A 32 year old primipara, at 39 þ 2 weeks, presented to labour ward, with left sided chest pain and shortness of breath. She was mildly hypotensive, tachycardic, dyspnoeic and extremely tender over the left side of her abdomen. There was no evidence of vaginal bleeding or uterine activity but fetal bradycardia was detected. It was presumed to be a major placental abruption. The patient was resuscitated with colloids and taken to theatre for immediate caesarean section.A live female, weighing 3.12 kg, was delivered with Apgar scores of 3 at 1 minute and 6 at 5 minutes. Cord bloods indicated a significant fetal acidosis (venous pH 6.77, BE À21.3, arterial pH 6.73, BE À24.0). The placenta had a succenturiate lobe but there was no retroplacental clot or evidence of haemorrhage. Her oxygen saturations remained stable throughout the anaesthetic state and there were no difficulties with ventilation. Post-operatively, she appeared fully recovered, with normal observations, although she still complained of a mild ache in her left loin. Post-operative electrocardiogram and chest X-ray were normal.One hour following delivery, she became hypotensive and her haemoglobin had fallen to 3.8 g/dL. She was acutely tender in the left loin with abdominal distension and increasing oedema. Abdominal ultrasound demonstrated a large haematoma in the area of the spleen suggesting spontaneous splenic rupture with retroperitoneal haemorrhage.The patient was returned to theatre with a combined surgical and obstetric team. Laparotomy was performed and massive retroperitoneal bleeding demonstrated. The liver, spleen and pelvic organs were confirmed to be normal. One thousand, two hundred and eighty grams of blood clot was removed, but despite extensive examination, no specific bleeding point was identified and the retroperitoneal space was packed with 18 abdominal packs. The bleeding appeared to be controlled and for the first time in several hours, her vital signs stabilised.Two hours following transfer to intensive therapy unit, she became hypotensive, tachycardic, hyperkalaemic and developed a coagulopathy suggesting continued intraabdominal bleeding. Her abdominal distension recurred resulting in abdominal compartment syndrome. She was taken back to theatre but once again no specific bleeding point was visualised. Therefore, the abdomen was repacked and the interventional radiology team was called.Using a right femoral artery approach, a flush aortogram was performed that identified the source of bleeding in the left upper quadrant. Selective angiograms of the splenic and left renal arteries were normal. Super-selective catheterisation of the left middle adrenal artery confirmed this to be the site of haemorrhage. There was no evidence of an aneurysm (Fig. 1a). The vessel was embolised with a 2 by 20 mm fibred platinum coil (Boston Scientific) using a coaxial catheter and haemostasis confirmed. Part of the coil was noted to be lying free in the aortic lumen but overall, the coil was thought to be secure (Fig. 1b). The radiologists felt it...

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We report a case of a 33-year-old nulliparous woman who, following a short prodromal illness, experienced a series of psychiatric and behavioural symptoms. These included states of terror, insomnia, delirium, self-harm and suicidal ideation, facial dyskinesias, verbigeration, cognitive impairment, reduced responsiveness, violence and paranoia. A diagnosis of anti-N-methyl-d-aspartate (NMDAR) encephalitis was made 50 days after symptom onset. Early tumour removal is associated with an improved prognosis and a laparoscopic oophorectomy was performed following detection of a dermoid cyst. Within 24 hours of the operation there was marked improvement in cognitive function and appetite.