PAIN IN PREGNANCY
A 35-year-old woman arrives on the labour ward complaining of abdominal pain and vaginal bleeding at 36 weeks 2 days’ gestation. The pain started 2 h earlier while she was in a café. She describes constant pain all over her abdomen with exacerbations every few minutes. It is not relieved by lying still or by walking around. The vaginal bleeding is bright red and was initially noticed on the toilet paper and now has stained her under- clothes and trousers. There are no urinary or bowel symptoms.
The baby has been moving normally until today, but the woman has not paid any attention to the movements since the pain started.
This is her first pregnancy and until now progress has been uneventful with shared care between the general practitioner and midwife. Both the 11–14-week and the anomaly scan at 20 weeks were reassuring. Booking and subsequent blood tests were normal. The book- ing blood pressure was 112/68 mmHg and the most recent blood pressure 2 days ago was 128/80 mmHg.
She is obviously in significant pain and feels clammy. She is apyrexial, her heart rate is 115/min and blood pressure 110/62 mmHg. The symphysiofundal height is 38 cm and the uterus feels hard and is very tender. It is not possible to feel the presentation of the fetus due to the uterine tightening. On speculum examination there is a trickle of blood through the cervix and the cervix appears closed. Vaginal examination reveals that the cervix is soft and almost full effaced but closed. No fetal heart sounds are heard on auscultation with the hand-held fetal Doppler. Ultrasound scan confirms that the fetus has died.
· What is the diagnosis?
· How do you interpret the examination and blood test findings?
· How would you manage this patient?
The pain and bleeding are due to placental abruption. In this case the presence of vaginal blood classifies it as a ‘revealed abruption’ but the other signs of hardened ‘couvelaire’ uterus, raised symphysiofundal height, tachycardia and low haemoglobin all suggest that the major part of the blood is still concealed. This is an extremely important point as the amount of visualized blood can be misleading when there may be 1–2 L of blood within the uterus.
The blood pressure appears normal, but this is because the woman is relatively young and fit – she is able to compensate by increasing heart rate and cardiac output for some time. By the time her blood pressure falls she has decompensated and is critically unwell, so normal blood pressure in young people should always be interpreted carefully. If her blood pressure were checked lying and standing, there would be a significant difference, which would reveal the extent of her hypovolaemia.
The increase in INR, decreased platelets and positive D-dimer test (a reflection of raised fibrin-degradation products) confirm that the woman has developed disseminated intravascular coagulopathy (DIC) as a result of the abruption.
The fetus has died (intrauterine fetal death) because the placenta has separated from the uterus and the uteroplacental circulation has therefore been interrupted.
This is an obstetric emergency as the woman is hypovolaemic and has developed a coag- ulopathy. The management centres on correction of the clotting and volume replacement as well as delivery of the baby. The anaesthetist and senior obstetrician should liaise closely in management.
As the baby has died there is no indication for Caesarean section, which would put her at risk of further bleeding. Therefore vaginal induction of labour should be initiated. Labour is often rapid after an abruption, and as the cervix is fully effaced and soft it may be suf- ficient to perform artificial rupture of membranes (ARM) to initiate the process of deliv- ery. At ARM, a large amount of blood is likely to be apparent.
A syntocinon infusion should be commenced immediately after delivery as uterine atony and postpartum haemorrhage are common after significant abruption.