View
225
Download
0
Category
Tags:
Preview:
Citation preview
WOGS meeting22 April 2015
Diagnostic Dilemma in pregnancy
Myriam Girgis
Year 1 ITP
Liverpool Hospital
Mrs KH
32 yo
G4P1 – NVD 8 years back
31+6
Epigastric + low back pain
HPCx- Epigastric + low back pain - 6/52
- Back pain: ‘horrid’, alternating sharp + dull, No radiation, not sciatic, trialled physiotherapy
- Epigastric pain: sharp, diffuse, worsening
- Loss of appetite - 2/52
- Loss of weight
- Bloating after meals
- Nausea & Vomiting
- Pruritus
- Reflux
FMF
- No contractions
- Nil PV loss/bleeding
- Nil headaches/visual disturbances
Antenatal HxHigh risk NT – T21 1:120
NT 1.6mm, PAPPA 0.63
CVS – normal male karyotype
Normal morph
Otherwise uncomplicated pregnancy
PMHx
Grave’s disease Dx 8yrs ago, antiTPO abs, neomercazole ceased at 6/40
SHx
Smoker 5 cigs/day, less during preg
Nil ETOH
FHx
Maternal aunt – ophthalmic Ca
Maternal grandmother – breast Ca at 37yo
Middle ear tumor maternal side
O/E
Obs nad
Scleral icterus, diffuse spider naevi
abdominal distension
soft, tender epigastrium & RUQ
normal reflexes, no clonus or LL oedema
non-specific back tenderness
CTG reassuring
BloodsHb 137
Plt 215
WCC 13.5
Bili 60
ALT 46
ALP 1574
GGT 441
AST 185
Lipase 812
Uric acid 0.59
Na 126
K 4.5
Urea 8.2
Creat 150
Corr Ca 4.28
CRP 72
INR 1.4 -> 1.7
Spot urine 85
Differentials?
Abdominal USS …
Abdominal USS …
- Hepatosplenomegaly
Abdominal USS …
- Hepatosplenomegaly- Normal pancreas- stone in GB, CBD 3mm, nil biliary dilatation or
obstruction- Normal kidneys- RIF 80-90 ml FF
Growth scan: EFW 1905g, AFI 13.3, normal dopplers, Cephalic
Issues
Hypercalcaemia
Acute renal impairment
Obstructive cholestasis and liver failure
Coagulopathy
Ascites and hepatosplenomegaly
DDx Cholestasis of pregnancy Acute fatty liver of pregnancy Gallstone pancreatitis (?ERCP) Atypical HELLP syndrome, preeclampsia PTHrP producing tumor or PT pathology Renal impairment ? secondary to hypercalcaemia Pancreatitis ? secondary to hypercalcaemia Hepatitis Obstructive jaundice ?Head of pancreas malignancy Lymphoma Multiple myeloma Other malignancies
TSH 1.41
PTH < 4
Fasting bile acid 28
Bili 60ALP 1574GGT 441AST 185Lipase 812
Uric acid 0.59
Urea 8.2Creat 150Corr Ca 4.28
Bile acids 28CRP 72INR 1.4 -> 1.7Spot urine 85
Management:
R/v by renal/gastro/gen surg: Decision made to expedite delivery.
Steroids, MgSO4
T/f to tertiary centre
IOL 32+1 -> NVB
2040g, APGARs 8 at 1 + 5mins
What now?
Revisiting history & exam
Further examination revealed…
Left breast lump
5x3cm on palpation
FHx
Maternal grandmother breast Ca Dx at 37yo
Further examination revealed…
Left breast lump
5x3cm on palpation
FHx
Maternal grandmother breast Ca Dx at 37yo
CA15-3 2403
LDH 325
Mammogram- Left breast mass 3 cm
BI-RADS Cat 5
BIRADS Breast Imaging-Reporting and Data System
Risk of cancer
BIRADS V: 95%
BIRADS Breast Imaging-Reporting and Data System
Risk of cancer
BIRADS V: 95% -> biopsy recommended
Left breast USS‘Highly suspicious ill-defined irregular hypoechoic lesion 5 o’clock, 4cm from nipple, 3cm size with internal vascularity’
Left axillary metastatic lymphadenopathy
USS-guided core biopsy- Invasive ductal carcinoma
- ER +ve, PR +ve, HER2 –ve
Staging CT- Extensive metastases to spine, liver, bone (lytic lesions)
- L main pulmonary artery filling defect ? Tumor
Staging MRI- Mets to all spinal vertebrae + pelvis
- patent spinal canal and exit foramina
Nil loss of power/sensation, nil incontinence issues
MRI: Pelvic metastases
MRI: hepatosplenomegaly
Placental Histopathology
– nil malignancy
Progress- Therapeutic clexane
- Axial + LL mets -> NWB due to risk of # (not for surgery)
Oncology + Pall care
- Incurable cancer, aim for symptom control
Management to date
- Abdominocenteses- Opioids- Dexamethasone + mirtazapine for appetite- Laxatives- Oral hygiene- Pressure area care
- Chemotherapy (Carboplatin/Gemcitabine)- Radiotherapy
- Ongoing support from family, pall care, oncology, allied health
Breast Cancer in pregnancy(Gestational Breast Cancer)
Breast Cancer diagnosed during pregnancy, in 1st postpartum year, or any time during lactation
Most common Ca in pregnancy
Up to 20% of BC in women <30 are pregnancy-associated
BCP really uncommon, low incidence 1:3000
Fewer BC cases diagnosed during pregnancy than during 1st postpartum yr
Breast Cancer in pregnancy(Gestational Breast Cancer)
Risk is age-related, expected to increase with delay in childbearing
no evidence that hyperestrogenic state of pregnancy contributes to development + growth of BCP
Dx usually at late stage
Symptoms mistaken for normal disorders of pregnancy
Breast changes – difficult to palpate
Lack of awareness
Reluctance to image
Larger, more advanced neoplasms @ diagnosis compared with age-matched non-pregnant cases
Average time for diagnosis from first symptoms 1-2m
Delay of Dx by 1m - 0.9% increased risk of nodal involvement
Diagnosis of BCP
History, examination, imaging (mammography, breast USS +/- MRI), histopathology
48% with early-onset BCP have +ve family Hx
Most common invasive ductal carcinoma
Management of BCP Control local disease, prevent metastases
Same as for non-pregnant women (RT, CT, surgery)
Breast surgery safe option during all trimesters
Breast RT ok in 1st and 2nd trimesters (foetal dose threshold)
Chemotherapy ok in 2nd + 3rd trimesters
Postpone delivery until 37/40 BUT
Do not delay Rx until delivery unless delivery in next 2-4 weeks
Thank you!
Recommended