HAZARDS OF GRAND MULTIPARITY: THE DOWN’S CASE

I hope its not too early to discuss this woman, since we just recently discussed a case of infertility. Anyway, I believe my esteemed readers are well aware of the fact that the world is created in pairs often in extremes.

We’re discussing a woman who is abundantly blessed with child-bearing. Clinically speaking, Grand multipara.
A bit of medical tutorials will go a long way in simplifying the term just mentioned.
Parity (or Parous experience) and its derivative para – is a term used to describe a woman’s delivery experience, that is any pregnancy carried beyond 28 weeks (which is tropically taken to be the age of viability)

We count the number of parous experience in ordinance fashion. When a woman has delivered for the first time, she is primipara, up to 2 times is multipara and up to 5 parous experience is grand multipara.

This woman we’re talking about has had 6 previous experiences and has come to us with the 7th pregnancy.
Expectedly, she is elderly, her age as at booking being 45 years and obviously of a large size.

What initially got me concerned about this woman is her level of literacy. She is a graduate and works in the Civil Service, so one would expect all these to rub off on her to inform her decision and protect her from avoidable risks and dangers.

However, my clinical experience and social interaction has shown that often times, too much “book reading” and “I know so much” mentality adversely affects a lot of the “alakowes” as far as certain professional issues are concerned, such is family planning. Most literates having read so much about all forms of contraception (which sincerely are almost not error free at all) consider the few, surmountable disadvantages more than the enormous indispensable advantages.
They talk about getting excessively fatter, dislodgement, irregular menstruation and all sorts ignoring the very important benefit of fertility control.
They also are not aware (or probably just ignore) the fact that there are numerous methods of contraception/family planning that there is always one method safe enough for everyone.

A ‘sovereign’, permanent method of contraception with little or no adverse effect is Bilateral Tubal Ligation (BTL). This is just appropriate for any woman who is sincerely not desirous of any more pregnancy.
However, talk–about gist of a certain woman who lost all her kids to inferno, or toad traffic accident and couldn’t bear anymore because of the BTL she did would not make most women consider this invaluable method. Then, I put it to them, what if she lost all her children after menopause, what would she do?
Please don’t get me wrong, I’ m not trying to sound cynical here but how does it feel when people have to pay such grievous prices for their inability to weigh risk-benefit in whatever action they’re about to take despite stern warnings and series of advice.

This Grand Multipara presented at ante-natal clinic at 27 weeks 5 days (almost 7 months) this again, is a challenge with most multi-para (not to talk of a grand multipara). They feel they have all the experience to deal with pregnancy and childbirth. They therefore tend to present late for ante-natal service (if at all they do) they often present only when they have some health challenges in pregnancy. They also have a tendency to be poorly cooperative or even uncooperative with medical personnel. They query every advice offered, sometimes jettison them, argue vehemently and sometimes don’t comply with drug regimen or visit schedules.

Fortunately for this woman, at presentation, she was discovered to have been hypertensive and diabetic. This necessitated her to be placed on admission for further observation and management.

Swiftly, the medical team was invited to properly manage these two often chronic medical conditions complicating her pregnancy. Their advice was strictly enforced (since she is on admission). The drug regimen was also adhered to for maximum outcome to ensure the viability of the fetus as well as the survival of the mother.

However, the primary aim of management in such condition is to deliver the baby at the safest period for both the mother and the child. Should need be, such pregnancies can be brought to an end especially as soon as the fetus reaches age of self-sustainability ( usually after 34 weeks).

At gestational age of 35 weeks and a day, the woman started having on and off contractions (known as labour pains) the options were weighed by the team of doctors managing her, and a caesarian section was considered best for her and as soon as possible.
She was prepared for the theatre; blood was secured, grouped and crossmatched for possible transfusion and off she went to the theatre.
In no time, the baby was out. My duties in the theatre on that day included liaising with the Pediatric team (Doctors who specialize in the care of children) monitoring the child, assessing her and giving feedback to the surgeons as soon as possible (while they close up).

I drew the attention of the pediatrician to what I saw as some unusually irregular (dysmorphic) features in the new born child albeit the struggle to resuscitate the child who wouldn’t cry immediately after birth. Heads put together, we agreed that the child has suspected Down’s syndrome (never mind us, we are almost quite sure though but it takes some specific laboratory investigations including chromosomal studies to particularly confirm our diagnosis).

Well, good enough, she has signed all the necessary documents requesting that her tubes be tied at delivery (BTL). Hence, the surgeons proceeded to tie only the right tube which was still visible (whatever had happened to the left one, we’re not sure).
The surgery was concluded, the mother wheeled from the resuscitation room to the ward and the baby, to the neonatal unit for further observation and management.

The essence of this blog is to learn from other people’s mistakes, possibly amend our ways and avoid taking such steps in life.
The import in this case of our grand multipara is clear, the concept of family planning is explicit, and it’s for all.

As we can also see literacy is not always the same as being educated. You can be learned and yet be uneducated with simple issues such as this. The consequences may however be irredeemable.

The government of Nigeria has institutionalized family planning such that it is quite affordable and readily available. It is not a one size fits all though but everyone has a size that would definitely be fitting.

Ranging from the permanent methods; the easily reversible contraceptive devices; the pills (emergency and long-term) to even the common barrier methods such as condoms. It is almost impossible for anyone to be intolerant to all methods; I don’t want to believe that has ever occurred.

Patients should be free, open-minded and learn to trust their health care givers, while the health care providers should also try as much as possible to be patient with patients. The need for tolerance, calmness and empathy in clinical practice can not be over-emphasized. This sets forth a better Doctor-patient rapport.
This woman, like it or not would be left with 6 (possibly healthy children) and a Down’s syndrome child to cope with for the rest of her life.
I wish her all the best.

Hamid Adediran is a Medical Doctor+Broadcaster=Medicaster. He tweets from @hamid_doctalk