Practice Interactive case report

A patient with suspected miscarriage is found to have hypertension, renal failure, and thrombocytopenia: case presentation

BMJ 2007; 334 doi: http://dx.doi.org/10.1136/bmj.39212.564745.BE (Published 28 June 2007) Cite this as: BMJ 2007;334:1372
  1. Chris M Laing, specialist registrar in nephrology1,
  2. Rhys Roberts, senior house officer in medicine2,
  3. Liz Lightstone, consultant nephrologist3,
  4. Alison Graham, consultant radiologist4,
  5. Terry H Cook, professor of renal pathology5,
  6. Shaun Summers, specalist registrar in nephrology and internal medicine3,
  7. Charles D Pusey, professor of medicine6
  1. 1Critical Care and Internal Medicine, Department of Medicine, University College London Hospital, London NW1 2BU
  2. 2Department of Medicine, Hammersmith Hospital, London W12 0HS
  3. 3West London Renal and Transplant Centre, Hammersmith Hospital
  4. 4Department of Radiology, Hammersmith Hospital
  5. 5Division of Investigative Science, Imperial College London, Hammersmith Hospital Campus, London W12 0NN
  6. 6Division of Medicine, Imperial College London, Hammersmith Hospital Campus
  1. Correspondence to: Chris M Laing christopher.laing{at}mac.com
  • Accepted 2 April 2007

A 46 year old white woman presented to her local casualty department. She had been experiencing vaginal bleeding for 10 days, and the bleeding had become particularly heavy in the past three days. She had also felt generally unwell for around a week with malaise, fatigue, headaches, anorexia, and vomiting.

She and her partner had been trying to conceive. Her last menstrual period had been 10 weeks ago and she had recently tested positive with a urinary (β human chorionic gonadotrophin) pregnancy testing kit. She had three children from a previous partner. Two of these pregnancies were complicated by hypertension from 36 weeks onwards. She thought that she may have had two miscarriages the previous year, which had not been investigated.

The previous year she had a measured blood pressure of 165/90 mm Hg. She gave a history suggestive of Raynaud's syndrome but had no other symptoms or past medical history of note. She was taking no regular medication.

She was initially referred to the on-call gynaecologist who found her to have a blood pressure of 240/127 mm Hg and a heart rate of 100 beats/minute. She appeared unwell and was dyspnoeic at rest. On abdominal examination the uterus was not palpable, and on vaginal examination the cervical os was open and bleeding. Chest auscultation demonstrated bi-basal, inspiratory crepitations. No other abnormalities were found on examination. Urinary β human chorionic gonadotrophin was negative. Urinalysis showed large amounts of blood and protein, but the patient was actively bleeding from the vagina when this test was done. The table shows the results of her laboratory tests.

Patient's laboratory test results at presentation

View this table:

She was referred for an urgent medical opinion. A central venous line was inserted and a chest radiography performed (figure). At this point, while still in the casualty department, she had several generalised tonic-clonic convulsions.

Figure1

Chest radiograph showing diffuse pulmonary oedema

Questions

  • 1 Would investigation for recurrent miscarriage have been appropriate given the patient's reproductive history, and if so, how?

  • 2 What diagnoses might explain the patient's presentation and the abnormalities found?

  • 3 What could account for the patient's chest radiography results?

  • 4 Outline how the patient should be investigated and managed during the first 24 hours

Please respond through bmj.com, remembering that the patient is real and that she and her carers will read the response

Footnotes

  • This is the first of a three part case report where we invite readers to take part in considering the diagnosis and management of a real patient using rapid responses on bmj.com. In four weeks' time we will report the outcome and summarise the responses

  • Competing interests: None declared.

  • We welcome contributions of interactive case reports. Cases should raise interesting clinical, investigative, diagnostic, and management issues but not be so rare that they appeal to only a minority of readers. Full details of criteria are available at: bmj.com/cgi/content/full/326/7389/564/DC1