133. Takeo Two: Baby David

Within a few days of conception the placenta invades the uterine wall.  Maternal and fetal blood vessels don't directly connect,  but as tiny capillaries from each system develop side to side, oxygen, water, nutrients and (from the fetus) waste products easily pass back and forth through thin vessel walls. 

It appears that early malfunction of this process may be the root cause of preeclampsia, the major cause of maternal mortality in the U.S. and second in the developing world (after hemorrhage). Symptoms usually don't appear until the increasing demands of late pregnancy stress the system.  The disease process can involve different organs: brain (seizures), liver (bleeding disorders), kidney (swelling, high blood pressure), and placenta (poor fetal growth).

So when 27 year old Kaun arrived at the Takeo hospital at 36 weeks with high blood pressure (173/117), massive swelling (lower legs looking like elephant trunks), Kaun's diagnosis was easy and the treatment straightforward: immediate cesarean delivery. 

Linda in grandma's arms; David is with his mother

She had been experiencing the swelling for a couple of weeks, but hadn't come in, we think because of she couldn't afford to.  Perhaps she heard that our free clinic was in town, so she came on the first day.  She did have some prenatal care, enough to know she had twins and hypertension, but did not have access (for whatever the reason) that either diagnosis would warrant. The surgery went well with the delivery of a 2.5 pound girl and a 4 pound boy.

During the first night Kaun experienced seizures with no apparent harm.  In the U.S. intravenous magnesium protects against seizures, given continuously from diagnosis until 24 hours postpartum; she received all that we had in a single dose, only finding out later that the hospital itself had magnesium, which the local night nurses knew and used, though only in response to seizures, not as a preventative measure.

After the first night, Kaun's blood pressure stabilized, her urine output increased (necessary to get rid of the extra fluid before it ends up in the lungs). Lower leg swelling continued, but with the placement of compression stockings and truly elevated feet (not just propped up in bed but higher than the level of the heart), swelling dramatically decreased.

Dad and Auntie with Twins

The main issue for the kids is not prematurity (36 weeks is about average for twins), but growth. At 2.5 pounds, baby Nancy had severe intrauterine growth retardation (IUGR) --the placenta just wasn't delivering. Once born and no longer dependent on placenta, IUGR kids should do okay. But feeding can be a problem. It takes a lot of energy to suckle, and 2.5 pound babies don't always have the energy reserves. They consume more calories nursing then they take in so need to be feed with tubes, eye droppers or gravity fed bottles. But miracles (a word I don't use easily) happen, and a few days later Mom, Dad and babies went home, all doing well. 

Kaun asked one of the nurses to name the babies, the result being David and Nancy, after the doctor and midwife who performed the surgery.  She also asked how much they owed us.  Nothing we said, and to carry this point further gave her some money so the babies could be seen in follow-up in a few days, otherwise they would not be able to do so. What else can you do?