Case 90: Pain in pregnancy

 CASE 90: PAIN IN PREGNANCY

History

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 underclothes 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 booking blood pressure was 112/68 mmHg and the most recent blood pressure 2 days ago was

128/80 mmHg.

Examination

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

fully 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.

INVESTIGATIONS

Normal range for

pregnancy

Haemoglobin 8.1 g/dL 11–14 g/dL

White cell count 6×109/L 6–16×109/L

Platelets 93×109/L 150–400×109/L

Sodium 137 mmol/L 130–140 mmol/L

Potassium 4.0 mmol/L 3.3–4.1 mmol/L

Urea 6.5 mmol/L 2.4–4.3 mmol/L

Creatinine 82 mmol/L 34–82 mmol/L

International normalized ratio (INR) 2.2 0.9–1.2

Activated partial thromboplastin time (APTT) 34 s 30–45 s

D-dimer: positive

Questions

• What is the diagnosis?

• How do you interpret the examination and blood test findings?

• How would you manage this patient?100 Cases in Obstetrics and Gynaecology

254

ANSWER 90

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.

Management

This is an obstetric emergency as the woman is hypovolaemic and has developed a coagulopathy.

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.

! Resuscitation of the mother (initial basic procedures)

• Insertion of two large-bore venous cannulae

• Crossmatch of 6 units of blood

• Request for fresh-frozen plasma and platelets

• Initial fluid resuscitation with intravenous fluids, probably volume expanders

• Insertion of a urinary catheter to monitor urine output

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 sufficient to

perform artificial rupture of membranes (ARM) to initiate the process of delivery. 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.Case 90: Pain in pregnancy

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KEY POINTS

• Placental abruption is an obstetric emergency and must be aggressively managed

as DIC can develop rapidly.

• Placental abruption is commonly associated with the development of preeclampsia.

• Labour is usually rapid after abruption, and vaginal delivery poses less risk to the

mother than caesarean section.

• Caesarean section should be reserved for delivering a live but potentially compromised baby.