The day started out fairly routine. I was moonlighting at my community hospital as the "house doc" while also covering for our family practice residency patients. I felt confident about handling both jobs since it wasn't difficult to triage for OB and also supervise the management of one or two low-risk patients in labor. Besides, the house OB was always available in case of emergencies. Although that night had been particularly busy, I'd been able to attend to all the patients at a steady pace.

The woman I'll call Mrs. Rios came in with her husband sometime between the deliveries of two residency patients. This was her fifth baby, and she'd had no complications with any of her prior pregnancies. She was in rapidly progressing labor, crying in pain. Her blood pressure was 150/100. Using my conversational Spanish, I talked with her briefly, made a quick evaluation, and paged her primary OB. Fortunately, he was just down the hall, and arrived immediately.

While I was managing the active labor of two other patients, Mrs. Rios had her baby without incident. Her OB finished his paperwork and left within an hour. During that time, I was struggling with a delivery in the next room, and had called the house OB to help with a vacuum delivery. A nurse informed me that Mrs. Rios was complaining of abdominal pain, and I told her I'd evaluate her as soon as possible.

"Okay," I said gently, wiping her sweaty brow. "Try to be calm, and take deep breaths."

I gathered from the nurse that her pain had continued after labor, and was diffuse throughout her abdomen, particularly in the epigastric region. Her blood pressure was now 155/95. She continued to sob and writhe in pain. Her husband began to yell at me, "What's wrong with her?"

"I don't know," I said truthfully, as alarmed as he was. "I'll give her something that should help."

An ominous feeling that something's going wrong

I left the room visibly shaken, with that doctor instinct that something was terribly wrong. Since I was only a few years out of residency and had never seen anything like this before, I called the house OB, whom I trusted. We discussed Mrs. Rios' case quickly. I told him I thought a uterine rupture was unlikely, since she wasn't bleeding, and her fundus was small and firm. She had a history of gastritis, so I considered the possibility of an ulcer. I was also concerned about pregnancy-induced hypertension, but the abdominal pain seemed too severe for that. Besides, she wasn't a classic PIH patient: this was her fifth baby, and it had already been delivered.

Could some other process be going on that was causing the pain and elevating her blood pressure? I didn't know, and relied heavily on the OB's experience. We ordered labs and started MgS04 for PIH, and gave her Maalox, Pepcid, and Demerol for ulcers. Then we notified her primary OB who agreed with the plan.

The house OB then came in with me to evaluate Mrs. Rios. If anything, she was worse. She wouldn't meet our eyes, and continued to writhe and moan in pain. She struggled to sit up and reached out to the bassinet. "Give him to me," she cried in Spanish. "I'm dying! I'm dying!" Her husband, stricken with panic, placed the baby in her arms. She rocked him back and forth, soaking his face with her tears. "Adios, mi amor," she murmured. "Te amo, te amo."

Mr. Rios turned to us, frantic with fear: "Help her," he cried. "Why won't you help her?"