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 Results Raised 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 guidelines Pre 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 accompaniedby 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 involvement o Thrombocytopenia o Hemolysis o Disseminated intravascular coagulation Liver involvement o Raised serum transaminases o Severe epigastric or right upper quadrant pain. Neurological involvement o Convulsions (eclampsia) o Hypereflexia with sustained clonus o Severe headache o Persistent visual disturbances (photopsia, scotomata, cortical blindness, retinal vasospasm) o Stroke Pulmonary edema Fetal growth restriction Placental abruption
Suspected After 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 Stones Elevated 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 threatenAt 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 surgeons 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 eclampsiaAdvocate for the womanRefer for 2nd opinion give impressions to theconsultant
Implications for labour Acute 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 postnatalperiod 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