A Goat and a Bag of Peanuts

“I only have a goat and a bag of peanuts. Can you save my wife?” When I say that almost everything is different here as it regards to medical care, I mean, really almost everything: the language, the terminology and classifications used, the medications and treatments available, the depth of poverty, the lack of a safety net for the poor, etc. As someone who was supposed to come in as an “expert,” I am so thankful that I am being given the opportunity these first weeks/month(s) to do more observation and learning of the system, rather than being primarily responsible or acting alone. Stories are better than abstract principles, so read on…

One of the differences- this is a main road leading to the hospital. Some patients are carried as in this photo (a woman in labor who is sitting on a wooden chair which is tied up to a pole that is carried by two men on their shoulders), others come by motorcycle or pedal bike, and most walk.

I met her in the ultrasound clinic room. She had been sent from the local health zone prenatal clinic, which is run by nurses, to get an ultrasound because her uterus was not growing in size as expected and she reported no fetal movement for 3 days. During the ultrasound, I confirmed the dreaded news—that her baby had died in her womb at almost 7 months. But something else was not quite right. Despite the abnormalities that can be seen on ultrasound with a fetus which has not had a heartbeat for an unknown amount of time, something about this was just unclear. Something was blocking the cervical canal. The quality of ultrasound is a bit different than in the US, but I could see that the placenta was in the front and low in the pelvis. The placenta was potentially blocking the cervix, which is bad news for someone who has had more than one previous C-section. The risk that the placenta has invaded the muscle of the uterus within the previous incision site is >60%, which can mean a hysterectomy would be necessary.

I normally avoid doing a cesarean section in cases where the fetus has died in the womb, but I found there was no choice in this case. I mentally prepared myself for a cesarean section with hysterectomy, just in case. Upon hearing the news, the patient was understandably distraught, but even more so after I told her she needed an operation. Both she and her husband were in tears. Both looked chronically malnourished, with very short stature and thin frames. The husband looked at me, and understanding the seriousness of the situation, said very sincerely, “I have only a goat and a bag of peanuts. Can you save my wife?”

Because this was an urgent (and not by choice) operation, we were able to proceed despite their inability to pay in full prior to the operation ($80-120 is a typical surgical fee). As with most surgeries, though, the family is required to find someone to donate blood, hopefully with a matching blood type. Sometimes the medical students and residents volunteer to donate money or blood to their patients. It is not uncommon to have a post-operative patient make the decision between an antibiotic and pain medication! Just as heart-wrenching as it is to see this, it is equally hard to see starving mamas selling—not eating—the little food that they have grown during this dry season so that they can pay for things like school fees.

After praying briefly for the operation and the health of this mama, we opened her abdomen. It was a mess. As with the ultrasound, nothing was clear, except thankfully, that the bladder was not involved (as can sometimes be the case when the placenta comes through a prior incision). The incision into the “uterus” was our first clue as to what the situation actually was. The “uterus” broke open just like one might expect the bag of waters to break… because it was the bag of waters (amniotic sac)!  The placenta in the front had masked the fact that there was no uterine muscle surrounding the amniotic sac. In actuality, what was “blocking the cervix” was in fact the uterus itself, empty. It is a very rare form of ectopic (outside the uterus) pregnancy called an abdominal pregnancy. Usually it is caused by a fertilized egg that implants in the tubes, which after it grows big enough, breaks open the tube and then re-implants somewhere if it finds a good blood supply. In this case, the placenta had attached to the intestines, the fat in the stomach, and the tubes and outside of the uterus itself. The baby had died simply because its need for blood outmatched the ability of the intestines to provide that blood to the placenta. Because of its numerous attachments, we were forced to leave much of the placenta in place to resorb on its own.

A few days after the surgery, the husband found me walking outside the maternity building and asked where our house was—he wanted to bring us some bananas from his village in gratitude. Indeed, this could have been deadly for his wife, but thanks to the team effort of the nurses at the health zone level, the small level of outside donations provided to the hospital for these situations, and the willingness of doctors here in Congo to work in a rural setting, she was able to get timely healthcare. And, I’m happy to report that here the 10 year contraceptive implant that will continue to protect her life (while the placenta is still in place, it would be very dangerous to get pregnant again) is only $5 instead of over $200 like in the US, and I think that a bag of peanuts sells for more than $5. Hopefully their family can keep the goat.