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GP beware - obstetrics

Dr Lucy C Chappell, consultant obstetrician, and GP registrar Dr Suzy Duckworth advise on three cases with misleading initial presentations

Case 1

Mrs A, aged 39 years, comes to see her GP at 28 weeks’ gestation in her first pregnancy for a routine check. She conceived by IVF, but has no other relevant medical history, and is currently well with no symptoms. Her blood pressure today is 145/95mmHg, with a booking blood pressure noted by the midwife as 135/85. She says she forgot to produce a urine specimen. The GP can hear the foetal heart on auscultation and asks her to make an appointment in one week’s time with the midwife at the practice.

A couple of days later, the woman feels increasingly unwell, with a headache and abdominal pain, and attends the obstetric assessment unit at the hospital. Her blood pressure is found to be 164/108, with 4+ dipstick proteinuria and foetal growth restriction on ultrasound. Within two days of admission, her LFTs become abnormal and she is delivered by emergency caesarean section. She recovers, but needs ongoing antihypertensive treatment, and the baby comes home after 10 weeks in the neonatal unit.

GP’s diagnosis

Routine antenatal findings.

Actual diagnosis

Pre-eclampsia.

Clues

All pregnant women should be asked to produce a urine specimen, and this is particularly important in women who are hypertensive. A woman may have risk factors for pre-eclampsia (first pregnancy, age 39 years, IVF, and a high booking blood pressure – a diastolic pressure over 80 in this case) but some women may develop pre-eclampsia with no risk factors.

Take-home message

Check blood pressure and dip a urine specimen on every pregnant woman at every visit. Refer a woman to the hospital if there is any suspicion of pre-eclampsia based on hypertension, proteinuria or other symptoms or signs. The pre-eclampsia community guidelines (PRECOG), published by the BMJ, are available through open access and include referral criteria for step-up care.1

Case 2

A 26-year-old, Miss B, comes to see the GP at 11 weeks of pregnancy with breathlessness, cough and right-sided chest soreness over the past few days. She is otherwise well, apart from a BMI of 32, and is not sure whether the breathlessness is due to the pregnancy or something else. She has an appointment with the midwife later in the week. On examination, she is tachycardic (104bpm), with a temperature of 37.4°C, and has some signs of left lower lobe consolidation.

The GP thinks she probably has a community-acquired lower respiratory tract infection and starts her on antibiotics. One day later she attends hospital with worsening pleuritic pain and breathlessness – her oxygen saturations are 93% on air and she has marked tachycardia and dyspnoea. A pulmonary embolus is subsequently diagnosed on computed tomography pulmonary angiography and she is anticoagulated for the rest of the pregnancy.

GP’s diagnosis

Community-acquired pneumonia.

Actual diagnosis

Pulmonary embolism.

Clues

It can be difficult to differentiate pneumonia and pulmonary embolism in primary care based on physical examination alone, but absence of a fever and presence of other suspicious signs should prompt further action.

Take-home message

Pregnant women are at increased risk of pulmonary embolism and the triennial Confidential Enquiry into Maternal Deaths repeatedly stresses the importance of having a raised suspicion for thromboembolic disease in pregnancy.2 Refer a pregnant woman to secondary care if there is suspicion of a thromboembolic event.

Case 3

Ms C, a 34-year-old, is discharged home on day two after a forceps delivery of her second child. She arrived in early pregnancy from Eastern Europe and speaks limited English. Her partner takes her to the out-of-hours GP on day three, as she is feeling feverish, shivery and unwell with a sore throat, diarrhoea and bad after-pains. The GP diagnoses a probable viral infection and advises paracetamol and fluids. She goes home, but her partner takes her to A&E a few hours later with severe lower abdominal pain and vomiting. A diagnosis of genital tract sepsis is suspected. Ms C is treated with broad-spectrum intravenous antibiotics. A vaginal swab grows group A streptococcus.

GP’s diagnosis

Viral infection.

Actual diagnosis

Group A streptococcal genital tract sepsis.

Clues

Diarrhoea is a common and important symptom of pelvic sepsis, and should raise suspicion of genital tract sepsis in the immediate postpartum period, particularly in conjunction with other signs such as fever.

Take-home message

Sepsis is now the leading direct cause of maternal death in the UK and group A streptococcal infection can lead to rapid progression of illness.

All of the mothers who died from group A streptococcal sepsis in the most recent three years reported (2006-8) either worked with, or had, young children, and several of the mothers had a history of recent sore throat.2 Refer a woman urgently with symptoms and signs of genital tract sepsis and consider prompt broad-spectrum intravenous antibiotic therapy. For GPs, the Confidential Enquiry into Maternal Deaths recommends being alert for severe after-pains and diarrhoea as symptoms and pyrexia, tachycardia or tachypnoea.2

Dr Lucy C Chappell is a clinical senior lecturer in obstetrics at King’s College London, and honorary consultant obstetrician at Guy’s and St Thomas’ NHS Foundation Trust

Dr Suzy Duckworth is a GP registrar in Norfolk

References

  1. Milne F, Redman C, Walker J et al. The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community. BMJ 2005;330:576
  2. Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006-08. The eighth report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118(suppl. 1):1-203

Readers' comments (5)

  • I personally find this series irrelevant & somewhat condescending. Are these actually cases or were they cooked up. What right thinking student, let alone doctor would see a post partum lady with a high fever & severe after pains & conclude it is a 'probable viral infection'. I was hoping to receive some real pearls of wisdom, reading this article but have been sadly disappointed by both this article & the vascular one. The take home message appears to be the hospital doctor always right, GP always wrong.

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  • Find it hard to believe that primary care physicians can miss especially the last one if not the first two. Thankfully an alternative diagnosis was there showing us what possible differentials can be there. But common things happen commonly and bmi 32 plus tachycardia and chest pain should point more towards an embolus rather than lrti!

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  • I agree with the other comments. I don't feel most GPs would deal with any of the cases as described. High BP In antenatal patient - don't bother to insist on urine sample. Fever with severe abdominal pain in a postnatal patient - viral ? Wtf? Cough and shortness of breath in pregnant patient - what GP would consider a PE? The message seems to be that GPs are incompetent, and thank goodness the patients went to hospital where they were dealt with properly.

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  • I think the previous 3 comments are a bit harsh. While the stories themselves might be somewhat contrived, I quite like a case-based discussion to think through differentials and what my approach to a case would be. Also, remember some of those reading will be trainees. Stop being so sensitive and reading GP-bashing into everything.

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  • these forums are not closed, but open to anyone including the daily mail and trolls. hence the GP bashing theme is important here and could be easily mis-reported with those with an axe to grind. I suggest a more balanced approach.

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