A 38 year old woman with hypotensive shock at the onset of menstruation: case presentation

BMJ 2009; 338 doi: (Published 09 February 2009) Cite this as: BMJ 2009;338:b6
  1. Sergio Serrano Villar, resident in internal medicine1,
  2. Juncal Perez-Somarriba, consultant in internal medicine 1,
  3. Talia Sainz Costa, resident in paediatrics1,
  4. Sarah Winstanley, foundation doctor2,
  5. Tomas Santillana Lopez, consultant in internal medicine1,
  6. Luis Escribano Mora, consultant in haematology3,
  7. Baltasar Orejas Gonzalez, professor in internal medicine1
  1. 1Hospital Clinico San Carlos, Madrid 28040, Spain
  2. 2Kingston Hospital, London
  3. 3Centro de Estudios de Mastocitosis de Castilla la Mancha, Hospital Virgen del Valle, Toledo, Spain
  1. Correspondence to: S Serrano Villar sergio1serrano{at}
  • Accepted 7 October 2008

Mrs Barroso, a 38 year old woman, collapsed while working in our hospital laundry. She was transferred to the emergency department unconscious and hypotensive with no known cause. Her temperature was 36.1°C, respiratory rate 18 per minute, and blood pressure 50/35 mmHg. She had a sinus tachycardia with a heart rate of 118 beats per minute and a weak pulse. Her oxygen saturation was 91% on supplemental oxygen. She was responsive to vigorous verbal stimuli and her pupils were equal and reactive to light. Physical examination found no other abnormalities. Relatives reported to the medical team that she had complained of abdominal pain and diarrhoea since she had begun menstruating the night before.

In the emergency department haemodynamic support was started and a total of 4500 ml of fluid replacement was administered intravenously. The box lists the results of biochemical investigations. Chest (figure) and abdominal radiography showed no abnormality, and transvaginal and abdominal ultrasonography also gave normal results

Diagnostic tests in the emergency department

  • Full blood count: normal

  • Blood chemical profile: normal

  • Human chorionic gonadotrophin: <5 IU/l

  • Haemoglobin: 127 g/l


Fig 1 Mrs Barroso’s chest radiograph

She was given dopamine and noradrenaline at high infusion rates but did not respond. Finally, she was injected with 60 mg of methylprednisolone and her blood pressure increased. Her condition improved rapidly and she regained consciousness.


  • 1 What are the possible causes of Mrs Barroso’s haemodynamic deterioration?

  • 2 Why did she respond to steroids but not to vasoactive drugs?

  • 3 What investigations are important now that her condition has stabilised?

  • 4 What biochemical test would have been useful in the emergency department?

Please respond through, remembering that Mrs Barroso is a real patient and that she and her carers will read your response


Cite this as: BMJ 2009;338:b6


  • 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 In five weeks’ time we will report the outcome and summarise the responses

  • Competing interests: None declared.

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