Laboring Under Pressure Episode 4: Obstetric Emergency in South Africa with Dr. Meghan Hurley

Contributors: Meghan Hurley MD, Travis Barlock MD, Jeffrey Olson MS3

Show Pearls

Map of South Africa Referenced

South Africa Geography Lesson

• There is a big disparity between Cape Town and its neighbor Khayelitsha.

• Cape Town is the legislative capital and economic hub of South Africa, known for its infrastructure, tourist attractions, and developed urban areas.

• Khayelitsha Township is a large informal settlement on the outskirts of Cape Town, with limited infrastructure and services compared to the city center. Many residents live in informal housing.

• This disparity is the lasting effect of how land was divided up and populations were moved around during Apartheid.

• Apartheid was a policy of segregation that lasted from 1948 to 1994.

How does medical education work in South Africa?

• Medical education in South Africa typically follows a 6-year undergraduate program directly after high school

• Registrars our the equivalent of Resident in America. They are graduated doctors who work in hospitals under the supervision of senior doctors as they progress toward becoming specialists.

Pearls from the case and the discussion afterward

• Whole blood from a draw can be used instead of urine on a POC pregnancy test. Wait a little bit longer before making a determination because blood is more viscous. Although the casettes are not approved for whole blood several studies have shown this to be efficacious.

• Free fluid in the abdomen and a pregnancy of unknown location is a rupture ectopic until proven otherwise.

• Appendicitis can present on the left side. Most commonly from an extra appendix, but can also result from situs inversus or mid-gut malrotation. This presentation can also be the result of an atypically large appendix.

• Fever is common in appendicitis (~40%) and becomes less common with older patients.

• Don’t be falsely reassured by a normal hemoglobin in acute bleeding because patients bleed whole blood and the hemoglobin concentration is not affected. These patients should be resuscitated with whole blood.

• Give rhesus factor negative blood to female patients of childbearing age to prevent them from developing antibodies to the rhesus factor which can lead to Rh disease in future pregnancies.

• Rhogam can be given in cases of ruptured ectopic pregnancies to lower the risk of alloimmunization.

• Blood transfusions carry the risk of lung and heart injury from the extra volume. The treatment for this condition is to diurese the patient.

Other topics discussed include the complications of working in a South African township hospital at night, the epidemiology of burns, and the importance of global health.

References

1. Akbulut S, Ulku A, Senol A, Tas M, Yagmur Y. Left-sided appendicitis: review of 95 published cases and a case report. World J Gastroenterol. 2010 Nov 28;16(44):5598-602. doi: 10.3748/wjg.v16.i44.5598. PMID: 21105193; PMCID: PMC2992678.

2. Barash, J. H., Buchanan, E. M., & Hillson, C. (2014). Diagnosis and management of ectopic pregnancy. American family physician, 90(1), 34–40.

3. Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82. doi: 10.1016/j.jemermed.2011.05.028. Epub 2011 Aug 27. PMID: 21875776.

4. Moris, D., Paulson, E. K., & Pappas, T. N. (2021). Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA, 326(22), 2299–2311. https://doi.org/10.1001/jama.2021.20502

5. Sowder AM, Yarbrough ML, Nerenz RD, Mitsios JV, Mortensen R, Gronowski AM, Grenache DG. Analytical performance evaluation of the i-STAT Total β-human chorionic gonadotropin immunoassay. Clin Chim Acta. 2015 Jun 15;446:16 5-70. doi: 10.1016/j.cca.2015.04.025. Epub 2015 Apr 25. PMID: 25916696.

Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII