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!