By Tsitsi Matope
MASERU — When a 34-year-old heavily-pregnant mother was recently rushed to the Queen ‘Mamohato Memorial Hospital labour ward, it had already been medically confirmed she was carrying twins.
However, after delivering a baby boy and the placenta was retrieved minutes later, two midwives and Dr Muluken Tesfaye Eshete, the obstetrician and gynaecologist, were momentarily stunned after discovering the other baby was missing in the uterus.
“The baby had to be somewhere because our previous scans had shown the mother had twins. In some cases, investigative modalities might fail to show the other baby, which can surprise us during an operation or after one baby has been delivered.
“But in this case, we were certain there were two babies because our scans had shown both babies,” Dr Eshete said in an interview at the state-of-the-art Queen ‘Mamohato Memorial Hospital, popularly known as Tšepong, last Friday.
However, another scan confirmed the other baby was still in its mother’s body but in the abdomen, outside the womb.
“Hours after the first baby had been safely delivered we had to operate on the mother and managed to bring out the other baby. Since the baby had developed outside the uterus he only weighed 1.6 kilogrammes, much less than the other twin who weighed 2.6 kilogrammes,” Dr Eshete said.
The woman had what Dr Eshete referred to as “heterotopic pregnancy”, which is another form of abnormality that occurs when the fertilised egg (zygote) somehow fails to move from the fallopian tubes into the uterus.
In some cases, the zygote starts to grow in the fallopian tube, or can move into the abdomen or cervix area. When this happens, as Dr Eshete explained, the pregnancy is medically referred to as ectopic pregnancy.
According to Dr Eshete, ectopic pregnancies are a rare phenomenon, adding however that there is a worrying trend in Lesotho, where ectopic cases have been increasing over the past year.
“We are surprised by the increase in abdominal pregnancies. Since last year, we have managed 18 cases of women aged between 18 and 30 years.”
Out of the 18 cases, a woman who had a baby developing in her stomach with the placenta attached to the liver, died early this year. Her 37-week-old baby, however, survived the operation.
In another case, a baby growing in its mother’s abdomen died after the operation to deliver the baby due to abnormalities, with the woman, however, surviving the surgery.
According to Dr Eshete, globally, one in every five mothers who dies during pregnancy dies due to ectopic-related complications every year.
“The fatality that is associated with ectopic pregnancy is what makes attending neonatal clinic by pregnant mothers, important. This enables early detection of any abnormality and allows appropriate decisions based on the circumstances. In most cases, fatalities increase with the advancement of the pregnancy,” Dr Eshete said.
A baby growing in the fallopian tube, for example, cannot exceed eight weeks before the tube ruptures and causes bleeding which, if not managed early in hospital, could kill the mother, Dr Eshete further explained.
He attributed the increase in cases of abdominal pregnancies to, among other factors, a high Human Immunodeficiency Virus (HIV) prevalence rate among women, a history of Pelvic Inflammation Disease (PID) and other sexually transmitted diseases, ineffective treatment of Sexually Transmitted Infections (STIs), and recurring STIs.
“The PID is the most common risk-factor and this could be because some women may fail to detect the symptoms until the infection has spread to vital parts of the reproductive system,” Dr Eshete said, adding symptoms include mild abdominal pain, suspicious genital discharge and fever.
Dr Eshete also said recurring STIs increase chances of scars in the reproductive system, especially in the fallopian tubes, adding: “When that happens, the scars can negatively affect the normal fertilisation processes, which include the movement of the fertilised egg into the uterus.”
Lesotho has one of the highest maternal and under-fives mortality rates in Southern Africa, with the country’s latest Demographic and Health Survey (2009) indicating that for every 100 000 live births, 1 155 mothers die and 117 under-five babies die per 1 000 live births.
High death rates are usually attributed to poor service delivery in some parts of the country and inaccessibility of services in the hard-to-reach areas — a situation that forces some mothers to deliver at home.
However, a high HIV-prevalence rate among women and poor or non-treatment of sexually transmitted diseases, according to Dr Eshete, also compromise the health of some women and their ability to fall pregnant “normally” and sustain the pregnancy until delivery.
Some mothers, both in good and poor health, also die six weeks after delivery often due to sepsis and according to Dr Eshete, over the last 20 months, post partum hemorrhage had been noticed to be the most common cause of death among mothers.
“Bleeding to death after giving birth is the number one killer of mothers, and the causes of this loss of blood range from genital tear, to when the placenta fails to be expelled after delivery, disabling the uterus from contracting.”
The second cause of deaths among expecting women is pregnancy- induced hypertension (high blood pressure), followed by post partum infections, illegal abortion and obstructed labour, Dr Eshete said.
“Obstructed labour occurs when the uterus ruptures and it’s common among women who deliver at home,” Eshete explained.
However, a visit to Queen ‘Mamohato’s maternity ward last Friday by the Lesotho Times, showed a significant number of mothers suffer from pregnancy-induced hypertension (also known as pre-eclampsia).
Two mothers confirmed they had previously lost their babies as a result of hypertension because they had associated their discomfort with pregnancy.
‘Mateboho Sekoai, 32, who is three months pregnant, said she was rushed to Tšepong from Lithoteng Clinic on Wednesday last week, after her blood pressure suddenly shot-up.
“This is my fourth pregnancy after one live child and two stillborn babies,” she said.
She explained it took her “a long time” before she realised hypertension was responsible for the death of her full-term babies.
“This is the first time I have been diagnosed with high blood pressure. I was attending clinic in Butha-Buthe when I had the two still births. I am having some of the symptoms I experienced in the previous pregnancies which include blurred vision, headaches, abdominal pain and decrease in urine production,” she said.
Malebohang Nteso, 35, who was admitted at the hospital when she was four months pregnant, said she lost her first pregnancy over a year ago and was not aware she had pregnancy induced hypertension until it was too late to save the baby.
“I was sick for several weeks and had not received medical attention because I had thought what I experienced were normal pains associated with the pregnancy. This time around I am not taking any chances,” she said.
Lebohang Tikiso, 19, is one of the lucky mothers after she was properly diagnosed with hypertension in the early stages of her pregnancy.
Due to the close monitoring she received at the hospital, Tikiso had not experienced much difficulty until September 26 when she was rushed to Tšepong hospital with labour pains.
“The doctor who attended me said my blood pressure was too high and had to immediately operate to save me and my son. I am lucky because my pregnancy was at an advanced stage,” she said.
However, according to Dr Eshete, the hospital was trying to educate every member of the public to be health-conscious.
“When people feel sickly, they should immediately seek help at various health centres. It is unfortunate that with improved care and facilities that now help us to diagnose ailments that were once difficult to detect, some people still die or develop complications because they don’t seek medical intervention on time.”
On pregnancy-induced hypertension, Dr Eshete said although its causes after 20 weeks of gestation are not known, treatment is possible to prevent fatalities.
The condition, Dr Eshete said, could be detected when urine test results indicate the presence of protein.
“The condition deprives nutrients and oxygen to the baby and as a result, affects proper growth of the baby. It can also affect most of the mother’s vital organs such as lungs, eyes and the liver especially if the pre-eclampsia condition is not treated to prevent the secondary condition, eclampsia, which can cause seizures and strokes.”
Dr Eshete explained the condition was common among mothers expecting more than one baby (twins, triplets or more), first pregnancy when a woman is above 30 years of age and in teenage pregnancies.
In some cases, the hospital attends to mothers as young as 12 years of age, Dr Eshete said.
“Two months ago, we operated on a 12-year-old girl and it is such cases that can be difficult and need close management to control hypertension and other complications that can be triggered by the tender age.”
Globally, Dr Eshete said, between six and 10 percent of pregnancies are complicated by hypertension.
Most healthcare professionals, he added, are usually faced with a management dilemma when presented with women suffering various levels of hypertension.
“The difficulty in that early delivery of the baby is a treatment modality to prevent progression to secondary hypertension (eclampsia).
“This could mean losing the baby to save the mother’s life. Another option would be to admit the patient to control all the symptoms for a few weeks and allow the baby to grow.”
On the other hand, Dr Eshete said the condition of women who suffer from chronic hypertension can worsen when they become pregnant.
“They might suffer from the ‘super imposed pre-eclampsia’ and the difference with pregnancy-induced hypertension is that no protein is found in the urine. The condition usually stabilises six weeks after delivery,” he said.
