A variant of Munchausen syndrome presenting as a gynaecological emergency

Abstract

A 42-year-old woman presented to the accident and emergency medicine department and was triaged to the gynaecological emergency unit with vaginal bleeding and incomplete miscarriage of 13 weeks’ gestation, which she brought in as a ‘specimen of products of conception’, following a miscarriage at home, in a plastic bag. Her last menstrual period was on 11 December 2005, which made her about 13 weeks’ gestation by date. She had three children and had had ‘three miscarriages’ previously. Her periods were regular, bleeding for 4–6 days in a regular cycle of 26–28 days. She had two ‘positive pregnancy tests’ at home but had never had an ultrasound scan before presentation. In her three previous miscarriages, there was no documented evidence of pregnancy either by a positive pregnancy test, elevated beta human chorionic gonadotrophin level, ultrasound scan findings of intrauterine pregnancy, whether viable or non-viable, or histological evidence of products of conception. She looked very distressed but her general physical examination was normal and her vital signs were within normal limits. Pelvic examination revealed minimal blood in the vagina and the cervix looked normal, but patulous. The uterus felt slightly bulky in size and mobile. An intravenous line was put up and blood taken for full blood count, C-reactive protein, grouping and saving serum, and serum beta human chorionic gonadotrophin estimation, and a pelvic ultrasound scan was arranged. The need for hospital admission was explained to complete the investigations and initiate appropriate management. She was also prescribed a course of antibiotics and analgesics. The specimen, which was in the early stage of decay, was inspected and found to be offensive. It was sent in formalin to the histopathology department for histology. The patient refused admission into the gynaecological ward and also a transvaginal ultrasound scan which had been arranged. She signed the discharge against medical advice form in spite of advice to the contrary. Further inquiry of her GP confirmed that she had had treatment for depressive illness in the past and has changed her GP frequently, making it difficult to arrange effective follow-up. The GP promised to a range psychiatric assessment as soon as practicable. It was not known at this stage that she was not actually having a miscarriage and that the purported products of conception were in fact chicken giblets.