alexa Progressive Nausea and Vomiting in Pregnancy: Eliminate Neurological Causes-A Case Report | Open Access Journals
ISSN: 2165-7920
Journal of Clinical Case Reports
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Progressive Nausea and Vomiting in Pregnancy: Eliminate Neurological Causes-A Case Report

Rosalie SC Linssen1*, Annelies Verdonkschot2, Jelle de Kruijk3 and W Peter Vandertop4

1Academic Medical Center/University of Amsterdam, The Netherlands

2Department of Gynaecology and Obstetrics, Tergooi Ziekenhuizen, The Netherlands

3Department of Neurology, Tergooi Ziekenhuizen, The Netherlands

4Department of Neurosurgery, Academic Medical Center and VU University Medical Center, Amsterdam, The Netherlands

*Corresponding Author:
Rosalie SC Linssen
Academic Medical Center/ University of Amsterdam
The Netherlands
Tel: +31 20 556 3316
E-mail: r.s.linssen@amc.uva.nl

Received Date: December 17, 2016; Accepted Date: January 23, 2017; Published Date: January 28, 2017

Citation: Linssen RSC, Verdonkschot A, Kruijk J, Vandertop WP (2017) Progressive Nausea and Vomiting in Pregnancy: Eliminate Neurological Causes-A Case Report. J Clin Case Rep 7:917. doi: 10.4172/2165-7920.1000917

Copyright: © 2017 Linssen RSC, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Clinical Case Reports

Abstract

Background: Severe nausea and vomiting in the first and second trimester of pregnancy is often diagnosed as hyperemesis gravidarum (HG), although true HG only appears in very few pregnancies. Anchoring, the tendency for clinicians to stick with an initial diagnosis even as new information becomes available, can lead to hesitation to perform MR-imaging in pregnant patients. As prompt diagnosis of intracranial neoplasm increases the chance on a favourable outcome, awareness among doctors is needed. Scant data on pregnant patients diagnosed with brain tumours is available; this case report pays attention to possible pitfalls for doctor’s delay.

Case summary: A 36-year-old G2PO presented with severe nausea, vomiting and vertigo in the first and second trimester of pregnancy after IVF-treatment. An increase of symptoms, headaches and a lurched walking pattern were initially attributed to dehydration, orthostatic hypotension and later to a proven B12 deficiency. When symptoms worsened despite vitamin suppletion and drowsiness and bradyphrenia developed, a MR-scan of the brain showed severe obstructive hydrocephalus caused by a mass in the fourth ventricle. Surgical resection of a ganglioglioma (WHO grade I) was performed at a gestational age of 25 weeks.

Conclusion: HG typically resolves around the 20th week of gestation, therefore persistent nausea and vomiting during pregnancy warrants a cerebral MR-scan in order to exclude neurological causes.

Keywords

Hyperemesis gravidarum; Morning sickness; Pregnancy; Ganglioglioma

Introduction

Hyperemesis gravidarum (HG) is a condition characterized by severe nausea and vomiting in the first and second trimester of pregnancy, leading to dehydration with hypokalaemia and ketonuria, malnutrition, and weight loss of more than 5% of the pre-pregnancy weight [1,2]. Although 50 to 90% of women experience some form of nausea and vomiting during the first trimester, true HG only appears in 0.5-3% of all pregnancies [3]. As HG typically resolves around the 20th week of gestation, an atypical clinical course of nausea and vomiting during pregnancy warrants reconsideration of this diagnosis. We report a case of a 36-year-old woman who presented with severe nausea, vomiting, and neurological symptoms.

Case Presentation

A 36-year-old G2PO presented with severe nausea, vomiting and vertigo at a gestation of 8 +6 weeks. Conception was induced by in vitro fertilization (IVF), indicated by male subfertility. Ultrasound examination showed a vital single-foetus pregnancy, positive heart action and a crown-rump-length (CRL) of 23.4 mm. As clinical symptoms and laboratory findings showed no signs of dehydration outpatient care was continued. At a gestational age of 14 weeks, she reported an increase of nausea and vertigo, together with headaches and a lurched walking pattern. She was re-admitted under the suspicion of dehydration, physical examination showed low blood pressure (90/60 mmHg). Neurological examination was normal, besides inconsistent Romberg and slight ataxia. The headaches were attributed to her dehydration and orthostatic hypotension. As laboratory findings showed low vitamin B12 levels, a vitamin B12 deficiency was suggested as a possible explanation for the ataxia. Despite vitamin B12 suppletion her neurological symptoms worsened with word retrieval difficulties, dysarthria, drowsiness and bradyphrenia.

A MR-scan of the brain showed severe obstructive hydrocephalus caused by a fourth ventricular mass (Figure 1). At a gestational age of 23 weeks an endoscopic third ventriculocisternostomy was performed which led to rapid improvement. Surgical resection of the 4th ventricular mass was performed at a gestational age of 25 weeks, as the required prone position would become increasingly difficult with increasing gestational age. Pathology showed a WHO grade I ganglioglioma (Figure 2). After labour induction at 39+5 weeks, a healthy girl weighing 4010 grams was born. A timeline of the case is found in (Table 1).

clinical-case-reports-ventricle-obstruction

Figure 1: Preoperative T1-weigthed coronal MR-image showing 1. Tumor with 4e ventricle obstruction; 2. Enlarged lateral ventricles with transependymal CSF egress.

clinical-case-reports-MR-images

Figure 2: T2-weigthed axial MR-images showing tumor in 4th ventricle (left) and after resection (right).

Pregnancy duration (weeks)  
9 First presentation; nausea and vomiting
14                   Re-admission, increasing symptoms and lurched walking
Consultancy Neurologist
Laboratory findings: high vitamin B12
23 MRI-brain & Endoscopic ventriculocisternostomy
25 Surgical resection of the 4th ventricular mass
Pathology: ganglioglioma WHO grade I
40 Labor induction and delivery

Table 1: Patient timeline.

Discussion

This case illustrates three important issues: first, the important role in clinical decision-making of a doctor’s ‘gut feeling’, a hard-totest phenomenon, but still considered to be one of the doctor’s most valuable tools [4,5]. In relation to this, a common pitfall in medicine is “anchoring”: the tendency to frame a clinical problem around the first piece of information received [6]. In retrospect, the behavioural changes and disturbed walking pattern had already been observed and reported during the IVF-treatment by the fertility doctors, and might have warranted further and earlier diagnostics, as they could not be completely explained by psychological factors. Second, this case illustrates that there is no special reason to be reluctant to perform a cerebral MR-scan in pregnant patients. Due to theoretical concerns for the fetus (including teratogenesis, tissue heating, and acoustic damage) possible hesitation to perform imaging might exist, though literature has shown MR-scanning is relatively safe in pregnancy. The American College of Radiology has concluded that there are no precautions or contraindications specific to the pregnant woman, and that no special consideration is recommended for the first (versus any other) trimester in pregnancy [7]. A prompter diagnosis enables doctors to plan interventions and treatment in a timely fashion after all experts have been consulted, decreasing the risk for urgent interventions with all it subsequent risks for mother and child. Third, as HG typically resolves around the 20th week of gestation, persistent nausea and vomiting during pregnancy warrants reconsideration of this diagnosis. Verheecke et al presented 27 cases of primary brain tumours or metastases diagnosed in pregnancy [8]. This case-report adds up to this information, illustrating that awareness on possible non-pregnancyrelated causes of nausea and vomiting could be improved.

Conclusion

As HG typically resolves around the 20th week of gestation, persistent nausea and vomiting during pregnancy warrants a cerebral MR-scan to exclude neurological causes, preferably before onset of severe neurological symptoms. This case-report illustrates that awareness on possible non-pregnancy-related causes of nausea and vomiting could be improved and adds up to currently existing information.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Recommended Conferences

  • Global Experts meeting on Oncology Case Reports
    Aug 29-31, 2017 London, UK
  • Global Experts Meeting on Case Reports
    Osaka, Japan October 09-11, 2017
  • 6th Global Experts Meeting on Medical Case Reports
    October 16-18, 2017 San Francisco, California, USA

Article Usage

  • Total views: 214
  • [From(publication date):
    January-2017 - May 23, 2017]
  • Breakdown by view type
  • HTML page views : 186
  • PDF downloads :28
 
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri, Food, Aqua and Veterinary Science Journals

Dr. Krish

agrifoodaquavet@omicsonline.com

1-702-714-7001 Extn: 9040

Clinical and Biochemistry Journals

Datta A

clinical_biochem@omicsonline.com

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

business@omicsonline.com

1-702-714-7001Extn: 9042

Chemical Engineering and Chemistry Journals

Gabriel Shaw

chemicaleng_chemistry@omicsonline.com

1-702-714-7001 Extn: 9040

Earth & Environmental Sciences

Katie Wilson

environmentalsci@omicsonline.com

1-702-714-7001Extn: 9042

Engineering Journals

James Franklin

engineering@omicsonline.com

1-702-714-7001Extn: 9042

General Science and Health care Journals

Andrea Jason

generalsci_healthcare@omicsonline.com

1-702-714-7001Extn: 9043

Genetics and Molecular Biology Journals

Anna Melissa

genetics_molbio@omicsonline.com

1-702-714-7001 Extn: 9006

Immunology & Microbiology Journals

David Gorantl

immuno_microbio@omicsonline.com

1-702-714-7001Extn: 9014

Informatics Journals

Stephanie Skinner

omics@omicsonline.com

1-702-714-7001Extn: 9039

Material Sciences Journals

Rachle Green

materialsci@omicsonline.com

1-702-714-7001Extn: 9039

Mathematics and Physics Journals

Jim Willison

mathematics_physics@omicsonline.com

1-702-714-7001 Extn: 9042

Medical Journals

Nimmi Anna

medical@omicsonline.com

1-702-714-7001 Extn: 9038

Neuroscience & Psychology Journals

Nathan T

neuro_psychology@omicsonline.com

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

John Behannon

pharma@omicsonline.com

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

social_politicalsci@omicsonline.com

1-702-714-7001 Extn: 9042

 
© 2008-2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version