wogs meeting 22 april 2015 diagnostic dilemma in pregnancy myriam girgis year 1 itp liverpool...
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WOGS meeting22 April 2015
Diagnostic Dilemma in pregnancy
Myriam Girgis
Year 1 ITP
Liverpool Hospital
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Mrs KH
32 yo
G4P1 – NVD 8 years back
31+6
Epigastric + low back pain
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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
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FMF
- No contractions
- Nil PV loss/bleeding
- Nil headaches/visual disturbances
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Antenatal HxHigh risk NT – T21 1:120
NT 1.6mm, PAPPA 0.63
CVS – normal male karyotype
Normal morph
Otherwise uncomplicated pregnancy
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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
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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
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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
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Differentials?
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Abdominal USS …
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Abdominal USS …
- Hepatosplenomegaly
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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
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Issues
Hypercalcaemia
Acute renal impairment
Obstructive cholestasis and liver failure
Coagulopathy
Ascites and hepatosplenomegaly
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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
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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
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What now?
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Revisiting history & exam
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Further examination revealed…
Left breast lump
5x3cm on palpation
FHx
Maternal grandmother breast Ca Dx at 37yo
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Further examination revealed…
Left breast lump
5x3cm on palpation
FHx
Maternal grandmother breast Ca Dx at 37yo
CA15-3 2403
LDH 325
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Mammogram- Left breast mass 3 cm
BI-RADS Cat 5
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BIRADS Breast Imaging-Reporting and Data System
Risk of cancer
BIRADS V: 95%
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BIRADS Breast Imaging-Reporting and Data System
Risk of cancer
BIRADS V: 95% -> biopsy recommended
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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
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USS-guided core biopsy- Invasive ductal carcinoma
- ER +ve, PR +ve, HER2 –ve
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Staging CT- Extensive metastases to spine, liver, bone (lytic lesions)
- L main pulmonary artery filling defect ? Tumor
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Staging MRI- Mets to all spinal vertebrae + pelvis
- patent spinal canal and exit foramina
Nil loss of power/sensation, nil incontinence issues
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MRI: Pelvic metastases
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MRI: hepatosplenomegaly
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Placental Histopathology
– nil malignancy
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Progress- Therapeutic clexane
- Axial + LL mets -> NWB due to risk of # (not for surgery)
Oncology + Pall care
- Incurable cancer, aim for symptom control
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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
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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
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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
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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
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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
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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
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Thank you!