. □ Intra Uterine Fetal Death □ The Price of Neglecting Antenatal Care

From my little experience one of the most challenging of the numerous nightmares faced by the ObGyn physician in our clime is the Grand Multiparous paturent;that woman that has carried 5 or more pregnancies to term, I.e the age of viability and delivery. More so when the said pregnancies were all normal culminating in equally normal deliveries with living children.

This group of women referred to as "Aka ochies"[veterans] in the "game" of pregnancy, labour and delivery see themselves as the gods of safe delivery, the custodians of the laws and tenets of safe pregnancy and motherhood; and therefore think that they don't need Antenatal care. Those are meant for Primips[ women pregnant for the 1st time] and the other "newbies" in the game, they say.

But this is what they don't know: □that even while one due to many years of experience may have mastered and adapted to the rigours of NORMAL pregnancy, that every pregnancy has an independent risk of going off course despite one's "aka ochie" status.
■that every pregnancy is a unique experience; no two pregnancies are the same!
□that contrary to popular opinion, certain pregnancy risks increases with each delivery!
■that the grand multiparous status is saddled with a catalogue of obstetric risks ranging from Malpresentation to the monstrous Post Partum Haemorrhage ["bleeding after delivery"] ; and as such is labelled by doctors as a "high risk" status.
□that body physiology and it's derangement in pathology is no respecter of the "aka ochie" status. ■that a pregnant woman is just like any other human and as such in addition to core obstetric factors, still runs the risk of other non obstetric medical problems that might affect the outcome of pregnancy negatively
□that even if all the above are false and that they have found a way of circumventing all the attendant problems of pregnancy by virtue of their "aka ochie" status, their unborn is yet a first timer, a delicate one at that ;one not saddled with the supposed "resilience" of the self acclaimed aka ochies, who needs all the care and norturing it can get to survive the tidal waves of the ocean called Liquor Amnii. They don't know these. And many a times because of their "snubbing" of antenatal care, they come down with numerous preventable obstetric complications including antepartum[while pregnant], intrapartum[during delivery] and postpartum[after delivery] complications.

□ Case study She is a 38 year old Grand Multiparous woman [ G6P5 +0, A5; is pregnant for the 6th time and has had 5 previous deliveries with all the kids alive and well ], and a known hypertensive not compliant with antihypertensive medications. She walked into my clinic one morning with an obviously advanced pregnancy and with an air of nonchalance and superiority, for her booking antenatal visit. The nonchalance was so palpable that she didn't know her LMP[last menstrual period], didn't know when she felt quickening and therefore there was no OBJECTIVE way of knowing the age of her pregnancy or assesing fetal wellbeing in terms of the expected growth rate. Quick history revealed she is a known hypertensive diagnosed few years back who had not being compliant with medications. Booking BP was 140/100mmHg and there were no signs of end organ dysfunction or damage due to hypertension. Urinalysis was free of blood and protein. She [size of the pregnancy] was 26.5cm making her gestational age probably 26 plus or minus 2 weeks, all things being equal.

After adequate counselling on the general risks attendant in the setting of hypertension and the peculiarities in pregnancy, including the mutually adverse relationship between the two[ pregnancy worsens hypertension, and hypertension on the other hand increases the risks in pregnancy], I gave her routine hematinics and IPT and placed her on antihypertensive therapy with Aldomet with a short appointment[1 week] and requested for an Ultrasound for obvious reasons. She vanished until 7 weeks later when she presented apprehensive with signs of genuine concern and worry etched deep into her forhead, with complaints of :
□Labour pains
□Excessive fetal movement
□Sore like feeling in the upper abdomen. All of 24hrs duration. I was furious and made it obvious, cos I had nothing to work with. No LMP to calculate the age of the pregnancy, no ultrasound to calculate same from and also get vital information like fetal well being and placental location. And a known hypertensive is badging in on me like that in labour with a BP of 200/110mmHg! Quick history revealed she's been having features of end organ dysfunction since 2 weeks prior to presentation ... □ Headaches, worse in the morning and associated with nausea and blurring of vision. □ Weakness and breathlessness exacerbated by mild to moderate exertion. □ Nil facial puffiness nor frothy urine □ No epigastric pain. Then I zeroed in on the abdomen, and realised why she was looking franctic and apprehensive when she came in; and why she had to present when she did after close to 24hours of labouring at home!There was no fetal heart tone! Simply put, the baby was already dead! And that was her fear when the "excessive fetal movement" suddenly ceased, and the reason why she even bothered coming. This is what she didn't know: □ Her weight on presentation was 80kg, lower than 82kg when she booked and ran away 7 weeks ago. □ On palpation of the uterus and content [ before I listened for the fetal heart tone], I was already worried cos SFH was 29.5cm and the fetal parts seemed rather small. □ The "excessive fetal movements" with onset of labour may have been an already stressed baby getting more stressed up by the intermittent hypoxia induced by uterine contractions. This is what I think: The worsened/long standing hypertension must have compromised fetomaternal circulation[the only source of oxygen and nutrients for the baby] leading to IUGR over a long time [IntraUterine Growth Restriction], with some elements of distress. The further stress of labour was just too much additional baggage for the baby to handle ... and he tried "protesting" by running arround[ the excessive movements] before giving up. This is akin to slowly torturing your baby like ISIS until it finally gives up! Now all these are things that could have been prevented by early antenatal booking with prompt commencement of antihypertensive; or earlier detected with adequate measures taken. Even with the late booking, serial measurement of SFH and doing Ultrasound as requested would have still picked it up and prompt measures would have been taken. But this "Aka Ochie" deceided to go AWOL against a doctor's advice and play ISIS with her child! [No pun intended] □ Morals Antenatal Care is golden no matter one's acclaimed "Aka Ochie" status! The aim is to monitor the progress of pregnancy, identify risks and full blown problems and tackle them head on, not just for the good of the mother .... but for the baby's as well.