SermoSolves: A challenging pregnancy in Panama

Our physician community frequently collaborates on “digital curbsides.”  Our case today comes from the jungles of Panama and involves a young woman struggling with her first pregnancy.   Dr. Ben LaBrot, a Sermo advisor, posted ultrasounds from the province of Bocas Del Toro and received suggestions for treatment within minutes.

Case

This case comes to us from The Floating Doctors, a non-profit medical relief team that provides free preventive health care services to isolated areas. Their team is currently working in a small impoverished village, in the northeast region of Panama. The patient is a 13 year old girl with an estimated pregnancy of four months. An ultrasound revealed a mass, about 3.5 cm, bordering the occipital region of the fetus’ head.

Patient Background

Floating Doctors note “Indigenous Ngabe girl (Western Panama) living in a small slum community of 250 families perched precariously over a mangrove swamp.  All sanitation and trash goes directly into the mud under the houses.  High worm loads, no treated water.  Very low-income area disenfranchised by the wider community. Diet is poor; high in starches and sugar and fat, low in fresh vegetables and protein.” With very little to no health knowledge, she also had not been taking pre-natal vitamins and has not seen a doctor. The patient has experienced no pain and no other complications during her pregnancy. Test ranging from urological, neurological, cardiovascular, respiratory, and gastrointestinal tract all showed no abnormal results.

The Ultrasound Images

First Response

Medics started the girl on pre-natal vitamins. The preliminary diagnosis is either Encephalocele or Myelomeningocele.

The Struggle

• Is this diagnosis correct?
• Is there a chance for treatment to save the child?
• Will the child survive to full term and what are the risks for the mother?
• It is illegal to terminate a pregnancy in Panama
• Exact gestational age is unknown. An estimation of 4-5 months is all that can be deciphered.
• Lack of funds and hospitals nearby

Consensus

Floating Doctors presented this case to the Sermo Community in July, 2014 asking for confirmation of their suspected diagnosis and any other feedback. There were a total of 32 comments left on this case and 32 participated in a poll asking whether the fetus would survive to full term. 41% voted “Yes, but it is not likely to survive the first week.” Many comments echoed the importance of maintaining the mother’s health.

One MD who specializes in genetics commented “…Triage decision is to preserve the teen mom’s health. NTDs are probably rampant in the population and related to diet low in folate. Sanitation, education, diet, and microloans for local small business. Teach everyone to read and give them books….”

While an obstetrician stated, “I agree the focus should be on the care of this young mother and preserving her ability to bear children safely later in life. A cesarean for a non viable fetus would put her at increased risk for subsequent pregnancies. She needs to terminate this pregnancy sooner than later. My heart goes out to this mother, who is no more than a child herself, and those caring for her with such limited resources.”

Patient Care Plan

Focus will remain on keeping the mother safe and healthy, knowing the child will not survive. Strong concerns surrounded damaging the young mother with a natural delivery. A goal was set to terminate the pregnancy, if possible, within two weeks. If termination cannot happen, the child will be carried to term and delivered via c-section. Counseling is being made available within the community with the Panamanian Red Cross to help explain to the mother the implications of what is happening to her baby.

Physicians consult regularly within the Sermo community.  If you’re an M.D. or D.O. you can log in for free at any time to use this dynamic and lifesaving service.  You can join anytime, just select iConsult to notify your peers, the first response is within minutes.