EARLY PREGNANCY

It is an absolute culture shock to relocate from Africa to a first-world country. After all these years of training, working, and saving lives, the first thing I hear is that only formal, departmental scans are accepted, and I do not have permission to scan because I have not been trained in the Irish system. We used to cover gynae unit calls as a registrar, and we would review up to 50 women with early pregnancy, with either vaginal bleeding or abdominal pain. In that busy setting, we would detect up to 5 ruptured ectopics, which we were managing laparoscopically if the patients were heamodynamically stable. Unstable ruptured ectopic cases, or unstable or septic incomplete miscarriage cases, would be taken to the theatre immediately, usually after the blood products are available. Most patients do well with IV fluids and blood transfusions. Still, some may require prolonged ventilation. The cases of missed miscarriage, or first-trimester miscarriage, will mostly be managed by Manual Vacuum Aspiration, which is done under anesthesia by the interns, in the MVA room with simple analgesia such as IMI diclofenac or pethidine. 

Women who have a viable intrauterine pregnancy are told to go to their local clinics to book their pregnancy and to take supplemental folic acid. 

In Ireland, women present to the ED with early pregnancy complaints, and then they are assessed in the gynecological assessment room, which gives us good privacy. If the patient is hemodynamically stable, they are booked for a formal departmental scan as soon as possible, if the point-of-care BHCG levels are more than 2000. The ultrasound department tries to accommodate these patients in the morning, and has the pregnancy growth scans later during the day. It will not be pleasant for these women to clash with heavily pregnant women and feel traumatized by their pregnancy loss. 

Women with a viable intrauterine pregnancy get assessed regarding risk of preeclampsia according to the checklist with moderate and major risk factors, and are started on Aspirin and counseled. Women with missed miscarriage or an incomplete miscarriage are counseled regarding their preferred mode of management, which can be conservative, medical, or surgical management. 

Evacuation of the uterus is done under anesthesia in the theatre by the consultants. Patients come on the day of the procedure, and are discharged on the same day to save bed space in the hospital and control the costs. There might be one ERPC done per week, and in the span of three months that I have spent here, I have seen 3 stable ruptured ectopics managed laparoscopically and 2 managed medically. All women with suspected pregnancy of unknown location or suspected early pregnancy are handed over meticulously, every day at the huddle meeting, so no cases are missed. 

The fascinating fetus is growing in a little gestational sac. This was me scanning myself after 3 months of amenorrhea, it was such a joy to see a fetus with a heart beat.