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 I have asked her was
about the last menstrual period: she could not recall it very well,
but she knew it was in the beginning of March 2013.
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 the 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. Giving 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 a 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.
The comment I want
to make and the reason why I have presented the case relate to the
same issue I was underlining few days ago when I was writing about
the clinical mistakes and the need not to judge the work of the
colleagues.
Even 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, but really I have to repeat that
mistakes happen not only in Chaaria.
We must not waste
time accusing others; rather we must be able to learn from our
mistakes in order not to repeat them again.
Br Dr Joseph Gaido
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