Case 33: Bleeding in pregnancy

 

Case 33: Bleeding in pregnancy

CASE 33: 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 initially

thought she had gastroenteritis as she had reduced appetite, abdominal pain, vomiting and

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 examination 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 bloodstained 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.

INVESTIGATIONS

Normal range for

pregnancy

Haemoglobin 10.4 g/dL 11–14 g/dL

White cell count 24.1×109/L 6–16×109/L

Neutrophils 18×109/L 2.5–7×109/L

Platelets 556×109/L 150–400×109/L

Sodium 135 mmol/L 130–140 mmol/L

Potassium 3.4 mmol/L 3.3–4.1 mmol/L

Urea 6 mmol/L 2.4–4.3 mmol/L

Creatinine 80 mmol/L 34–82 mmol/L

C-reactive protein 127 mg/L <5 mg/L

The transvaginal ultrasound is shown in Fig. 33.1.

Transvaginal ultrasound report: single intrauterine gestational sac, fetus present with

crown–rump length 42.7 mm, fetal heart beat absent.

Questions

• What is the diagnosis?

• Why is this presentation relatively

uncommon in current clinical

practice?

• How would you further investigate

and manage this woman?

Figure 33.1 Transvaginal ultrasound

scan showing a midsagittal view of the

uterus.100 Cases in Obstetrics and Gynaecology

82

ANSWER 33

The woman is pregnant with a dead fetus and signs of sepsis. This is referred to as a septic

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.

COMPLICATIONS OF SEPTIC MISCARRIAGE

• Massive haemorrhage

• Hysterectomy

• Disseminated intravascular coagulopathy

• Multisystem failure (secondary to haemorrhage or sepsis)

• Death

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.

• Surgical evacuation of the uterus 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

massive 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 cardiovascular, respiratory and haematological state.

KEY POINTS

• Septic miscarriage is rare since the legalization of termination of pregnancy.

• It should be recognized promptly and treated aggressively due to the risk of rapid

deterioration and mortality.

• Complete evacuation of the uterus is essential to eliminate the focus of infection.