Thursday, April 27, 2017

The Cervical Length Study in Botswana

Ingrid Liff
Maternal Fetal Medicine Fellow at MGH

The Cervical Length Study in Botswana: Entry 2

Ingrid and Findo, research assistant for the Botswana Harvard Partnership, outside Scottish Livingstone Hospital in Molepolole, Botswana

I am coming up on my last week of recruitment for the Cervical Length Study in Botswana. This recruitment push so far we have screened 204 women, recruited 23 patients, including 9 HIV-infected women. Our recruiting has been less robust this month due to a scheduling glitch. The usual scheduler at the front desk, a friend of the Cervical Length Study, is actually on maternity leave. We realized this week that the substitute scheduler who does not understand our study as well was sending women away when she felt our schedule was “fully booked”. We fixed the issue this past week, and were able to call the midwives at the surrounding clinics to apologize and tell them to send the patients back who were not seen in ultrasound. I have always promised the midwives that when I am here, no woman who needs a scan in early pregnancy will be sent away. It is one of the ways I support Scottish Livingstone Hospital clinically while I am here.

A large part of fellowship in Maternal Fetal Medicine is teaching and supporting ongoing clinical care in the hospital. When I am at MGH I teach medical students and residents; and when I am at Scottish Livingstone Hospital I teach medical officers and interns. Each morning I arrive at the hospital for morning report before the ultrasound unit opens for scanning. The medical officers and interns report the cases from overnight, and often there are questions and teaching moments that come up. We recently talked about the difficulties of second stage cesarean sections, and the challenges of dating pregnant women presenting in the third trimester without an early ultrasound to confirm gestational age. We talked about arrest of descent, and the diagnosis of cephalo-pelvic disproportion. Last time I was here I gave a lecture on premature rupture of membranes. These are the ways I contribute to clinical teaching while I am here in Botswana recruiting for the study.

I also contribute to clinical care through the ultrasound unit. Midwives from the surrounding clinic and Dr. Rebecca Luckett, the director of OBGYN at Scottish Livingstone Hospital, sometimes send patients for ultrasound. My second month in Botswana I was able to diagnose a rare skeletal dysplasia in a fetus, and counsel the family. About a week ago I scanned a woman with known polyhydramnios. I was able to raise concern for a fetal trachea-esophageal fistula in this patient, along with other related anomalies. Now that I am later in my Maternal-Fetal Medicine training, I am able to contribute more clinically, which is fun.

But the patients of Botswana also continue to teach me, and humble me as a physician. Last week I diagnosed an intrauterine fetal demise at 31 weeks of gestation. As usual, especially since I am still early in my career, I spent most of the scan concerned about how I was going to deliver this terrible news. I looked inferiorly, and thought I identified the cervix continuous with the pregnancy in the setting of an intrauterine pregnancy per routine. There was almost no fluid around the fetus, and the scan was hard for sure. I measured the fetus as well as I could and assessed that the placenta was low and there was clot inferiorly. This patient later failed induction and was taken for a cesarean delivery. Intra-operatively she was diagnosed with an abdominal pregnancy, a rare type of ectopic pregnancy. I felt absolutely terrible that I had missed this very important ultrasound diagnosis. Certainly I will never forget this case as I continue in my career.

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