Case StudyPamela Harnden

Introduction 37yr old woman

Gravida 5 Para 4

38wks

Previous history of raised blood pressure in previous pregnancies

Presents with epigastric pain, +1 protein, mild oedema of the hands, normotensive

Normal fetal growth and movements

Impressions?

Lab ResultsRaised WCC

Raised AST & ALT on Liver Function Test

Normal fetal growth & normal dopplers on ultrasound

Diagnosis?

Actually happened It was recommended by the medical officer on

duty that despite 4 previous normal births she should undergo immediate emergency caesarean section for the diagnosis of Pre Eclampsia

SOMANZ guidelinesPre Eclampsia is a multi system disorder,

characterized by hypertension and involvement of one or more other organ systems and/or the fetus

As this classification is based on clinical data, it is possible that women with another condition will sometimes be classified incorrectly as having preeclampsia during pregnancy. (SOMANZ guidelines)

Diagnosis of Pre EclampsiaHypertension arises after 20 weeks gestation and is accompanied by one or more of the following:

Significant proteinuria – dipstick proteinuria subsequently confirmed by spot urine protein/creatinine ratio ≥ 30mg/mmol. In view of the close correlation between spot urine protein/creatinine ratio and 24 hour urine excretion, the latter is rarely required

Serum or plasma creatinine > 90 μmol/L

Oliguria

Hematological involvemento Thrombocytopeniao Hemolysiso Disseminated intravascular coagulation

Liver involvemento Raised serum transaminaseso Severe epigastric or right upper quadrant pain.

Neurological involvemento Convulsions (eclampsia)o Hypereflexia with sustained clonuso Severe headacheo Persistent visual disturbances (photopsia, scotomata, cortical blindness, retinal vasospasm) o Stroke

Pulmonary edema

Fetal growth restriction

Placental abruption

SuspectedAfter appendicitis, biliary tract disease is the second most

common general surgical condition encountered in pregnant women (Sungler et al, 2000)

Repeated pregnancy causes increased gallstone formation due to changes in gallbladder kinetics leading to stasis and stone formation (Hossain et al, 2003)

It has been postulated that pregnancy is associated with an increased percentage of colic acid, increased cholesterol secretion, increased bile acid pool size, decreased enterohepatic circulation, decreased percentage of chenodeoxycholic acid and increased bile stasis (Barone et al 1999)

Lab Results for Gall StonesElevated ALT

Bilirubin and the enzyme alkaline phosphatase are usually elevated in acute cholecystitis, and especially in choledocholithiasis (common bile duct stones). Bilirubin is the orange-yellow pigment found in bile. High levels of bilirubin cause jaundice, which gives the skin a yellowish tone

Levels of liver enzymes known as aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are elevated when common bile duct stones are present.

A high white blood cell count is a common finding

Ultrasound of Gall Bladder Identifies stones

Thickening of the Gall bladder wall

Air in the gallbladder wall may indicate gangrene.

Management (Surgical) Laparoscopic cholecystectomy can be safe in the 2nd

trimester of pregnancy with the administration of tocolytic should premature labour threaten

At present, the general contra-indications for laparoscopy include:

Absolute contra-indications:

Hypovolemic shock, massive bleeding or hemodynamic instability.

Severe cardio respiratory disease.

Uncontrolled coagulopathies.

Relative contra-indications:

Peritonitis

Portal hypertension

Multiple previous procedures/extensive intraabdominal adhesions

Morbidities Morbidity ranges from 1 to 9% and CBD injuries

from 0.2 to 0.7% and they both largely depend on the surgeon's experience. Conversion rates are from 1.8 to 7.8%. Specific complications include hemorrhage, bile leaks, retained stones, wound infections and incisional hernias

Management (medical)Known to resolve following pregnancy

Oral Dissolution therapy – Contraindicated in pregnancy (Fromm, 1989)

Intravenous fluids

Antibiotics

Analgesia

(Crass & Bellows, 2005)

Role of the MidwifeTo promote normal birth

Understand the definition of pre eclampsia

Question the diagnosis

Support the woman to question the diagnosis of pre eclampsia

Advocate for the woman

Refer for 2nd opinion give impressions to the consultant

Implications for labourAcute attack during labour could mean the

need for strong analgesic

Misdiagnosis of pre eclampsia has serious implications for mode of birth

Induction – cascade of intervention

Emergency C/S increased risk of morbidities related to surgery

Implications for postnatal period Informing GP of suspected diagnosis

Ongoing dietary control

Education of suspected signs of cholecystitis

Further acute attacks could result in the need for surgery which could affect breastfeeding

References Barone JE, Bears S, Chen S, Tsai J, Russell JC. (1999)Outcome study of

cholecystectomy during pregnancy. Am J Surg. 177:232–6

Crass, R.A. & Bellows, C.F. (2005) Management of Gallstones. Am Fam Physician. 15;72(4):637-642. Dig Dis Sci. 34(12 Suppl):36S-38S.

Fromm, H (1989) Gallstone dissolution therapy with ursodiol. Patient selection.

Hossain GA, Islam SM, Mahmood S, Chakrabarty RK, Akhter N. (2003) Gall stone in pregnancy. Mymensingh Med J. 12(2):112-6.

Sungler P, Heinerman PM, Steiner H, Waclawiczek HK, Holzinger J, Mayer F, et al.(2000) Laparoscopic cholecystectomy and interventional endoscopy for gallstone complications during pregnancy. Surg Endosc. 14:267–71