Pregnancy outcome in a patient with chronic malnutrition: Case report

M.P. O'Connell1,3, O.F. Wilson1, E.A. Masson2 and S.W. Lindow1

1 Academic Department Obstetrics & Gynaecology, University of Hull, Hull Maternity Hospital, Hull HU9 5LX and 2 Department of Medicine, University of Hull, Hull Royal Infirmary, Anlaby Road, Hull HU3 2JZ, UK


    Abstract
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 Abstract
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This case report describes the management of a chronically malnourished woman during her first and second pregnancies. The emphasis of the management is on the investigation of her dysphagia and subsequent bypassing of her colonic interposition by the formation of a percutaneous gastrostomy. The case highlights spontaneous conception with a body mass index of 14 and the safety of enteral feeding during pregnancy.

Key words: gastrostomy/malnutrition/pregnancy


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 Abstract
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A 24 year old nulliparous patient presented at 11 weeks gestation following a spontaneous conception with a body mass index (BMI) of 14 kg/m2 (height 1.41 m, weight 28 kg, estimated body fat 12%). She was born with a tracheo-oesophageal fistula/oesophageal atresia which was initially managed by gastrostomy, and subsequently had a colonic interposition at the age of 2 years. Over the years there was evidence of intermittent and progressive dilatation of the colonic remnant, with evidence of stenosis of the distal anastomosis.

Her menarche was at 16 years of age and was followed by amenorrhoea for 3 years. Having gained weight from the age of 20 years, she assumed a regular 28 day cycle.

This was an unplanned pregnancy, as she was under the mistaken belief that she could not conceive secondary to her chronic malnutrition state. At the time of booking the colonic interposition had increased in size to such an extent that it was almost filling the left chest (Figure 1Go). She had recently had an infective exacerbation of her bronchiectasis and asthma and was being treated with budesonide and terbutaline inhalers and prednisolone.



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Figure 1. Chest X-ray. (a) Anterior/posterior view showing an almost opaque left hemithorax with a clear right lung field. (b) Lateral view demonstrating loops of bowel in the left hemithorax.

 
At her following visit she had lost a further 2 kg and complained of dysphagia and post-prandial vomiting but could tolerate fluids. It was apparent that there was a structural or functional obstruction in her upper gastro-intestinal tract.

It proved impossible to negotiate the colonic remnant endoscopically or to pass a guidewire with fluoroscopic control.

A computerized tomography scan confirmed the presence of multiple redundant loops of colon but did not demonstrate an outflow tract obstruction (Figure 2Go).



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Figure 2. CT with no contrast. (a) A large colonic interposition occupies most of the left hemithorax and the remaining left lung is completely solid with an air bronchogram. (b) The body and fundus of the stomach are below the diaphragm. The right lung is clear.

 
Eventually a gastric bubble was located by ultrasonography and a transcutaneous guide wire was inserted. Radiological contrast studies confirmed the sub-diaphragmatic anatomy was normal and a permanent gastrostomy was fashioned. Enteral feeding was commenced and after a short hospital stay, performed on an outpatient basis. It was successful in that she gradually increased her weight to a maximum of 35 kg at 31 weeks gestation. She was treated with prophylactic corticosteroids on a weekly basis from 28 weeks gestation in anticipation of early delivery. At 31 weeks she was admitted with increasing dyspnoea primarily due to abdominal distension with diaphragmatic splinting. As the fetal growth was on the 50th centile, delivery was deferred until 33 weeks gestation when she became dyspnoeic at rest.

She then underwent an uneventful lower segment Caesarean section and a 1620 g male was delivered in good condition (APGAR: 9 at 1 min, 9 at 5 min). The weight was noted to be on the 10th centile if no correction was made for maternal size. Her postoperative course was uneventful and she was discharged on day 5. The percutaneous gastrostomy was left in situ. At 6 weeks post partum she weighed 32 kg and was well.

She presented in her second pregnancy at 10 weeks with a BMI of 15.45 following a spontaneous conception. Enteral feeding was instituted via her percutaneous gastrostomy on an outpatient basis and her pregnancy progressed well until she developed epigastric pain at 27 weeks. Corticosteroids were given at this time. She was noted to be constipated and once this was relieved the pain subsided. She was seen on a weekly basis at the medical antenatal clinic. However, at 31 weeks, as in her first pregnancy, she was admitted with increasing shortness of breath. She underwent an emergency lower segment Caesarean section at 31 weeks with an indication of breech presentation in labour. She delivered a live born male 1620 g (50th centile) with APGAR 9 at 1 min and 9 at 5 min.

The patient underwent a sterilization at 6 weeks post-Caesarean.


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This case highlights an apparently normally functioning hypothalamic-pituitary-ovarian axis in a patient with a BMI of 14. Her menarche was at 16 years of age and was followed by irregular menstrual cycles for 1 year and then a period of amenorrhoea until the age of 20 years. She then developed a regular menstrual cycle followed by two spontaneous conceptions. It has been reported that fat must comprise at least 17% of body composition for the onset of menarche (Frisch and McArthur, 1974Go) and 22% for the maintenance of ovulatory cycles (Apter et al., 1978Go; Frisch, 1984Go). This patient reported a significant weight gain at this stage of her life, but her estimated body fat was only 12% at conception. The relationship between body fat and ovulation is not fully understood in humans.

However, in animals, food restriction results in leptin and neuropeptide Y effects on the hypothalamus, resulting in ovulation suppression (Keisler et al., 1999Go). The biological role of leptin in human adults has not been clearly elucidated.

Chronic maternal malnutrition results in increased risk to the fetus. Women who have a BMI of <19.1, who ovulate spontaneously, have a three-fold increased risk of a low birth weight baby (van der Spuy et al., 1988Go). Nutritional support for the mother in pregnancy can reverse this adverse outcome for the fetus. The option of enteral feeding via a nasogastric tube was not possible due to an inability to negotiate the stricture in the colonic interposition. In this case parenteral nutrition was not considered, as the risk of insertion of a central line was deemed too high on the basis of the colonic interposition filling the left side of the chest and the reliance for respiratory function on the right lung.

This is the first case report of the use of percutaneous gastrostomy in a pregnant patient with a colonic interposition. Five cases have been reported of enteral feeding using a gastrostomy. Three cases involved comatose patients who required long-term nutritional support (Hill et al., 1985Go; Landye, 1988Go; Koh and Lipkin, 1993Go) and the remaining two cases were in pregnancies complicated by hyperemesis gravidarum and anorexia nervosa (Godil and Chen, 1997Go). All cases resulted in a favourable fetal outcome.

This patient not only ovulated spontaneously, but conceived with a BMI well below what is normally considered adequate for normal reproductive function. Following her second Caesarean section, she elected to have a sterilization at 6 weeks post-delivery. She has continued percutaneous gastrostomy feeding and has maintained her BMI at 14.5 kg/m2.


    Notes
 
3 To whom correspondence should be addressed at: Academic Department Obstetrics & Gynaecology, University of Hull,Hull Maternity Hospital, Hull HU9 5LX, UK. Back


    References
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 Abstract
 Case report
 Discussion
 References
 
Apter, D., Viinikka, L. and Vihko, R. (1978) Hormonal pattern of adolescent menstrual cycles. J. Clin. Endocrinol Metab., 47, 944–954.[Abstract]

Frisch, R.E. (1984) Body fat, puberty and fertility. Biol. Rev., 59, 161–188.[ISI][Medline]

Frisch, R.E. and McArthur, J.W. (1974) Menstrual cycles: fatness as a determinant of minimum weight for height necessary for their maintenance or onset. Science, 185, 949–951.[ISI][Medline]

Godil, A. and Chen, Y.K. (1997) Percutaneous endoscopic gastrostomy for nutrition support in pregnancy associated with hyperemesis gravidarum and anorexia nervosa. J. Ent. Parent. Nutrit., 22, 238–241.

Hill, L.M., Parker, D. and O'Neill, B.P. (1985) Management of maternal vegetative state during pregnancy. Mayo Clin. Proc., 60, 469–472.[ISI][Medline]

Keisler, D.H., Daniel, J.A. and Morrison, C.D. (1999) The role of leptin in nutritional status and reproductive function. J. Reprod. Fertil. Suppl., 54, 425–435.[Medline]

Koh, M.L. and Lipkin, E.W. (1993) Nutritional support of a pregnant comatose patient via percutaneous endoscopic gastrostomy. J. Ent. Parent. Nutrit., 17, 384–387.

Landye, S.T. (1988) Successful enteral nutrition support of a pregnant comatose patient: a case study. J. Am. Diet. Assoc., 88, 718–720.[ISI][Medline]

van der Spuy, Z.M., Steer, P.J., McCusker, M. et al. (1988) Outcome of pregnancy in underweight women after spontaneous and induced ovulation. Br. Med. J., 296, 962–965.[ISI][Medline]

Submitted on June 5, 2000; accepted on July 31, 2000.