Q: 34 year old female who is on long term peritoneal dialysis for End Stage Renal Disease is admitted to ICU for community acquired pneumonia. Nephrology service decided to continue peritoneal dialysis while patient is in ICU. On third day of admission in ICU peritoneal fluid appeared to be blood stained. Labs including hemoglobin remains stable. Clinically patient continue to show signs of improvement. Your next step?

A) Order serial H/H (Hb and Hematocrit)
B) Obtain CT of abdomen to rule out retroperitoneal hematoma
C) Obtain menstrual history from patient
D) Make her NPO 
E) Order CPK to rule out rhabdomyolysis 


Answer: C

Though there could be other causes of blood stained peritoneal dialysate but in a young female patient who has no other clinical signs of deterioration, the most common cause is menstruation unless proved otherwise! It is either due to ovulation which occurs in mid-cycle or due to endometriosis , where retrograde menstruation could be the reason of blood stained peritoneal dialysate. Alike hematuria, even one cc of blood is enough to give the whole peritoneal dialysate an appearance of blood stained. It requires rapid flushes and instillation of heparin in the dialysate to prevent catheter clotting. Usually, it clears on its own.


References:

1. Tse KC, Yip PS, Lam MF, et al. Recurrent hemoperitoneum complicating continuous ambulatory peritoneal dialysis. Perit Dial Int 2002; 22:488.

2. Dimitriadis CA, Bargman JM. Gynecologic issues in peritoneal dialysis. Adv Perit Dial 2011; 27:101.