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A 46 year old white woman presented to her local casualty department. She had been experiencing vaginal bleeding for 10 days, and the bleeding had become particularly heavy in the past three days. She had also felt generally unwell for around a week with malaise, fatigue, headaches, anorexia, and vomiting.
She and her partner had been trying to conceive. Her last menstrual period had been 10 weeks ago and she had recently tested positive with a urinary (β human chorionic gonadotrophin) pregnancy testing kit. She had three children from a previous partner. Two of these pregnancies were complicated by hypertension from 36 weeks onwards. She thought that she may have had two miscarriages the previous year, which had not been investigated.
The previous year she had a measured blood pressure of 165/90 mm Hg. She gave a history suggestive of Raynaud's syndrome but had no other symptoms or past medical history of note. She was taking no regular medication.
She was initially referred to the on-call gynaecologist who found her to have a blood pressure of 240/127 mm Hg and a heart rate of 100 beats/minute. She appeared unwell and was dyspnoeic at rest. On abdominal examination the uterus was not palpable, and on vaginal examination the cervical os was open and bleeding. Chest auscultation demonstrated bi-basal, inspiratory crepitations. No other abnormalities were found on examination. Urinary β human chorionic gonadotrophin was negative. Urinalysis showed large amounts of blood and protein, but the patient was actively bleeding from the vagina when this test was done. The tabletable shows the results of her laboratory tests.
She was referred for an urgent medical opinion. A central venous line was inserted and a chest radiography performed (figure(figure).). At this point, while still in the casualty department, she had several generalised tonic-clonic convulsions.
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Competing interests: None declared.
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