Scary!

Ms. M was a very sweet 23 year old woman who was involved in a minor car accident this morning. She went over to Other Major Emergency Department complaining of some minor neck and abdominal pain. They examined her, took x-rays of her neck and sent her home with some ibuprofen, end of story.

She comes back to our ED about six hours later complaining of continued abdominal cramping and a gush of vaginal bleeding when she went to the bathroom earlier. She states that her last period was about five weeks ago and that it's been pretty much regular every month until then. I order a quick pregnancy test, thinking maybe she's 5-6 weeks pregnant and having a spontaneous abortion, draw some labs, and go back to examine her.

So her exam is essentially normal except for some stretch marks on her stomach and a fullness in her lower abdomen that feel remarkably like uterus full of baby. Strange for someone who's last period was only five weeks ago.

Well, I set up for a pelvic exam, sit down at the foot of the bed, lift the sheet. . . and there is fully formed loop of umbilical cord protruding from her entirely open cervix. . . which has a head pushed up against it. This young lady was not having a spontaneous abortion, she was in full-on labor. The bleeding she felt earlier was apparently her water breaking.

I rushed out, trying my very best to look like a calm and competent professional and not like the scared medical student I was, and called ob-gyn. End of the story, this young woman was more than six months pregnant. She had no idea. The baby, by now, had no heartbeat, and she ended up being rushed to OR to deliver the dead fetus.

It's impossible to say when the pregnancy terminated, but I can't help but wonder if the other hospital had caught the pregnancy this morning if she might have been able to successfully deliver. I don't know.

Moral of the story: Every single woman who could conceivably, remotely be pregnant must must must must have a pregnancy test no matter what they come in complaining of.

(The triage nurse apparently took this lesson to heart, my next patient was a 71 year old woman with abdominal pain. The triage sheet helpfully stated "urine pregnancy test negative.")