Author: Thomas Mac Mahon / Editor: Nigel Salter / Reviewer: Jolene Rosario, Thomas Mac Mahon / Codes: ACCS LO 2, IP1, IP3, ObC12, ObC16, ObC9, ObP3, RP6, RP7, SLO3Published: 04/03/2023

A 40-year-old female presents to the Emergency Department (ED) feeling lethargic for 24 hours. She complains of a frontal headache, nausea, mild photophobia and left sided neck pain with stiffness. She is 17 weeks pregnant with a confirmed intrauterine pregnancy.

Recently she had been well, apart from a viral respiratory tract infection five weeks previously. She has a background medical history of hypothyroidism and a caesarean section for shoulder dystocia 18 months ago. She takes levothyroxine and folic acid. She has had no foreign travel in the last twelve months.

On initial assessment, she has a pyrexia of 38.5 C, pulse rate of 110/minute, oxygen saturations of 99% on room air, blood pressure of 124/58 and respiratory rate of 30/minute. She is noted to be photophobic and to have neck stiffness which is more marked on the left, a mildly erythematous pharynx but no cervical lymphadenopathy. Pupils are equal and reactive. Cardiovascular, respiratory and neurological examinations are unremarkable. Her abdomen is soft, with a fundal height equal to her dates. She has no rash.

You make an initial diagnosis of possible bacterial meningitis and cover her with appropriate antibiotics while awaiting the results of your investigations.

Her blood tests show a raised white cell count of 23.4, with a marked neutrophilia (20.7). Her CRP is elevated at 64.3, with a mildly raised INR of 1.15. Her lactate is 3.3. Her renal and liver profiles are normal. Chest x-ray and urinalysis are normal. A lumbar puncture is performed and results are within normal limits, with an opening pressure of 19cm H2O, white cell count of 5, red cell count of 8 and no xanthochromia. Blood cultures are sent.

Over the next two hours in the Emergency Department, she develops increasing lower back pain, followed by suprapubic and right iliac fossa pain and a small amount of vaginal bleeding. You reassess her and find that she now has palpable and painful uterine contractions. You cannot detect a fetal heartbeat with a Doppler ultrasound.

Despite antibiotics, fluids and paracetamol she remains febrile and tachycardic.

You reassess her vital signs and note that her blood pressure has now dropped to 84/54. You insert an arterial and central line, commence her on a noradrenaline infusion and arrange for her admission under the obstetric team with a diagnosis of septic shock due to septic abortion.