FP-1. A mysterious case of shock and Disseminated Intravascular Coagulation.

A 38-year-old female was brought to our ER, intubated and ventilated. As per the EMS report, she was discovered in a hypotensive, drowsy and disorientated state in her home. Immediately after transportation to the ambulance, it was established that she had an asystolic rhythm. She was resuscitated for nearly 20 minutes on her way to the hospital. Just before reaching the hospital, she regained her pulse but continued to be in a hypotensive condition. Her hemodynamic status was stabilized with pressers. We immediately realized that she had Disseminated Intravascular Coagulation. We admitted her to ICU for hemodynamic monitoring and support. Xigris was not on formulary during that time. She was a single parent of three grown children and had recently undergone a stressful period in her personal life. Her mother was a nurse, and this made it easier for us to obtain a detailed history of what had happened at her home, just prior to her sudden, unexpected collapse. Apparently, She had not been feeling very well for the past three days. Her mother informed us that she had complained of nausea, vomiting and epigastric pain. On the day of the event, she had felt very weak and lethargic. It seems that even then, the patient continued to refuse her mother's persistent request that she at least go to a nearby hospital for a general health check. We all agreed that the amount of fluid loss, due to the minor episodes of vomiting, could not explain the severity of her hypotension. The presentation did not look like a straightforward case of sepsis, either. Further detailed examination of the CNS, respiratory, cardiovascular and gastrointestinal systems did not reveal any foci of infection. She did not have any significant medical problems in the past. Although she was a morbidly obese lady, with a BMI of 40, she was in her usual healthy state until this event occurred. Her course in the ICU was downhill, as expected. She was coded again, and died early in the morning. By this time, we were still perplexed, as we could not find a reason for her sudden collapse and development of DIC. Autopsy solved the mystery. We were in utter disbelief. She had been carrying a 6-month-old fetus; its chord had tangled around its neck. A placenta previa was also present. It still remains a mystery, as to whether the patient knew that she was pregnant, or whether she had purposely hidden the fact from her family. In either case, it cost her her life and left her mother and three children in total distress. This case illustrates the importance of a complete and thorough physical examination. It is particularly important to keep in mind, that one should not miss examining the pelvic organs in a female patient of childbearing age. This is especially true, if the presenting signs and symptoms do not correlate with or do not help to solve the puzzle of the presenting disease process.

Senthil Nachimuthu, MD, and Priyankha Balasundaram, MBBS. Department of Medicine, Tulane University School of Medicine, New Orleans, LA.