they stopped while Harakatmo's mother-in-law delivered the baby. It was already dead; the tiny corpse was wrapped in a cloth and placed next to Harakatmo. Lying in the hospital that evening, she said she considered herself lucky. "When I left my house this morning, I thought I would die."
More will die if health-care systems are not reformed. In the first half of this year, 889 babies were delivered in Freetown's crumbling Princess Christian Maternity Hospital. During that period, 70 women died giving birth, and about eight more women have died since--an astonishing death rate of about 9%. Yet far from being overstretched, the hospital most days feels desultory, with nurses lingering in near empty wards because people cannot afford to pay for care. Emergency maternity care is supposed to be free in Sierra Leone, but in reality, patients are asked to pay for every item, including cotton swabs, gauze and syringes--this in a country where the average income is about $200 a year. If transfusions are needed, relatives have to donate blood to replace what is used.
More will die if health-care systems are not reformed. In the first half of this year, 889 babies were delivered in Freetown's crumbling Princess Christian Maternity Hospital. During that period, 70 women died giving birth, and about eight more women have died since--an astonishing death rate of about 9%. Yet far from being overstretched, the hospital most days feels desultory, with nurses lingering in near empty wards because people cannot afford to pay for care. Emergency maternity care is supposed to be free in Sierra Leone, but in reality, patients are asked to pay for every item, including cotton swabs, gauze and syringes--this in a country where the average income is about $200 a year. If transfusions are needed, relatives have to donate blood to replace what is used.
One morning I watched a fierce argument between nurses and the relatives of a woman whose unborn baby was already dead inside her. As she sat on a bed awaiting an emergency C-section, her relatives pleaded that they could not afford 400,000 leones (about $135) for the operation. Finally the woman's aunt handed some 250,000 leones (about $85) to a nurse, who counted the banknotes before jamming them into her pocket, explaining to me that the money was "for drugs and to pay the doctor." Since nurses and doctors earn about $150 a month, "the staff is struggling to survive," says Peter Sikana, technical adviser for the U.N. Population Fund in Sierra Leone.
The scribbled notes from nurses in patient records, many of them in school exercise books paid for by relatives, describe their battles to keep women alive. In one such note, a nurse describes a woman, 18, who arrived at the hospital in late July suffering convulsions days after a traditional birth attendant delivered her baby at home. Four days later, the nurse wrote, "All due nursing care rendered but in vain. May her soul rest in peace." Six weeks later, I find the woman's father sitting outside the tiny family home atop an escarpment that overlooks Freetown. Holding the newborn baby, he says his daughter gave birth at home because "the terrain is too rough to reach the hospital." By the time he carried her, half conscious, down the slope to the hospital, she was too sick to be saved. Even for women who give birth in a hospital, survival is no sure thing. Another woman, 20, was admitted in late July in early labor and began having seizures hours after giving birth. Through the night the nurses scrawled frantic notes, including this one at 1:30 a.m.: "Dr. was tried ... via mobile [phone] to no avail." The woman died two hours later. I find her husband grinding peanuts in a Freetown market. "She delivered a healthy baby," he says, showing me a photograph of his wife, a tall woman with a confident, beaming smile.
Hope, for Some
Though many die in hospitals, researchers say the riskiest births are those without any nurse, midwife or doctor in attendance--about 35% of all the world's births. In addition to age-old problems like unclean instruments and poor-quality water--in Sierra Leone, I visited a traditional birth attendant who said she had delivered hundreds of babies in a windowless room in a slum of cramped shanties, with no indoor plumbing--there are new hazards. Afghanistan, for example, has seen growing sales of over-the-counter oxytocin, an injectable hormone that is used to stanch postpartum bleeding and speed labor but that can kill if administered incorrectly. Shamisa, a midwife, says that recently a heavily pregnant woman was brought to her rural Badakhshan clinic in a coma after being given a range of drugs by a pharmacist; both she and the baby died.
After millions of deaths and years of muddled government policies, a groundswell of distress at maternal mortality rates is at last stirring action. At the July G-8 summit of industrialized nations in Hokkaido, Japan, leaders for the first time discussed maternal deaths as a crucial obstacle to development. And there has been progress. Some poor countries have shown rapid results from investments in maternal health: in Honduras, for example, maternal mortality rates dropped about 50% from 1990 to '97 after officials opened scores of rural clinics and trained thousands of midwives. Nepal and Sri Lanka have trained midwives in emergency obstetrics. In the Indian states of Assam, Madhya Pradesh and Orissa, pregnant women now get 1,400 rupees ($32) to spend on whatever maternity services they choose--even a taxi ride to a clinic to give birth. Afghanistan has built 1,465 clinics and trained about 19,000 community health workers since the Taliban was ousted in 2001. The incidence of this worldwide tragedy can be reduced.
Even in Sierra Leone there are glimmers of hope. Aid organizations recently began training traditional birth attendants; several towns now demand that they deliver babies in clinics, where nurses can monitor their work. An hour east of Freetown, I visited a village where local elders had just passed a law requiring all women to give birth at a clinic or face fines of about $8--more than the clinic fee. And the World Bank, UNICEF and the British government's Department for International Development have agreed to jointly invest $262 million over the next three years to overhaul Sierra Leone's shambolic health system. "We will lose two or three more generations," says Geert Cappelaere, UNICEF's representative in Freetown. "But the core message is one of hope."
For some, that hope has come too late. A week after Conteh's death, her relatives gathered to name her baby girl after the dead mother. Weeping, Conteh's parents and her boyfriend hugged and kissed the infant, a bittersweet reminder of their loss. They are not alone. In the time it has taken to read this story, about 20 more women have died in childbirth.
Safety in Numbers
By Jeffrey D. Sachs Thursday, Aug. 28, 2008
AIDS can kill by stigma even when lifesaving medical treatment is available. Until recently, an HIV-infected woman in Sauri, Kenya, was discouraged by her husband, also HIV-infected, from seeking medical care because of his fear of stigma. All too often, death quickly ensues in such cases. But not in this one. Husband and wife were saved by Mary Wasonga, a fellow villager recently trained to be a community health worker by the Millennium Village Project, which is helping more than 400,000 people in dozens of African communities fight extreme poverty, hunger and disease. Wasonga visited the couple and encouraged them to get home-based HIV testing and counseling, and then helped them enroll in a treatment program. Indeed, she and the 82 other community health workers in Sauri have helped thousands of villagers do the same.
These workers also attend to women in labor who need urgent transport to a delivery room, individuals too weakened by cholera to get to a clinic, children with malaria and many others. They do this with one year of on-the-job training that builds on at least some secondary education. That basic training is enough to save lives in vast numbers.
Across Africa, Asia and Latin America, programs are under way that are reminiscent of China's successful use of village-based health workers--the so-called barefoot doctors--a few decades ago, but today's workers have even better health-care tools. The mother of all community health efforts is India's National Rural Health Mission. Initiated by Prime Minister Manmohan Singh and spearheaded by the young, dynamic Minister of Health, Dr. Anbumani Ramadoss, the program has, in just over three years, mobilized more than half a million new community health workers, each known as an ASHA--short for "accredited social health activist," and the Hindi word for hope.
Technology companies and foundations are also joining the effort to support community health workers. Mobile-phone giant Ericsson is empowering these workers with phones and support systems for training, reporting vital statistics and calling ambulances, among other services. In India, Satyam Computer Services and other organizations have partnered with the state government of Andhra Pradesh to provide emergency-response coverage for 80 million people. The Gates Foundation is similarly stepping up its programs of mobile-phone-based health delivery.
In the coming years, community health workers can support a breakthrough in the decisive control of many devastating diseases. The rich world can help through expanded financial support for community health workers and training programs by its universities. And the U.S. can learn something from these programs: we too need to enlist more community workers to help our own poor and vulnerable gain access to a health-care system that far too often is remote and utterly bewildering.
HOW CAN THE INCIDENCE OF MATERNAL MORTALITY BE REDUCED?
In a hospital ward in Freetown, the capital of Sierra Leone, Fatmata Conteh, 26, lay on a bed, having just given birth to her second child. She had started bleeding from a tear in her cervix, the blood forming a pool on the floor below. Two doctors ran in and stitched her up, relatives found blood supplies, and nurses struggled to connect a generator to the oxygen tank. One nurse jammed an intravenous needle into Conteh's arm, while another hooked a bag of blood to a rusted stand, and a third slapped an oxygen mask over her face. In the corner of the room, a tiny baby--3 hours old--lay on a bed, wailing, swaddled in bright-colored African fabric. "Listen! You must feel happy to hear your baby cry," said a nurse, pleading with Conteh to find strength. Three visiting members of a neighborhood church began chanting over Conteh: "Jesus, put blood into this woman! Thank you, Lord!" But as their chants grew louder, the nurses stepped back from the bed. Conteh was dead.
Some version of that scene is repeated around the world about once a minute. Death in childbirth is not just something you find in a Victorian novel. Every year, about 536,000 women die giving birth. In some poor nations, dying in childbirth is so common that almost everyone has known a victim. Take Sierra Leone, a West African nation with just 6.3 million people: women there have a 1 in 8 chance of dying in childbirth during their lifetime. The same miserable odds apply in Afghanistan. In the U.S., by contrast, the lifetime chance that a woman will die in childbirth is about 1 in 4,800; in Britain, 1 in 8,200; and in Sweden, 1 in 17,400. Deaths are heavily weighted to the poorest and most isolated in each country, which means that many politicians remain largely ignorant of the scale of the tragedy. "Often the people in the cities do not know what is happening in their own rural areas," says Sarah Brown, wife of British Prime Minister Gordon Brown and patron of the White Ribbon Alliance, a global advocacy organization that works with governments to lower maternal mortality rates. Brown--who lost a baby 10 days after giving birth in 2001--says that when she tells heads of state and their spouses how many women die in childbirth, "they are aghast."
The Gains Not Made
They have reason to be. For here is the truly ghastly reality of maternal mortality: in 20 years--two decades that have seen spectacular medical breakthroughs--the ratio of maternal deaths to babies born has barely budged in poor countries. To be sure, maternal health has seen advances, with new drugs to treat deadly postpartum bleeding and pregnancy-related anemia. But in many places, such gains are dwarfed by a multitude of problems: scattershot care, low pay for health workers and a scarcity of midwives and doctors. In Mozambique, where women have a 1 in 45 lifetime chance of dying in childbirth, there are just 3 doctors per 100,000 people; in all of Sierra Leone, there are 64 government doctors, only five of whom are gynecologists. Millions of families have never seen a doctor or nurse and give birth at home with traditional birthing helpers, while those who make it to a clinic--some being carried on bicycles or in hammocks--often find patchy electricity, dirty water and few drugs or nurses. Explaining the task of reducing maternal deaths, Sierra Leone's Minister of Health, Saccoh Alex Kabia, who returned home last year after decades of working as a surgeon in Atlanta, says, "The whole health sector is in a shambles."
Many hope that maternal death rates in poor nations will naturally fall over time, as they did in much of the world in the 20th century. They well might. But international officials say governments often lack the political will--as well as the money--to tackle the issue, perhaps because there are too few women politicians to push it. Monir Islam, director of the maternal-health program of the World Health Organization in Geneva, calls governments' low level of investment in reducing deaths in childbirth a "sinful neglect."
In an attempt to jolt officials into action, governments at the U.N. General Assembly in 2000 chose to make a drastic reduction in maternal mortality one of the eight Millennium Development Goals (MDGS)--a series of targets in a program that channels aid to key issues, including education and clean water--to be met by 2015. The MDGS hold people "to a golden standard for progress," says Jamie Drummond, executive director of the antipoverty organization DATA. When world leaders gather in New York City this month to take stock of the MDGS, their speeches are likely to tout the many achievements since 2000: millions more African children now attend school and sleep under mosquito nets; thousands of new water wells have been dug. Yet though maternal health care underpins many other development goals (healthy mothers are more likely to ensure that their children are well fed and educated), the total number of women dying in childbirth has remained virtually unchanged in eight years.
Why? Health officials are clear in their answers. Aside from lack of money and political will, they also face entrenched traditions and fatalistic attitudes to maternal mortality, especially in very poor communities. "People think that dying in childbirth is not preventable," says Nadira Hayat, Afghanistan's Deputy Minister of Health. "They say it is up to God."
So it seemed before dawn one Sunday in August in Kora Olia, a remote village in Afghanistan's northeastern province of Badakhshan, where maternal mortality is about four times the country's already high rate. Nine months pregnant, Harakatmo, 19, began bleeding heavily. Her husband and mother-in-law were concerned, but the local doctor was far away, and expensive, so they waited. When Harakatmo was still bleeding the next morning, they sent a horseman to fetch a village health worker, but Harakatmo's bleeding continued. Panicked, her husband strapped her to a makeshift stretcher and carried her down the steep track from their home until he found a police truck to take them to a clinic several miles away. The doctor there urged the family to rush Harakatmo to Badakhshan's only hospital, in Faizabad, the provincial capital. Harakatmo's husband hired a ramshackle minivan for the journey--a five-hour ride along rutted dirt roads. On the way, they stopped while Harakatmo's mother-in-law delivered the baby. It was already dead; the tiny corpse was wrapped in a cloth and placed next to Harakatmo. Lying in the hospital that evening, she said she considered herself lucky. "When I left my house this morning, I thought I would die."
More will die if health-care systems are not reformed. In the first half of this year, 889 babies were delivered in Freetown's crumbling Princess Christian Maternity Hospital. During that period, 70 women died giving birth, and about eight more women have died since--an astonishing death rate of about 9%. Yet far from being overstretched, the hospital most days feels desultory, with nurses lingering in near empty wards because people cannot afford to pay for care. Emergency maternity care is supposed to be free in Sierra Leone, but in reality, patients are asked to pay for every item, including cotton swabs, gauze and syringes--this in a country where the average income is about $200 a year. If transfusions are needed, relatives have to donate blood to replace what is used.
More will die if health-care systems are not reformed. In the first half of this year, 889 babies were delivered in Freetown's crumbling Princess Christian Maternity Hospital. During that period, 70 women died giving birth, and about eight more women have died since--an astonishing death rate of about 9%. Yet far from being overstretched, the hospital most days feels desultory, with nurses lingering in near empty wards because people cannot afford to pay for care. Emergency maternity care is supposed to be free in Sierra Leone, but in reality, patients are asked to pay for every item, including cotton swabs, gauze and syringes--this in a country where the average income is about $200 a year. If transfusions are needed, relatives have to donate blood to replace what is used.
One morning I watched a fierce argument between nurses and the relatives of a woman whose unborn baby was already dead inside her. As she sat on a bed awaiting an emergency C-section, her relatives pleaded that they could not afford 400,000 leones (about $135) for the operation. Finally the woman's aunt handed some 250,000 leones (about $85) to a nurse, who counted the banknotes before jamming them into her pocket, explaining to me that the money was "for drugs and to pay the doctor." Since nurses and doctors earn about $150 a month, "the staff is struggling to survive," says Peter Sikana, technical adviser for the U.N. Population Fund in Sierra Leone.
The scribbled notes from nurses in patient records, many of them in school exercise books paid for by relatives, describe their battles to keep women alive. In one such note, a nurse describes a woman, 18, who arrived at the hospital in late July suffering convulsions days after a traditional birth attendant delivered her baby at home. Four days later, the nurse wrote, "All due nursing care rendered but in vain. May her soul rest in peace." Six weeks later, I find the woman's father sitting outside the tiny family home atop an escarpment that overlooks Freetown. Holding the newborn baby, he says his daughter gave birth at home because "the terrain is too rough to reach the hospital." By the time he carried her, half conscious, down the slope to the hospital, she was too sick to be saved. Even for women who give birth in a hospital, survival is no sure thing. Another woman, 20, was admitted in late July in early labor and began having seizures hours after giving birth. Through the night the nurses scrawled frantic notes, including this one at 1:30 a.m.: "Dr. was tried ... via mobile [phone] to no avail." The woman died two hours later. I find her husband grinding peanuts in a Freetown market. "She delivered a healthy baby," he says, showing me a photograph of his wife, a tall woman with a confident, beaming smile.
Hope, for Some
Though many die in hospitals, researchers say the riskiest births are those without any nurse, midwife or doctor in attendance--about 35% of all the world's births. In addition to age-old problems like unclean instruments and poor-quality water--in Sierra Leone, I visited a traditional birth attendant who said she had delivered hundreds of babies in a windowless room in a slum of cramped shanties, with no indoor plumbing--there are new hazards. Afghanistan, for example, has seen growing sales of over-the-counter oxytocin, an injectable hormone that is used to stanch postpartum bleeding and speed labor but that can kill if administered incorrectly. Shamisa, a midwife, says that recently a heavily pregnant woman was brought to her rural Badakhshan clinic in a coma after being given a range of drugs by a pharmacist; both she and the baby died.
After millions of deaths and years of muddled government policies, a groundswell of distress at maternal mortality rates is at last stirring action. At the July G-8 summit of industrialized nations in Hokkaido, Japan, leaders for the first time discussed maternal deaths as a crucial obstacle to development. And there has been progress. Some poor countries have shown rapid results from investments in maternal health: in Honduras, for example, maternal mortality rates dropped about 50% from 1990 to '97 after officials opened scores of rural clinics and trained thousands of midwives. Nepal and Sri Lanka have trained midwives in emergency obstetrics. In the Indian states of Assam, Madhya Pradesh and Orissa, pregnant women now get 1,400 rupees ($32) to spend on whatever maternity services they choose--even a taxi ride to a clinic to give birth. Afghanistan has built 1,465 clinics and trained about 19,000 community health workers since the Taliban was ousted in 2001. The incidence of this worldwide tragedy can be reduced.
Even in Sierra Leone there are glimmers of hope. Aid organizations recently began training traditional birth attendants; several towns now demand that they deliver babies in clinics, where nurses can monitor their work. An hour east of Freetown, I visited a village where local elders had just passed a law requiring all women to give birth at a clinic or face fines of about $8--more than the clinic fee. And the World Bank, UNICEF and the British government's Department for International Development have agreed to jointly invest $262 million over the next three years to overhaul Sierra Leone's shambolic health system. "We will lose two or three more generations," says Geert Cappelaere, UNICEF's representative in Freetown. "But the core message is one of hope."
For some, that hope has come too late. A week after Conteh's death, her relatives gathered to name her baby girl after the dead mother. Weeping, Conteh's parents and her boyfriend hugged and kissed the infant, a bittersweet reminder of their loss. They are not alone. In the time it has taken to read this story, about 20 more women have died in childbirth.
Safety in Numbers
By Jeffrey D. Sachs Thursday, Aug. 28, 2008
AIDS can kill by stigma even when lifesaving medical treatment is available. Until recently, an HIV-infected woman in Sauri, Kenya, was discouraged by her husband, also HIV-infected, from seeking medical care because of his fear of stigma. All too often, death quickly ensues in such cases. But not in this one. Husband and wife were saved by Mary Wasonga, a fellow villager recently trained to be a community health worker by the Millennium Village Project, which is helping more than 400,000 people in dozens of African communities fight extreme poverty, hunger and disease. Wasonga visited the couple and encouraged them to get home-based HIV testing and counseling, and then helped them enroll in a treatment program. Indeed, she and the 82 other community health workers in Sauri have helped thousands of villagers do the same.
These workers also attend to women in labor who need urgent transport to a delivery room, individuals too weakened by cholera to get to a clinic, children with malaria and many others. They do this with one year of on-the-job training that builds on at least some secondary education. That basic training is enough to save lives in vast numbers.
Across Africa, Asia and Latin America, programs are under way that are reminiscent of China's successful use of village-based health workers--the so-called barefoot doctors--a few decades ago, but today's workers have even better health-care tools. The mother of all community health efforts is India's National Rural Health Mission. Initiated by Prime Minister Manmohan Singh and spearheaded by the young, dynamic Minister of Health, Dr. Anbumani Ramadoss, the program has, in just over three years, mobilized more than half a million new community health workers, each known as an ASHA--short for "accredited social health activist," and the Hindi word for hope.
Technology companies and foundations are also joining the effort to support community health workers. Mobile-phone giant Ericsson is empowering these workers with phones and support systems for training, reporting vital statistics and calling ambulances, among other services. In India, Satyam Computer Services and other organizations have partnered with the state government of Andhra Pradesh to provide emergency-response coverage for 80 million people. The Gates Foundation is similarly stepping up its programs of mobile-phone-based health delivery.
In the coming years, community health workers can support a breakthrough in the decisive control of many devastating diseases. The rich world can help through expanded financial support for community health workers and training programs by its universities. And the U.S. can learn something from these programs: we too need to enlist more community workers to help our own poor and vulnerable gain access to a health-care system that far too often is remote and utterly bewildering.
Tuesday 9 September 2008
Secondary Postpartum Hemorrhage
1. Infection and retained products co-exist.
2. Under-estimation of hemorrhage is very common as compared to primary PPH, secondary PPH invariably happens at home. and waiting that bleeding will settle on its own is very common.
3. When should women think that they are having secondary PPH. If she is channging vaginal sanitary towels every hour, that menas she has significant hemorrhage. Generally feeling unwell and feeling faint and shivery are other indicators.
4.One common reason for secondary PPH is clot retention. This commonly occurs in women who undergo elective cesarean and have never laboured before. Eventhough one may have completley cleaned the uterine cavity during cesarean, taking all the placental and membranous tissues stiil there's a possibility that she may hemorrhage and collect the clot in the uterine cavity and later present as Secondary PPH. This bring s the argument for cervical dilatation during elective cesarean in women who are not in albour and also to warn them before.
5.The other thing to think about is putting a little dilator or a plastic cannula inside the cervix for few days for the bllod to seep out.
2. Under-estimation of hemorrhage is very common as compared to primary PPH, secondary PPH invariably happens at home. and waiting that bleeding will settle on its own is very common.
3. When should women think that they are having secondary PPH. If she is channging vaginal sanitary towels every hour, that menas she has significant hemorrhage. Generally feeling unwell and feeling faint and shivery are other indicators.
4.One common reason for secondary PPH is clot retention. This commonly occurs in women who undergo elective cesarean and have never laboured before. Eventhough one may have completley cleaned the uterine cavity during cesarean, taking all the placental and membranous tissues stiil there's a possibility that she may hemorrhage and collect the clot in the uterine cavity and later present as Secondary PPH. This bring s the argument for cervical dilatation during elective cesarean in women who are not in albour and also to warn them before.
5.The other thing to think about is putting a little dilator or a plastic cannula inside the cervix for few days for the bllod to seep out.
Indicators of successful instrumental delivery
1. Feeling of both fetal ears - success is almost 100%. feeling of both fetal ears indicates fetal head is sufficiently low. At the same time if one can't feel both fetal ears, it indicates that actually the fetal head is higher than you think. Therefore reconsider the decision to deliver by instrumental.
when you feel the fetal ear, the occiput is just there. In other owrds if you fell the fetal air nar the pubis, then it is OA and ears around the perineum being OP
2. Feeling of one fetal ear, success is about 80%
3. Easy space between the fetal head and side of the pelvis.
4.Nice lubrication of fetal head with amniotic fluid.
5. Perineal bulge.
6. Situation where you cannot feel fetal ears to identify the position is where the mother is in labour for a long time and there is deep coning of head and presence of caput
6. Filling of perineum on both sides with pushing.
7. Anal opening with pushing.
8. Seeing fetal head with pushing without separating the labia.
9. The longer the duration between rupture of membranes and attempt to instrumental delivery, the higher the failure rate.
10. Presence of caput and moulding and hence obscuring to define the fetal position.
11.
Creating Sympohony Band Wagon atompshere, i.e, making sure that she is effectively contracting and are regular, effectively pushing, if not starting synto and training her to effective pushing and observing descent with pushing and seeing how many finger creases it descends.
when you feel the fetal ear, the occiput is just there. In other owrds if you fell the fetal air nar the pubis, then it is OA and ears around the perineum being OP
2. Feeling of one fetal ear, success is about 80%
3. Easy space between the fetal head and side of the pelvis.
4.Nice lubrication of fetal head with amniotic fluid.
5. Perineal bulge.
6. Situation where you cannot feel fetal ears to identify the position is where the mother is in labour for a long time and there is deep coning of head and presence of caput
6. Filling of perineum on both sides with pushing.
7. Anal opening with pushing.
8. Seeing fetal head with pushing without separating the labia.
9. The longer the duration between rupture of membranes and attempt to instrumental delivery, the higher the failure rate.
10. Presence of caput and moulding and hence obscuring to define the fetal position.
11.
Creating Sympohony Band Wagon atompshere, i.e, making sure that she is effectively contracting and are regular, effectively pushing, if not starting synto and training her to effective pushing and observing descent with pushing and seeing how many finger creases it descends.
Friday 5 September 2008
Management of Postpartum Hypertension
1.If recheck BP is > or = 160/110, then recheck in 15minutes, if still the same, then, give
a. Emergency Nifedipine 10mg OD and then start
b. Oxprenolol 40mg QDS and can increase to 120mg QDS, if still not
controlled,
c. Nifedipine SR 10mg BD
d. can increase Nifedipine SR to 10mg QDS
e. can increase Nifedipine SR to 20mg QDS
a. Emergency Nifedipine 10mg OD and then start
b. Oxprenolol 40mg QDS and can increase to 120mg QDS, if still not
controlled,
c. Nifedipine SR 10mg BD
d. can increase Nifedipine SR to 10mg QDS
e. can increase Nifedipine SR to 20mg QDS
Tuesday 2 September 2008
Urinary Incontinence_ NICE helpful hints
- Bladder diaries should be used in the initial assessment of women with UI or OAB. Women should be encouraged to complete a minimum of 3 days of the diary covering variations in their usual activities, such as both working and leisure days.
A trial of supervised pelvic floor muscle training of at least 3 months’ duration should be offered as first-line treatment to women with stress or mixed UI.
Immediate release non-proprietary oxybutynin should be offered to women with OAB or mixed UI as first-line drug treatment if bladder training has been ineffective. If immediate release oxybutynin is not well tolerated, darifenacin, solifenacin, tolterodine, trospium, or an extended release or transdermal formulation of oxybutynin should be considered as alternatives. Women should be counselled about the adverse effects of antimuscarinic drugs.
Bartter Syndrome and pregnancy
Bartter's syndrome and pregnancy
Ref: European Journal of Obstetrics & Gynecology and Reproductive Biology 121 (2005) 117–123
We found a 33 year-old woman, gravida 3 Para 1-0-1-1, showing hyperemesis, diarrhea and fever at 9 weeks gestation. Three years before she had a vaginal delivery of a healthy infant, born at term after normal pregnancy. She also presented a second trimester abortion.
With the diagnosis of gastroenteritis she was admitted to hospital. Routine analysis, including electrolytes, showed severe hypokalemia (1.5 mmol/L). The diagnosis of Bartter's syndrome was based on increased sodium and potassium fractional excretion, and the family history of a brother diagnosed and treated for classic Bartter's syndrome of adult onset subsequently revealed through the accurate collection of medical history data.
She was started on potassium replacement therapy to maintain serum levels at 2.5 mmol/L and was discharged and treated on an outpatient basis. She was closely followed up with potassium level determinations in our prenatal clinic until 19 weeks gestation when she presented a viral infection and required hospital admission. Serum potassium decreased to 1.7 mmol/L and was corrected to normal range with intravenous potassium (80 mmol/day). After discharge she was maintained on oral supplementation.
Serial ultrasonographic examination during pregnancy showed adequate intrauterine growth and normal amounts of amniotic fluid. Serum potassium was stabilized with oral potassium without needing spironolactone therapy to control symptoms. However, an increasing demand for potassium supplements was documented.
At 37 gestational weeks she presented a decrease in serum potassium and sodium levels (2.1 and 133 mmol/L), respectively. Pregnancy termination was proposed by prostaglandin induction. She had a vaginal delivery of a male infant weighing 3200 g with normal Apgar scores. Postpartum potassium controls at 24, 48, and 72 h were all over 2.4 mmol/L. The infant did not present the renal disorder and both were discharged normally. Because of maternal breastfeeding, ibuprophene and amiloride were used as treatment.
Bartter's syndrome is a rare recessive autosomal disorder characterized by hypokalemia secondary to renal potassium wasting, metabolic alkalosis, normal to low blood pressure and increased production of renal prostaglandins. Recent studies have described mutations in genes encoding transport proteins important in sodium and chloride reabsorption in the thick ascending limb of the loop of Henle. Different phenotypes of Bartter's syndrome have been recognized. Antenatal Bartter's syndrome is characterized by polyhidramnios and premature delivery while the classic Bartter's syndrome usually presents during childhood, adolescence, or in women in pregestational age as weakness or muscle cramps.
Bartter's syndrome, although extremely rare in pregnancy, requires prompt recognition and careful management as it may have significant maternal and neonatal implications [1], and should be suspected in case of hypokalemia without other origin.
There are few cases reported in literature of pregnant women with Bartter's syndrome of childhood onset [2], [3] and [4], and we have found a case of a pregnant diagnosed only during the treatment for preterm delivery in third trimester [5], but not either during the first part of pregnancy or during the course of the third pregnancy.
An increasing demand of potassium supplements is usually required in the treatment. Sometimes the use of spironolactone is needed as well as prostaglandin synthetase inhibitors to reduce potassium wasting and to control symptoms. Since the syndrome was diagnosed during the first term of pregnancy, using other treatments was not considered due to a possible repercussion on maternal and fetal hemodinamic. Our patient managed to reach 37th week gestation only with oral potassium supplements maintaining acceptable levels of serum potassium considered safe and well tolerated.
Absence of pregnancy complications such as polyhydramnios indicated that the fetus was unlikely to be affected. Although it seems patients with this syndrome may have an increased risk of developing intrauterine growth retardation [2], the fetus presented an adequate growth.
2. Bartter's syndrome and pregnancy
Ref: European Journal of Obstetrics & Gynecology and Reproductive Biology 82 (1999) 17–18
1. Introduction
Bartter's syndrome (BS) is a rare autosomal recessive inherited renal tubular disorder characterized by severe hypokalemia, metabolic alkalosis, hyperaldosteronism and normal blood pressure. Because of its rarity, reports on pregnancy associated to this disease are scant, and maternal and fetal risks are still unknown.
2. Case report
A 31-year-old white pregnant woman with Bartter's syndrome was referred to the Maternal-Fetal Unit of the Department of Obstetrics and Gynecology, Santa Maria University Hospital, Lisbon, in October 1996 with a 9-week gestation. She had a long standing history of frequent vomiting, polyuria, polydipsia, growth retardation and learning difficulties, until she was presented to the Pediatric Nephrology Unit at the age of 19 years. She had a thin distinctive appearance with a triangular face, emotional lability, mild mental retardation (IQ 61%), hyperreflexia, intentional tremor and slightly spastic gait. Cortical atrophy was noted at magnetic resonance image. On initial presentation, hypokalemia (2.4 mEq/l), hypochloremia (87 mEq/l), metabolic alkalosis (HCO3 32 mEq/l) and increased urinary calcium/creatinine ratio (1.4 mmol/mmol) were noted, with normal serum calcium and magnesium. Renal ultrasound showed extensive medullar nephrocalcinosis. The glomerular filtration rate was low (70 ml/min/1.73 m2).
After extensive testing the diagnosis of Bartter's syndrome was defined based on the above mentioned electrolytic alterations and increased plasma renin (35.4 ng/min/h; normal=1.8–6.7) and aldosterone (736 pg/ml; normal=70–295) with normal blood pressure, increased urinary potassium excretion (CK/100 ml GFR 37.8%) and a low fractional distal reabsorption of chloride (CH2O/CH2O+Cl=58.7%) during hypotonic saline diuresis (performed according to the protocol of Rodriguez Soriano [1]). Treatment with potassium chloride and indomethacin (2 mg/kg/day) was started with clinical and laboratorial improvement. She had her growth spurt and menarche by the age of 21 years. When she was 23 years old, her weight was 44 kg and her height 145 cm. Later, in 1995, genetic study (performed by the Boyer Center for Molecular Medicine of Yale University School of Medicine) showed a mutation in the Na-K-2Cl cotransporter (NKCC2).
Indomethacin was intentionally discontinued 6 months before pregnancy and she was put only on oral potassium supplementation. Diuresis increased from 4.5 to 6 l/day and urinary calcium creatinine rate from 0.4 to 0.6 (mg/mg). Throughout the first and second trimesters of pregnancy the daily dose of oral potassium chloride supplementation was progressively increased (320 to 480 mEq/day). Although she had no clinical complaints, hypokalemia was frequently found with levels of 2.5–3.0 mEq/l. In the third trimester potassium serum levels stabilized at levels of 3.3–3.7 mEq/l with a regimen of 480 mEq potassium chloride daily. During pregnancy, blood pressure and plasma creatinine (90–95 mmol/l) remained within normal levels. At 29 weeks, gestational diabetes mellitus was diagnosed and controlled only with dietary measures. Follow-up sonographic examination demonstrated adequate fetal growth. At 38 weeks a cesarean delivery was done for breech presentation. The male infant weight was 3850 g and the Apgar scores were 8 and 9 at the 1st and 5th min, respectively. At birth his serum potassium was normal (3.8 mEq/l) and was discharged with the mother on the fifth day after delivery.
Maternal medication at discharge was 480 mEq potassium chloride per day. Over the next 6 weeks the daily dose was reduced and indomethacin was added.
3. Comments
In BS, clinical disease results from defective renal reabsorption of sodium chloride in the ascending thick limb of Henle's loop [1, 2, 3]. There are few reports of pregnancy in women with BS but fetal risks do not seem to be increased [4, 5]. The mainstay of medical management of these patients, especially during pregnancy, is close monitoring of potassium serum levels since maintenance of normal levels is difficult, probably due to the increase of potassium needs. Indomethacin, the drug most frequently used in these patients, should be avoided in gestation, since oligohydramnios and/or fetal renal failure may occur. Potassium sparing diuretics (amiloride and spironolactone) have been used during pregnancy in patients with BS without hazards to the fetus [5, 6, 7] however undervirilization in the male fetus induced by spironolactone and its natriuretic effect may increase the risk of volume depletion.
In our patient, an almost normal serum potassium level was achieved in the third trimester only with oral potassium supplementation and no fetal growth retardation was noted despite the maternal episodes of hypokalemia. Since the potential ominous effects of the treatment on the fetus are a clinical concern the outcome of our case allows the conclusion that conservative therapy with potassium chloride supplementation alone may be effective and safe in the management of this subtype of maternal Bartter's syndrome. In fact, three genetic defects have been described in BS: mutation in the Na-K-2Cl cotransporter (type I BS), in ROMK 1 (type II BS) and recently in ClCNKB (type III BS) [8]. Although all of these patients have the same clinical features of hypokalemic alkalosis, salt wasting, normal serum magnesium and normal or increased calciuria, nephrocalcinosis was only found in patients who have the ROMK or the Na-K-2Cl cotransporter mutations, as in our patient.
Ref: European Journal of Obstetrics & Gynecology and Reproductive Biology 121 (2005) 117–123
We found a 33 year-old woman, gravida 3 Para 1-0-1-1, showing hyperemesis, diarrhea and fever at 9 weeks gestation. Three years before she had a vaginal delivery of a healthy infant, born at term after normal pregnancy. She also presented a second trimester abortion.
With the diagnosis of gastroenteritis she was admitted to hospital. Routine analysis, including electrolytes, showed severe hypokalemia (1.5 mmol/L). The diagnosis of Bartter's syndrome was based on increased sodium and potassium fractional excretion, and the family history of a brother diagnosed and treated for classic Bartter's syndrome of adult onset subsequently revealed through the accurate collection of medical history data.
She was started on potassium replacement therapy to maintain serum levels at 2.5 mmol/L and was discharged and treated on an outpatient basis. She was closely followed up with potassium level determinations in our prenatal clinic until 19 weeks gestation when she presented a viral infection and required hospital admission. Serum potassium decreased to 1.7 mmol/L and was corrected to normal range with intravenous potassium (80 mmol/day). After discharge she was maintained on oral supplementation.
Serial ultrasonographic examination during pregnancy showed adequate intrauterine growth and normal amounts of amniotic fluid. Serum potassium was stabilized with oral potassium without needing spironolactone therapy to control symptoms. However, an increasing demand for potassium supplements was documented.
At 37 gestational weeks she presented a decrease in serum potassium and sodium levels (2.1 and 133 mmol/L), respectively. Pregnancy termination was proposed by prostaglandin induction. She had a vaginal delivery of a male infant weighing 3200 g with normal Apgar scores. Postpartum potassium controls at 24, 48, and 72 h were all over 2.4 mmol/L. The infant did not present the renal disorder and both were discharged normally. Because of maternal breastfeeding, ibuprophene and amiloride were used as treatment.
Bartter's syndrome is a rare recessive autosomal disorder characterized by hypokalemia secondary to renal potassium wasting, metabolic alkalosis, normal to low blood pressure and increased production of renal prostaglandins. Recent studies have described mutations in genes encoding transport proteins important in sodium and chloride reabsorption in the thick ascending limb of the loop of Henle. Different phenotypes of Bartter's syndrome have been recognized. Antenatal Bartter's syndrome is characterized by polyhidramnios and premature delivery while the classic Bartter's syndrome usually presents during childhood, adolescence, or in women in pregestational age as weakness or muscle cramps.
Bartter's syndrome, although extremely rare in pregnancy, requires prompt recognition and careful management as it may have significant maternal and neonatal implications [1], and should be suspected in case of hypokalemia without other origin.
There are few cases reported in literature of pregnant women with Bartter's syndrome of childhood onset [2], [3] and [4], and we have found a case of a pregnant diagnosed only during the treatment for preterm delivery in third trimester [5], but not either during the first part of pregnancy or during the course of the third pregnancy.
An increasing demand of potassium supplements is usually required in the treatment. Sometimes the use of spironolactone is needed as well as prostaglandin synthetase inhibitors to reduce potassium wasting and to control symptoms. Since the syndrome was diagnosed during the first term of pregnancy, using other treatments was not considered due to a possible repercussion on maternal and fetal hemodinamic. Our patient managed to reach 37th week gestation only with oral potassium supplements maintaining acceptable levels of serum potassium considered safe and well tolerated.
Absence of pregnancy complications such as polyhydramnios indicated that the fetus was unlikely to be affected. Although it seems patients with this syndrome may have an increased risk of developing intrauterine growth retardation [2], the fetus presented an adequate growth.
2. Bartter's syndrome and pregnancy
Ref: European Journal of Obstetrics & Gynecology and Reproductive Biology 82 (1999) 17–18
1. Introduction
Bartter's syndrome (BS) is a rare autosomal recessive inherited renal tubular disorder characterized by severe hypokalemia, metabolic alkalosis, hyperaldosteronism and normal blood pressure. Because of its rarity, reports on pregnancy associated to this disease are scant, and maternal and fetal risks are still unknown.
2. Case report
A 31-year-old white pregnant woman with Bartter's syndrome was referred to the Maternal-Fetal Unit of the Department of Obstetrics and Gynecology, Santa Maria University Hospital, Lisbon, in October 1996 with a 9-week gestation. She had a long standing history of frequent vomiting, polyuria, polydipsia, growth retardation and learning difficulties, until she was presented to the Pediatric Nephrology Unit at the age of 19 years. She had a thin distinctive appearance with a triangular face, emotional lability, mild mental retardation (IQ 61%), hyperreflexia, intentional tremor and slightly spastic gait. Cortical atrophy was noted at magnetic resonance image. On initial presentation, hypokalemia (2.4 mEq/l), hypochloremia (87 mEq/l), metabolic alkalosis (HCO3 32 mEq/l) and increased urinary calcium/creatinine ratio (1.4 mmol/mmol) were noted, with normal serum calcium and magnesium. Renal ultrasound showed extensive medullar nephrocalcinosis. The glomerular filtration rate was low (70 ml/min/1.73 m2).
After extensive testing the diagnosis of Bartter's syndrome was defined based on the above mentioned electrolytic alterations and increased plasma renin (35.4 ng/min/h; normal=1.8–6.7) and aldosterone (736 pg/ml; normal=70–295) with normal blood pressure, increased urinary potassium excretion (CK/100 ml GFR 37.8%) and a low fractional distal reabsorption of chloride (CH2O/CH2O+Cl=58.7%) during hypotonic saline diuresis (performed according to the protocol of Rodriguez Soriano [1]). Treatment with potassium chloride and indomethacin (2 mg/kg/day) was started with clinical and laboratorial improvement. She had her growth spurt and menarche by the age of 21 years. When she was 23 years old, her weight was 44 kg and her height 145 cm. Later, in 1995, genetic study (performed by the Boyer Center for Molecular Medicine of Yale University School of Medicine) showed a mutation in the Na-K-2Cl cotransporter (NKCC2).
Indomethacin was intentionally discontinued 6 months before pregnancy and she was put only on oral potassium supplementation. Diuresis increased from 4.5 to 6 l/day and urinary calcium creatinine rate from 0.4 to 0.6 (mg/mg). Throughout the first and second trimesters of pregnancy the daily dose of oral potassium chloride supplementation was progressively increased (320 to 480 mEq/day). Although she had no clinical complaints, hypokalemia was frequently found with levels of 2.5–3.0 mEq/l. In the third trimester potassium serum levels stabilized at levels of 3.3–3.7 mEq/l with a regimen of 480 mEq potassium chloride daily. During pregnancy, blood pressure and plasma creatinine (90–95 mmol/l) remained within normal levels. At 29 weeks, gestational diabetes mellitus was diagnosed and controlled only with dietary measures. Follow-up sonographic examination demonstrated adequate fetal growth. At 38 weeks a cesarean delivery was done for breech presentation. The male infant weight was 3850 g and the Apgar scores were 8 and 9 at the 1st and 5th min, respectively. At birth his serum potassium was normal (3.8 mEq/l) and was discharged with the mother on the fifth day after delivery.
Maternal medication at discharge was 480 mEq potassium chloride per day. Over the next 6 weeks the daily dose was reduced and indomethacin was added.
3. Comments
In BS, clinical disease results from defective renal reabsorption of sodium chloride in the ascending thick limb of Henle's loop [1, 2, 3]. There are few reports of pregnancy in women with BS but fetal risks do not seem to be increased [4, 5]. The mainstay of medical management of these patients, especially during pregnancy, is close monitoring of potassium serum levels since maintenance of normal levels is difficult, probably due to the increase of potassium needs. Indomethacin, the drug most frequently used in these patients, should be avoided in gestation, since oligohydramnios and/or fetal renal failure may occur. Potassium sparing diuretics (amiloride and spironolactone) have been used during pregnancy in patients with BS without hazards to the fetus [5, 6, 7] however undervirilization in the male fetus induced by spironolactone and its natriuretic effect may increase the risk of volume depletion.
In our patient, an almost normal serum potassium level was achieved in the third trimester only with oral potassium supplementation and no fetal growth retardation was noted despite the maternal episodes of hypokalemia. Since the potential ominous effects of the treatment on the fetus are a clinical concern the outcome of our case allows the conclusion that conservative therapy with potassium chloride supplementation alone may be effective and safe in the management of this subtype of maternal Bartter's syndrome. In fact, three genetic defects have been described in BS: mutation in the Na-K-2Cl cotransporter (type I BS), in ROMK 1 (type II BS) and recently in ClCNKB (type III BS) [8]. Although all of these patients have the same clinical features of hypokalemic alkalosis, salt wasting, normal serum magnesium and normal or increased calciuria, nephrocalcinosis was only found in patients who have the ROMK or the Na-K-2Cl cotransporter mutations, as in our patient.
Sunday 31 August 2008
Couvelaire uterus
http://en.wikipedia.org/wiki/Couvelaire_uterus
28/40 kn0wn t0 have retroplacental bleed at 18/40. of approximately of 8cms in size presented with bleeding and the bleeding got settled up unitl 28 weeks of gestation. At 28 weeks she presented with bleeding and pain. CTG was normal. She had a scan which showed retroplacental clot and normally grown fetus and normal liqour volume. During the two days of her admission this tiem she kept going to the toilet more frequently to open her bowels. At one stage suddenly the CTG became abnormal within a span of 10 minutes with a tachycardic baseline and decrease in the variability. A decision for cesarean delivery taken. During cesarean section she was found to have hemoperitoneum
28/40 kn0wn t0 have retroplacental bleed at 18/40. of approximately of 8cms in size presented with bleeding and the bleeding got settled up unitl 28 weeks of gestation. At 28 weeks she presented with bleeding and pain. CTG was normal. She had a scan which showed retroplacental clot and normally grown fetus and normal liqour volume. During the two days of her admission this tiem she kept going to the toilet more frequently to open her bowels. At one stage suddenly the CTG became abnormal within a span of 10 minutes with a tachycardic baseline and decrease in the variability. A decision for cesarean delivery taken. During cesarean section she was found to have hemoperitoneum
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