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An intracranial tumour — an uncommon cause of hyperemesis in pregnancy
European Journal of Obstetrics & Gynecology and Reproductive Biology 95 (2001) 182±183
Case report
An intracranial tumour Ð an uncommon cause of hyperemesis in pregnancy Steven G.K. Van Calenbergha, Willy A.J. Poppea,*, Frank Van Calenberghb a
Department of Obstetrics and Gynaecology, The University Hospital Gasthuisberg, Herestraat 49, B 300 Leuven, Belgium b Department of Neurosurgery, The University Hospital Gasthuisberg, Leuven, Belgium Received 4 November 1999; received in revised form 23 March 2000; accepted 22 June 2000
Abstract Brain tumours in pregnancy are rare. In this case vomiting and headache were the only signs. An assessment of the patient with vomiting in pregnancy to help reach a diagnosis when faced with vomiting in pregnancy is given. Following the diagnosis of a brain tumour during pregnancy, management should be tailored to the individual patient. # 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Pregnancy; Brain tumour; Vomiting; Hyperemesis gravidarum
1. Case report A 32-year old G3P1A1 patient was admitted to our hospital at 14th weeks of gestation. She complained of a persistent frontal headache and vomiting and anorexia for 2 weeks. She was using anti-emetic drugs and paracetamol without any real improvement. Her ®rst pregnancy had been uneventful and she had delivered a healthy girl at term. She had a missed abortion in 1998 treated with a suction curettage. In her past medical history she mentions meningitis during childhood. Our initial diagnosis was atypical hyperemesis gravidarum and a routine differential diagnosis investigation was conducted. Ultrasound showed a normal intrauterine fetus, with a crown rump length appropriate to the gestational age. Routine blood tests, full blood count, electrolytes, thyroid function and liver function tests were normal. A urine sample showed signi®cant ketonuria. On the same day, a fundoscopy was performed which showed poorly de®ned optic discs, suggesting papilloedema. Upon this ®nding a magnetic resonance imaging (MRI)scan was performed, showing a cystic mass lesion located in the vermis and extending into the right cerebellar hemisphere, with important perilesional oedema, and supratentorial hydrocephalus.
* Corresponding author. Tel.: 32-16-344204; fax: 32-16-344202. E-mail address: [email protected] (W.A.J. Poppe).
The patient was transferred to the neurosurgery ward, where the tumour was totally resected via a midline suboccipital craniotomy. Post-operatively, a slight and transient dysmetry of the right arm was seen. The patient left the hospital 7 days later in good condition. Fetal ultrasound was normal. Microscopic examination of the tumour revealed pilocystic astrocytoma. Neurological examination 6 weeks later showed complete recovery. At 39 weeks of gestation the patient had a normal vaginal delivery of a healthy boy. A new MRI was done a few weeks later con®rming total resection of the tumour. 2. Discussion Nausea and vomiting are common in the ®rst trimester of pregnancy and have long been looked upon as one of the many discomforts accompanying approximately half of all gestations. The peak occurrence is between the 8th and the 12th weeks of pregnancy [1]. Typical in the case of true hyperemesis gravidarum is however that onset happens before the 10th week of pregnancy with peak symptoms in the 9th week [5]. In some cases, the complaints are more severe or remain after the ®rst trimester. We should, as a rule, always differentiate between several causes of vomiting. There are two groups, those related to the pregnancy and those who are not (Table 1) [1]. When faced with vomiting during pregnancy, one should keep all causes in mind and try to eliminate other causes
0301-2115/01/$ ± see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 1 - 2 1 1 5 ( 0 0 ) 0 0 4 4 4 - 9
S.G.K. Van Calenbergh et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 95 (2001) 182±183 Table 1 Causes of vomiting in pregnancya Pregnancy related causes Hyperemesis gravidarum Hydatidiform mole Multiple pregnancy Hydramnios with hydrops fetalis Pregnancy induced hypertension Abruptio placentae Causes not related to pregnancy Gastro-intestinal and hepatobiliary causes Peptic disorders Diaphragmatic hernia Hepatitis Biliary tract disease Pancreatitis Appendicitis Inflammatory and obstructive bowel diseases Genitourinary Pyelonefritis Uremia Ovarian torsion Necrotic uterine leiomyoma Others Drug effects Metabolic disorders Hyperthyroidism Lesions of the central nervous system and or intracranial Hypertension Vestibular disorders a
For details, see [1].
before diagnosing it as hyperemesis gravidarum. It remains a diagnosis of exclusion. An assessment to help reach a correct diagnosis, described in Table 2, is based upon the present approach of the patient with vomiting during pregnancy in our hospital. Brain tumours in pregnancy are rare [2] and the diagnosis is often delayed because the symptoms, like vomiting and headache may be similar to typical pregnancy associated complaints. A rapid diagnosis and management tailored to the individual patient are essential [2]. Table 2 Assessment of the patient with vomiting during pregnancy History Routine history and course of current pregnancy Onset, duration, severity, weight loss, food or fluid intake still possible, associated symptoms like headache, visual disturbances, other atypical findings Clinical examination Including blood pressure, abdominal palpation, fundoscopy and reflexes Blood tests Full blood count, electrolytes, liver function tests and thyroid function Urine sample for ketonuria and proteinuria, urine sediment and midstream culture Fetal US Determine singleton or multiple pregnancy Signs of hydatidiform mole, hydramnios with hydrops fetalis or abruptio placentae Psychological assessment: in severe cases with normal findings for the above.
183
The clinical manifestation can be different for different brain tumours. Gliomas appear to be more frequent in the ®rst and second trimester, whereas meningiomas increase slightly in number during pregnancy and may remit postpartum [2]. Some authors have suggested that water retention in the body and increased ¯uid content of the tumour favour its growth during pregnancy. There is also a possibility that hormonal changes that accompany pregnancy favour the growth of some tumours [2]. Isla et al. [2] found high levels of progesterone receptors in meningiomas and astrocytomas. Diagnosis is best achieved with MRI or CT scan. Much data exists regarding the safety of MR imaging for the fetus [3] and although there is no convincing evidence that MR imaging could cause fetal injury, it still should only be used in selected cases [4]. Iodated contrast agents are inert and pose only a small risk for the fetus [2]. Once the diagnosis is made, the management should be in view of the gestational age at presentation. When the diagnosis is made during the ®rst half of gestation and CT scan or MRI show only a small sized tumour in absence of neurological signs surgical treatment may be delayed until the end of the pregnancy. When neurological symptoms or patient's condition worsen, as in the case presented, the tumour should be excised. When the brain tumour presents in the second half of pregnancy and the patient's condition permits so, fetal maturation can be accelerated with steroids and brain surgery can be performed immediately after an early caesarean delivery [2]. This case shows the constant need of a critical appraisal of the ill pregnant patient. Some symptoms are easily attributed to normal pregnancy associated complaints and may so delay an early diagnosis of perhaps uncommon but possibly hazardous conditions. Acknowledgements The authors wish to thank Sheridan RJ, FRCOG, FRCS, Watford General Hospital, for helpful criticisms and correction of the English language. References [1] Hod M, Orvieto R, Kaplan B, Friedman S, Ovidia J. Hyperemesis gravidarum, a review. J Reprod Med 1994;39:605±12. [2] Isla A, Alvarez F, Gonzalez A, GarcõÂa-Grande A, Perez-Alvarez M, GarcõÂa-Blazquez M. Brain tumor and pregnancy. Obstet Gynecol 1997;89:19±23. [3] Kanal E. Pregnancy and the safety of magnetic resonance imaging. Magn Reson Imaging Clin N Am 1994;2:309±17. [4] Colletti PM, Sylvestre PB. Magnetic resonance imaging in pregnancy. Magn Reson Imaging Clin N Am 1994;2:291±307. [5] Gadsby R, Barnie-Adshead AM, Jagger C. A prospective study of nausea and vomiting during pregnancy. Br J Gen Pract 1993;43: 245±8.
Case report
An intracranial tumour Ð an uncommon cause of hyperemesis in pregnancy Steven G.K. Van Calenbergha, Willy A.J. Poppea,*, Frank Van Calenberghb a
Department of Obstetrics and Gynaecology, The University Hospital Gasthuisberg, Herestraat 49, B 300 Leuven, Belgium b Department of Neurosurgery, The University Hospital Gasthuisberg, Leuven, Belgium Received 4 November 1999; received in revised form 23 March 2000; accepted 22 June 2000
Abstract Brain tumours in pregnancy are rare. In this case vomiting and headache were the only signs. An assessment of the patient with vomiting in pregnancy to help reach a diagnosis when faced with vomiting in pregnancy is given. Following the diagnosis of a brain tumour during pregnancy, management should be tailored to the individual patient. # 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Pregnancy; Brain tumour; Vomiting; Hyperemesis gravidarum
1. Case report A 32-year old G3P1A1 patient was admitted to our hospital at 14th weeks of gestation. She complained of a persistent frontal headache and vomiting and anorexia for 2 weeks. She was using anti-emetic drugs and paracetamol without any real improvement. Her ®rst pregnancy had been uneventful and she had delivered a healthy girl at term. She had a missed abortion in 1998 treated with a suction curettage. In her past medical history she mentions meningitis during childhood. Our initial diagnosis was atypical hyperemesis gravidarum and a routine differential diagnosis investigation was conducted. Ultrasound showed a normal intrauterine fetus, with a crown rump length appropriate to the gestational age. Routine blood tests, full blood count, electrolytes, thyroid function and liver function tests were normal. A urine sample showed signi®cant ketonuria. On the same day, a fundoscopy was performed which showed poorly de®ned optic discs, suggesting papilloedema. Upon this ®nding a magnetic resonance imaging (MRI)scan was performed, showing a cystic mass lesion located in the vermis and extending into the right cerebellar hemisphere, with important perilesional oedema, and supratentorial hydrocephalus.
* Corresponding author. Tel.: 32-16-344204; fax: 32-16-344202. E-mail address: [email protected] (W.A.J. Poppe).
The patient was transferred to the neurosurgery ward, where the tumour was totally resected via a midline suboccipital craniotomy. Post-operatively, a slight and transient dysmetry of the right arm was seen. The patient left the hospital 7 days later in good condition. Fetal ultrasound was normal. Microscopic examination of the tumour revealed pilocystic astrocytoma. Neurological examination 6 weeks later showed complete recovery. At 39 weeks of gestation the patient had a normal vaginal delivery of a healthy boy. A new MRI was done a few weeks later con®rming total resection of the tumour. 2. Discussion Nausea and vomiting are common in the ®rst trimester of pregnancy and have long been looked upon as one of the many discomforts accompanying approximately half of all gestations. The peak occurrence is between the 8th and the 12th weeks of pregnancy [1]. Typical in the case of true hyperemesis gravidarum is however that onset happens before the 10th week of pregnancy with peak symptoms in the 9th week [5]. In some cases, the complaints are more severe or remain after the ®rst trimester. We should, as a rule, always differentiate between several causes of vomiting. There are two groups, those related to the pregnancy and those who are not (Table 1) [1]. When faced with vomiting during pregnancy, one should keep all causes in mind and try to eliminate other causes
0301-2115/01/$ ± see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 1 - 2 1 1 5 ( 0 0 ) 0 0 4 4 4 - 9
S.G.K. Van Calenbergh et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 95 (2001) 182±183 Table 1 Causes of vomiting in pregnancya Pregnancy related causes Hyperemesis gravidarum Hydatidiform mole Multiple pregnancy Hydramnios with hydrops fetalis Pregnancy induced hypertension Abruptio placentae Causes not related to pregnancy Gastro-intestinal and hepatobiliary causes Peptic disorders Diaphragmatic hernia Hepatitis Biliary tract disease Pancreatitis Appendicitis Inflammatory and obstructive bowel diseases Genitourinary Pyelonefritis Uremia Ovarian torsion Necrotic uterine leiomyoma Others Drug effects Metabolic disorders Hyperthyroidism Lesions of the central nervous system and or intracranial Hypertension Vestibular disorders a
For details, see [1].
before diagnosing it as hyperemesis gravidarum. It remains a diagnosis of exclusion. An assessment to help reach a correct diagnosis, described in Table 2, is based upon the present approach of the patient with vomiting during pregnancy in our hospital. Brain tumours in pregnancy are rare [2] and the diagnosis is often delayed because the symptoms, like vomiting and headache may be similar to typical pregnancy associated complaints. A rapid diagnosis and management tailored to the individual patient are essential [2]. Table 2 Assessment of the patient with vomiting during pregnancy History Routine history and course of current pregnancy Onset, duration, severity, weight loss, food or fluid intake still possible, associated symptoms like headache, visual disturbances, other atypical findings Clinical examination Including blood pressure, abdominal palpation, fundoscopy and reflexes Blood tests Full blood count, electrolytes, liver function tests and thyroid function Urine sample for ketonuria and proteinuria, urine sediment and midstream culture Fetal US Determine singleton or multiple pregnancy Signs of hydatidiform mole, hydramnios with hydrops fetalis or abruptio placentae Psychological assessment: in severe cases with normal findings for the above.
183
The clinical manifestation can be different for different brain tumours. Gliomas appear to be more frequent in the ®rst and second trimester, whereas meningiomas increase slightly in number during pregnancy and may remit postpartum [2]. Some authors have suggested that water retention in the body and increased ¯uid content of the tumour favour its growth during pregnancy. There is also a possibility that hormonal changes that accompany pregnancy favour the growth of some tumours [2]. Isla et al. [2] found high levels of progesterone receptors in meningiomas and astrocytomas. Diagnosis is best achieved with MRI or CT scan. Much data exists regarding the safety of MR imaging for the fetus [3] and although there is no convincing evidence that MR imaging could cause fetal injury, it still should only be used in selected cases [4]. Iodated contrast agents are inert and pose only a small risk for the fetus [2]. Once the diagnosis is made, the management should be in view of the gestational age at presentation. When the diagnosis is made during the ®rst half of gestation and CT scan or MRI show only a small sized tumour in absence of neurological signs surgical treatment may be delayed until the end of the pregnancy. When neurological symptoms or patient's condition worsen, as in the case presented, the tumour should be excised. When the brain tumour presents in the second half of pregnancy and the patient's condition permits so, fetal maturation can be accelerated with steroids and brain surgery can be performed immediately after an early caesarean delivery [2]. This case shows the constant need of a critical appraisal of the ill pregnant patient. Some symptoms are easily attributed to normal pregnancy associated complaints and may so delay an early diagnosis of perhaps uncommon but possibly hazardous conditions. Acknowledgements The authors wish to thank Sheridan RJ, FRCOG, FRCS, Watford General Hospital, for helpful criticisms and correction of the English language. References [1] Hod M, Orvieto R, Kaplan B, Friedman S, Ovidia J. Hyperemesis gravidarum, a review. J Reprod Med 1994;39:605±12. [2] Isla A, Alvarez F, Gonzalez A, GarcõÂa-Grande A, Perez-Alvarez M, GarcõÂa-Blazquez M. Brain tumor and pregnancy. Obstet Gynecol 1997;89:19±23. [3] Kanal E. Pregnancy and the safety of magnetic resonance imaging. Magn Reson Imaging Clin N Am 1994;2:309±17. [4] Colletti PM, Sylvestre PB. Magnetic resonance imaging in pregnancy. Magn Reson Imaging Clin N Am 1994;2:291±307. [5] Gadsby R, Barnie-Adshead AM, Jagger C. A prospective study of nausea and vomiting during pregnancy. Br J Gen Pract 1993;43: 245±8.