Placenta praevia, the silent killer

Rosina* sat gloomily on her bed, the first one right next to the nurses’ desk. She responded in monosyllables, expressing her discontentment at being here.

We all listened to our colleague updating us about Rosina. She had been admitted two weeks before, having been brought to the hospital with vaginal bleeding, a huge red flag at any stage of pregnancy. 

All Rosina knew was that she was woken up by a warm wetness between her legs in the middle of the night, when she was 29 weeks along. She thought she had passed urine in her sleep. She reached for the light switch and turned on the light, only to let out a stifled scream. Her bed was blood stained, a bad sign for every pregnant woman. What was perplexing though, was the fact that she was pain-free. 

The scream woke up her husband who was snoring softly beside her, unaware of the brewing complications. He woke up with a start, sitting up while trying to find his clothes in confusion. He eventually managed to recollect himself, call a cab and wake up his sister next door to come and stay with their three-year old son as he brought Rosina to the hospital.

By the time they arrived at the hospital, the bleeding had slowed down but the labour ward team sprang into immediate action. Blood samples were hastily taken, an intravenous access line put in her hand and intravenous fluids set up. She was carted off to an urgent ultrasound. 

The ultrasound showed Rosina’s baby was safe but the placenta was not appropriately located. Instead of it being on the upper part of the uterus, above the baby, it was lying across the lower segment, covering the cervix completely, a condition known as placenta praevia. 

Observation

Let us just say Rosina did not take the news kindly but the fear of death led her to hold her peace.

Two weeks later, her patience had worn thin and the thought of death was a remote possibility. She missed her son dearly and it tore her heart every night when he cried on the phone for mum to come back home.

She was tired of sitting on her bed all day doing nothing, having an intravenous access line that was changed every three days and yet was never used, having blood drawn every week for reservation at the blood bank, should she need an immediate transfusion. The list was endless. 

On this day, our ward teams were changing rotations. Our team was taking over and we were all new to Rosina. She devised ingenious ways to convince us to let her go home. She knew that there was a different doctor every day for the ward rounds and that the entire team only did rounds together twice a week. She figured it was easier to convince one doctor instead of a dozen. 

We all began dreading the daily rounds. No one wanted to engage with Rosina about the impossible discharge. She would sulk, cry, cause a scene and threaten, to no avail.

One day, she learnt of a special form that she could sign to allow her to discharge herself home against medical advice. The nurses ensured that none of these forms could be found in the ward. Three days later, the cunning Rosina convinced a naïve medical student to borrow one from the neighbouring ward. 

The next morning, Rosina was ready for me. It was my turn to do the round and she waved the form in my face and asked me to witness her signing so she could go home. She had turned into a lawyer, using terms like she was ‘absolving’ us of any responsibility, should she die. 

It was within Rosina’s rights to sign the form and leave the hospital. However, for us who knew exactly how she was literally a moving target with a bull’s eye on the lower segment of her uterus, we were not willing to participate in her suicide mission.

I spent an hour convincing Rosina that as a gynaecologist in training, I had no authority to sign the form. We negotiated that she would present her request the next morning to the entire team at the major ward round and have the most senior professor in the round sign the dotted line that would set her free. This, she agreed to. 

The next morning, I walked into the ward expecting the usual tirade from Rosina. I was disappointed hence curious. Rosina lay quietly on her bed with a forlorn look. I asked if she was okay.

After a long moment, she looked at me and apologised. She went on to tell me that she now understood what it meant to stare death in the eye. She got there and could not believe she survived to tell the story. 

The nurse later explained that the previous night, Rosina had gone to bed only to wake up shouting for the nurse. The nurses responded, finding Rosina in a pool of blood. They grabbed her and sped off to the operating theatre. The theatre team took all of five minutes to have her on the operating table. 

It was a messy bloody surgery but Rosina’s little girl came out yelling despite being premature. She was in the newborn unit under strict observation while Rosina completed her fifth unit of blood for transfusion. 

Danger

Placenta praevia can easily turn life threatening in a matter of moments. Any pressure on the placenta causes it to shear off the uterine wall, breaking the interconnecting blood vessels, leading to painless bleeding. In some instances, the bleeding may be spontaneous but just like in Rosina’s case, it may be precipitated by sexual intercourse. It may be mild, easing off on its own, or it may be torrential, putting both mother and baby in grave danger. 

Thankfully, Rosina’s bleeding stopped spontaneously and she was able to avoid a blood transfusion. She was transferred to the antenatal ward. The following morning, the doctor explained to Rosina about her diagnosis. He further informed her that due to the possibility of unpredictable torrential spontaneous bleeding, Rosina could not go home. She had to remain in hospital until delivery. 

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