A very septic patient

Jane came to our hospital at night, at about 10 pm. She was shivering and she had high fever of 40°. She complained of massive purulent vaginal discharge for the last one month, and she had been treated repeatedly in a local facility for PID (pelvic inflammatory disease) without improvement.

Because Jane is 32 years old and she is married, the first question  have asked her was about the last menstrual period: she could not recall it very well.

With the patient in bed I have done a simple palpation of the abdomen and I have noticed a mass below the umbilicus, which was highly suggestive of a gravid uterus.

I have asked the patient about a possible pregnancy, but she was not sure about it because her periods had always been irregular since adolescence.

I have also noticed a vertical umbilico-pubic scar and the patient confirmed to me that it was a previous caesarean section.

Next step has been to do a pelvic ultrasound, which has given me the correct diagnosis: it was a case of intra-uterine fetal death at about 16 weeks’ gestational age, with severe oligohydramnios and signs of maceration: that was the reason of the abundant, foul smelling, and purulent discharge… not a PID!

We have covered the patient with broad spectrum antibiotics and with paracetamol because of fever. Given the fact that she was at risk of  puerperal sepsis, it was urgent to remove the dead child from the uterus, but the previous C/S scar has given us new challenges, because  in itself it is a contraindication to the use of oxytocin. Induction was therefore contraindicated and doing another caesarean section on  dead fetus was to be the very last resort.

I have therefore tried to buy some time and I have done “ballooning”, a simple procedure which consists of inserting a catheter through the cervix and filling the balloon up to 40 ml, then attaching a weight to the catheter itself in order to make the balloon press on the cervix and stimulate dilation.

The procedure was actually successful and Jane started having uterine contractions and she delivered the macerated fetus during the night.

Because the pelvic U/S has later shown that some products of  conceptions were retained, we have also performed a D & C (dilatation and curettage).

The general conditions of the patient are now very much improved. She is still in hospital because I want to finish the course of intra-venous antibiotics, but she is bright: no fever, no pain, no discharge and no confusion.

In today’s patient, a simple question about the last menstrual period, or a simple abdominal palpation, or a pregnancy test would have helped the other clinicians to reach the diagnosis much earlier without putting the life of the patient at risk.

Thanks be to God, everything is going on well.

Br Beppe Gaido