Obstetric case reports 855 Alvarez M, Lockwood CJ, Ghidini A et al. 1992. Prophylactic and Mitty H, Sterling K, Alvarez M et al. 1993. Obstetric haemor- emergent arterial catheterization for selective embolisation in rhage: prophylactic and emergency arterial catheterization and obstetric hemorrhage. American Journal of Perinatology 9:441 – embolotherapy. Radiology 188:183 – 187. 444. Nikolic B, Spies JB, Lundsten MJ et al. 2000. Patient radiation Badawy SZA, Etman A, Singh M et al. 2001. Uterine artery dose associated with uterine artery embolisation. Radiology embolisation: the role in obstetrics and gynecology. Clinical 214:121 – 125. Imaging 25:288 – 295. Ojala K, Perala J, Kariniemi J et al. 2005. Arterial embolisation and ¨ ¨ Brown BJ, Heaston DK, Poulson AM et al. 1979. Uncontrollable prophylactic catheterization for the treatment for severe obstetric postpartum bleeding: a new approach to hemostasis through haemorrhage. Acta Obstetricia Gynecologica Scandinavica angiographic arterial embolisation. Obstetrics and Gynecology 84:1075 – 1080. 54:361 – 365. Pelage JP, Le Dref O, Mateo J et al. 1998. Life threatening Chou YJ, Cheng YF, Shen CC et al. 2004. Failure of uterine postpartum haemorrhage: treatment emergency selective arterial arterial embolisation: placenta accreta with profuse postpartum embolisation. Radiology 208:359 – 362. haemorrhage. Acta Obstetricia Gynecologica Scandinavica Salomon LJ, De Tayrac R, Castaigne-Meary V et al. 2003. Fertility 83:688 – 690. and pregnancy outcome following pelvic arterial embolisation Combs CA, Murphy EL, Laros RK. 1991. Factors associated with for severe postpartum haemorrhage. A cohort study. Human postpartum haemorrhage with cesarean deliveries. Obstetrics Reproduction 18:849 – 852. and Gynecology 77:77 – 82. Seror J, Allouche C, Elhaik S. 2005. Use of Sengstaken – Blakemore Dildy GA. 2002. Postpartum haemorrhage: new management tube in massive post partum haemorrhage: a series of 17 cases. options. Clinical Obstetrics and Gynecology 45:330 – 344. Acta Obstetricia Gynecologica Scandinavica 184:660. Greenwood LH, Glickman MG, Schwartz PE et al. 1987. Silver RM, Landon MB, Rouse DJ et al. 2006. Maternal morbidityJ Obstet Gynaecol Downloaded from informahealthcare.com by HINARI on 06/27/12 Obstetrics and nonmalignant gynecological bleeding: treat- associated with multiple repeat caesarean deliveries. Obstetrics ment with angiographic embolisation. Radiology 164:155 – and Gynecology 107:1226. 159. Vedantham S, Goodwin SC, McLucas B et al. 1997. Uterine Hansch E, Chitkara U, McAlpine J et al. 1999. Pelvic arterial artery embolisation: an underused method of controlling pelvic embolisation for control of obstetric hemorrhage; a ﬁve year hemorrhage. American Journal of Obstetrics and Gynecology experience. American Journal of Obstetrics and Gynecology 176:938 – 948. 180:1454 – 1460. Yamashita Y, Harada M, Yamamoto H et al. 1994. Transcatheter Maier RC. 1993. Control of post partum hemorrhage with uterine arterial embolisation of obstetric and gynecological bleeding: packing. American Journal of Obstetrics and Gynecology efﬁcacy and clinical outcome. British Journal of Radiology 169:317 – 321. 67:530 – 534. For personal use only. Correspondence: S. Mushtaq, Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Centre, MBC 52, PO Box 3354, Riyadh 11211, Saudi Arabia. E-mail: email@example.com DOI: 10.1080/01443610701748658 Pregnancy following Whipple’s procedure A. E. MADU & O. OSOBA Department of Obstetrics and Gynaecology, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK Introduction Case history Neoplasms of the endocrine pancreas may be functional (secretory) A 28-year-old primigravida booked at our unit for antenatal care and thus can cause clinically recognisable syndromes. They may at 8 weeks’ gestation. She had pancreaticoduodenectomy for a also be non-functional (non-secretory) causing mainly pressure pancreatic tumour about 8 weeks before her booking. She had a effects. Whatever the type of tumour, the treatment is basically the 1-year history of epigastric pain and occasional nausea and same, that is pancreaticoduodenectomy (Whipple’s Operation or vomiting. The pain had increased in severity, occurred mainly Whipple’s procedure). The procedure was ﬁrst performed by after food and mostly in the early hours of the morning. Her GP Alessandro Codivilla in 1898, however, it is widely associated with who thought it was peptic ulcer had prescribed omeprazole Allan Whipple (who performed it in 1935), after whom it was (proton pump inhibitor), which gave her some relief from time to named. time. She also had weight loss but her appetite remained Early procedures were associated with very high mortality, up to unchanged. Her symptoms however had nocturnal exacerbations. 25% in the 1970s but this is now 54%. The pancreaticojejunost- There was associated moderate vertigo for which she was given omy is the Achilles’ heels of the procedure, because in the best betahistine. She smoked 15 cigarettes/day but did not take surgical hands, the leak rate is 10 – 20% (USC 2002; Boonnuch alcohol. She was known to suffer from irritable bowel et al. 2005; Chabot 1993). When the procedure is performed during syndrome and was on mebeverine. She had a family history of pregnancy or shortly before pregnancy, the emphasis would focus hypertension. Abdominal ultrasound showed a benign-looking on the survival of the fetus irrespective of the functional state of the pancreatic mass measuring (3 6 3 cm) at the head of the tumour. Here, we present a case of fetal survival and normal delivery pancreas, probably a pseudocyst. The liver, kidneys and at 36 weeks’ gestation following Whipple’s procedure. gallbladder were normal.
856 Obstetric case reports Her GP referred her to the physician/gastroenterologist for spontaneous but was later augmented with oxytocin to correct assessment. The proton inhibitor was stopped and the assessment incoordinate uterine contractions. She however progressed to included a test for insulin C-peptide to rule out insulinoma; tests normal delivery of a healthy male baby weighing 2,635 g in direct for gut hormones; urgent gastroscopy to look for duodenal ulcers occipitoposterior position following episiotomy. The baby had that may be caused by a gastrinoma and a CT scan. The C-peptide Apgar scores of 9 at 1 min and 9 at 5 min. Labour had lasted for and gut hormone proﬁle tests were all normal. A gastroscopy was 8 h 40 min and the total blood loss was 350 ml. Mother and baby attempted but the procedure was abandoned because she was had no problems in the immediate puerperium and the latter unable to tolerate it. needed no admission to the special baby care unit. She was A CT scan showed a large mass of 3.7 cm, round and well discharged with a follow-up arranged with the medical, surgical deﬁned in the inferior head of the pancreas and the uncinate and obstetric teams. process of the pancreas. There was some associated calciﬁcation but no dilatation or obstruction of either the bile or pancreatic duct. The tumour was in contact with the ﬁrst jejunal branch of the Discussion superior mesenteric vein but not with the main vein. No lymphadenopathy or intrahepatic lesion was seen. The mass was The occurrence of a benign pancreatic tumour in pregnancy is not particularly vascular and thus unlikely to be a gastrinoma or very rare. A prolonged and extensive literature search did not insulinoma. She was then referred for review by a hepatobiliary yield any article on pregnancy following Whipple’s operation. surgeon who after review concluded that at her age, the tumour There were no articles on the incidence of Whipple’s procedure was most likely to be neuroendocrine in origin and non-secreting. in pregnancy or the incidence of benign neuroendocrine She later had a pancreaticoduodenectomy (Whipple’s resection). pancreatic tumour in pregnancy for citation. Pancreatic tumours She had no intraoperative complications but the postoperative in pregnancy should be surgically removed. Even those classed asJ Obstet Gynaecol Downloaded from informahealthcare.com by HINARI on 06/27/12 period was complicated by intermitted diarrhoea (steatorrhea) and benign could grow rapidly in pregnancy due to the inﬂuence of occurred after intake of any fatty foods. Her stool tended to ﬂoat the female sex hormones (Ganepola et al. 1999), causing greater on water. She was then given pancreatic enzyme supplementation pressure symptoms. The procedure of choice, Whipple’s proce- 10,000 units, two tablets, three times daily, to be adjusted dure, is a major surgical operation. For the recuperating woman according to her fat intake. She also suffered nocturnal reﬂux who is in the ﬁrst 13 weeks of pregnancy, one of the signiﬁcant symptoms postoperatively and was given omeprazole 40 mg daily. risks is miscarriage. Many would consider termination of She was recommended to have higher doses of the proton pump pregnancy on the grounds of maternal well-being. Since our inhibitors in the long term because her duodenum was removed patient did not have any period before the pregnancy, we but as a temporary measure she was given esomeprazole to provide calculated retrospectively that our patient may have become a better control of her symptoms. pregnant in 52 weeks following the procedure. Thus, her drug For personal use only. Histology conﬁrmed a pancreatic tumour measuring use in pregnancy had occurred in the pre-embryonic and 3.5 6 3 cm, benign and neuroendocrine in origin. It had a small embryonic phases of organogenesis. possibility of local recurrence with low-grade malignant potential. Of the seven cases Sciscione et al. (1996) studied, that had the Immunohistochemistry studies show tumour cells to be positive for operation in pregnancy, six resulted in live births and one had a neurone speciﬁc enolase and negative for cytokeratin. There was maternal postoperative complication of pseudomembranous colitis demonstrable immunoreactivity for chromogranin and synapto- caused by Clostridium difﬁcile. Despite the effective treatment given, physin. the fetus was compromised at 27 weeks and suffered in-utero She was discharged, with follow-up arranged to take place every intracranial haemorrhage and did not survive despite prompt 3 months with the hepatobiliary unit. However, 8 weeks following caesarean section. The authors advised consideration of mother the operation, she went to her GP for routine checks and and fetus before such a major procedure. In other isolated complained she had not had a period. A urinary pregnancy test malignant cases reported (Ruano et al. 2001; Haddad et al. was positive and vaginal examination revealed a 6 – 8-week 2005), the authors advocated radical surgery and special prenatal sized uterus. A transvaginal scan later conﬁrmed a viable care to improve pregnancy outcome. intrauterine of 6 weeks’ gestation. She was then referred for early Our patient had her postoperative period complicated by obstetric care. steatorrhea which apparently had no signiﬁcant adverse effect on Concerns were raised about her medication following the the fetus. There had been concerns about her medication prior to operation. She continued taking folic acid, esomeprazole, Creon the discovery of her pregnancy; possible nutritional deﬁciency and Gaviscon but mebeverine was discontinued. Her body mass following the operation (and in association with steatorrhea) and index (BMI) on booking was 26. Routine booking investigations subsequent development of gestational diabetes, which was were normal, including the triple test at 16 weeks and anomaly controlled by diet. These are risks factors for pregnancy loss and scan at 19 weeks. growth restriction, and thus made fetal surveillance imperative. She developed signiﬁcant glycosuria at 27 weeks and glucose Also, our patient had cholangitis at 34 weeks, risking pre-term tolerance test conﬁrmed gestational diabetes, which was later labour and delivery. Her pregnancy was complicated by recurrent controlled by diet. She was seen every 2 weeks in the antenatal upper abdominal and epigastric pain which can be common in clinic and had shared care with input from the local surgical team pregnancy but simulates post-Whipple’s complaints. The hypo- and the surgical team that performed the Whipple’s procedure. chondrial and epigastric pain persisted during the intra-partum A serial growth scan at 30 and 34 weeks showed growth in the period, thus simulating uterine rupture or placental abruption. She 50 – 95th centile. was also very strong-willed and went on to have a normal vaginal At 23 and 26 weeks, she was admitted for upper abdominal pain delivery. and was treated symptomatically, as no cause was found after Thus our experience and that of others (Ruano et al. 2001; Levy clinical and biochemical investigations. At 34 weeks, she was et al. 2004; Fernandez et al. 2005) strongly suggests that admitted for feeling unwell, vomiting and upper abdominal pain. pregnancy after Whipple’s procedure does not have a signiﬁcant She had pyrexia, a raised white cell count (17.7 6 109/l and harmful effect on the fetus if adequate prenatal care is in place. neutrophilia (16.8 6 109/l. Alanine transaminase (128 m/l) was also raised and she was treated for cholangitis with intravenous Augmentin. References At 36 weeks, she was admitted with another episode of severe right upper abdominal pain. A decision was then made to induce Boonnuch W, Akaraviputh T, Lohsiriwat D. 2005. Whipple’s labour. On vaginal examination, Bishop’s score was 7 and an operation with an operative mortality in 37 consecutive patients: amniotomy was performed; the liquor was clear. She had an Thai surgeons’ experience. Journal of the Medical Association of epidural anaesthetic for pain relief in labour. Labour was Thailand 88:467 – 472.
Obstetric case reports 857 Chabot JA. 1993. The Whipple Procedure 1935 – 1993. PandS Levy C, Pereira L, Dardarian T, Cardonick E. 2004. Solid Medical Review 1:1. pseudopapillary pancreatic tumor in pregnancy. A case report. Fernandez EML, Malagon AM, Gonzalez IA, Montes RM, Luis Journal of Reproductive Medicine 49:61 – 64. HD, Hermoso FG et al. 2005. Mucinous cystic neoplasm of the Ruano R, Hase EA, Bernini C, Steinman DS, Birolini D, Zugaib pancreas during pregnancy: the importance of proper manage- M. 2001. Pancreaticoduodenectomy as treatment of adenocar- ment. Journal of Hepatobiliary Surgery 12:494 – 497. cinoma of the papilla of Vater diagnosed during pregnancy. Ganepola GAP, Gritsman AY, Asimakopulos N, Yiengpruksawan Journal of Reproductive Medicine 46:1021 – 1024. A. 1999. The American Surgeon 65:105 – 111. Sciscione AC, Villeneuve JB, Pitt HA, Johnson TR. 1996. Haddad O, Porcu-Buisson G, Sakr R, Guidicelli B, Letreut YP, American Journal of Perinatology 13:21 – 25. Gamerre M. 2005. Diagnosis and management of adenocarci- USC. 2002. Whipple Operation. Los Angeles: University of noma of the ampulla of Vater during pregnancy. European Southern California, Center for Pancreatic and Biliary Disease. Journal of Obstetrics, Gynaecology and Reproductive Biology pp 1 – 4. 119:246 – 249. Correspondence: A. E. Madu, Yeovil District Hospital NHS Foundation Trust, Yeovil, Somerset, UK. E-mail: firstname.lastname@example.org DOI: 10.1080/01443610701800319J Obstet Gynaecol Downloaded from informahealthcare.com by HINARI on 06/27/12 Negative pregnancy test: Could it be a molar pregnancy? O. OFINRAN1, S. PAPAIOANNOU1, V. KANDAVEL1, S. SHRIVASTAVA1, S. HALL1 & J. TZAFETTAS2 1 Department of Obstetrics and Gynaecology, Heart of England NHS Foundation Trust, Princess of Wales Women’s Unit, For personal use only. Heartlands Hospital, Birmingham, UK and 2Department of Obstetrics and Gynecology, Aristotle University, Ippokration University Hospital, Thessaloniki, Greece however four pregnancy tests in a row had been negative. Pelvic Introduction examination this time revealed a closed cervical os with minimal The urine pregnancy test is the standard instrument used in the bleeding and a 20-week size uterus. A urine pregnancy test was triage of reproductive age women presenting with lower abdominal faintly positive on this occasion and an urgent pelvic ultrasound pain and/or vaginal bleeding. A positive result directs the diagnostic scan showed a mass in the uterine cavity with solid areas process towards complications of early pregnancy (miscarriage, interspaced with cystic areas consistent with the presence of ectopic, molar) that need immediate attention. A negative molar tissue. Serum beta human chorionic gonadotrophin (bhCG) pregnancy test on the other hand essentially excludes the above. was in excess of 500,000 IU/l and her haemoglobin level was The case presented illustrates a noteworthy exception to the above 10.6 g/dl. common sense emergency gynaecology algorithm. Failure to take A suction evacuation of the uterus under ultrasound guidance account of this exception might lead to delays in the diagnosis of a was performed the same day, during which 1.3 l of blood-stained molar pregnancy, as well as in the appropriate management and soft vesicular tissue was evacuated. Her haemoglobin on the third prognosis of women with this potentially malignant condition. postoperative day was 7.0 g/dl. She declined blood transfusion and was discharged home on oral iron. Histopathology conﬁrmed a complete hydatidiform mole and she was registered with the Case report Trophoblastic Tumour Screening and Treatment Centre at Charing Cross Hospital, London, in accordance with current A 17-year-old woman presented to the gynaecology emergency guidelines. When she was seen in the clinic 2 months later, she felt department with a 2-week history of vaginal bleeding, suprapubic well and reported that she had her periods as usual. pain and persistent vomiting. A home urine pregnancy test had been negative. Her last menstrual period was reported to be about 2 weeks previously and her menstrual cycles had been regular. On Discussion examination, she was tachycardic, while her blood pressure was normal. Her abdomen was soft. A non-tender, smooth and mobile The incidence of gestational trophoblastic neoplasia in the UK is 1 lower abdominal mass was palpable. Pelvic examination revealed a in 714 live births (Tham et al. 2003). The majority of women with closed cervix and an enlarged uterus equivalent to 14 weeks’ complete hydatidiform mole present with vaginal bleeding, an gestation size. However, the repeat urine pregnancy test was again enlarged uterus with a size larger than dates and abnormally high negative. The gynaecology registrar on-call felt there was no serum bhCG levels. Medical complications such as hyperemesis, urgency, thus the patient was discharged home and given an anaemia, early pregnancy induced hypertension and hyperthyroid- appointment for a gynaecology outpatient clinic for investigation of ism are relatively rare (Jauniaux 1998). A positive urine pregnancy the enlarged uterus. test plays a pivotal role in the early diagnosis by prompting further She collapsed at home 2 weeks later and at the Accident and investigations in these patients. In countries with restricted Emergency department, she gave a history of heavy vaginal facilities, severe genital tract haemorrhage, pulmonary embolism bleeding with passage of clots for 8 days, persistent vomiting and and high output cardiac failure are still potentially lethal com- increasing abdominal distention and pain. She recalled that she last plications that affect women with molar pregnancies (Mehra et al. had unprotected sexual intercourse about 5 months before, 2005; Flam et al. 1998). Characteristic ultrasound appearances