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
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Abstract |
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Key words: gastrostomy/malnutrition/pregnancy
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Case report |
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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 1). 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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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 2).
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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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Discussion |
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However, in animals, food restriction results in leptin and neuropeptide Y effects on the hypothalamus, resulting in ovulation suppression (Keisler et al., 1999). 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., 1988). 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., 1985; Landye, 1988
; Koh and Lipkin, 1993
) and the remaining two cases were in pregnancies complicated by hyperemesis gravidarum and anorexia nervosa (Godil and Chen, 1997
). 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.
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Notes |
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References |
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Submitted on June 5, 2000; accepted on July 31, 2000.