Case Study Reports: Bleeding In Pregnancy

BLEEDING IN PREGNANCY

History

A 19-year-old woman presents at 13 weeks’ gestation with vaginal bleeding and a smelly watery discharge. She feels generally unwell and has had fevers for the last 48 h. She ini- tially thought she had gastroenteritis as she had reduced appetite, abdominal pain, vomi- ted and had loose stools.

All her booking bloods were normal and the 11 week ‘nuchal’ scan was reassuring. She had a previous normal vaginal delivery at 38 weeks’ gestation. She has no significant gynaecological or general medical history.

Examination

On examination the temperature is 38.1°C, pulse 96/min and blood pressure 110/68 mmHg. She looks flushed and her peripheries are warm. Chest and cardiac examin-ation are normal.

She is tender over the uterus, which feels approximately 14 weeks’ size. There is no guarding or rebound. On speculum examination the cervical os is closed but an offensive blood-stained discharge is seen. Bimanual examination reveals a very tender and hot uterus that also feels ‘boggy’. No adnexal masses are palpable but bilateral adnexal tenderness is evident.

Questions

·              What is the diagnosis?

·              Why is this presentation rela- tively uncommon in current clin- ical practice?

·              How would you further investi- gate and manage this woman?

ANSWER

The woman is pregnant with a dead fetus and signs of sepsis. This is referred to as a sep- tic miscarriage. This used to be a common diagnosis due to the high incidence of illegal terminations performed by unqualified people without appropriate sterile technique, instruments or anaesthesia. Since the 1967 Abortion Act, morbidity and mortality from septic miscarriage has fallen dramatically but it remains a cause of maternal mortality, often because it is not recognized early enough. It should therefore be recognized promptly and treated aggressively.

Further investigations necessary are: blood cultures; liver function tests; coagulation screen, group and save; high vaginal and endocervical swabs.

Management

·              The woman should be admitted and commenced on broad-spectrum intravenous antibiotics pending culture and sensitivity.

·              Aggressive intravenous fluids should be given as she has intravascular depletion due to sepsis (vasodilatation) and vomiting.

·              Evacuation of retained products of conception should be arranged urgently, once the first dose of antibiotics has been given.

·              A senior gynaecologist should be involved as the risks of uterine perforation or of mas- sive haemorrhage are significant in the presence of sepsis.

·              A urinary catheter should be inserted to monitor renal function.

·              The woman may need transfer to the intensive care unit depending on her cardiovas- cular, respiratory and haematological state.