Anaesthetic Management of a Patient with Advanced Abdominal Pregnancy, Intrauterine Foetal Death and Celiac Disease
Correspondence Address :
Dr. Mamta Jain,
Associate Professor, Department of Anaesthesia and Critical Care,
Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India.
E-mail: mamtajainsingh@gmail.com
Abdominal pregnancy is a rare form of ectopic pregnancy where implantation of fertilised ovum occurs in the abdominal cavity. If diagnosed late maternal and foetal mortality is very high. The major cause of death in abdominal pregnancy is haemorrhage. The case report is about a 31-year-old gravida two with 36 weeks of gestation period with Intrauterine Foetal Death (IUFD) and celiac disease. Celiac disease is a chronic malabsorptive disease of the small intestine occurring due to hypersensitivity to gluten ingestion. Due to chronic malabsorption, the patient presented with calcium deficiency. She also had lesions of dermatitis herpetiformis over the whole body sparing only the face. It is a rare case of advanced abdominal pregnancy with the IUFD, with celiac disease. The patient was managed successfully under general anaesthesia with preparedness for difficult airway management, securing wide bore peripheral cannulas, central venous cannulation and invasive blood pressure monitoring. Massive haemorrhage intraoperatively was managed with crystalloids, colloids, blood products and tranexamic acid. The intraoperative period was uneventful. The patient was extubated at the end of the surgery, and followed-up in a high dependency unit.
Gluten sensitive, Haemorrhage, Laparotomy
A 31-year-old female complained of pain abdomen and absent foetal movements for one day. She was gravida two with 36 weeks period of gestation with IUFD. She had one previous spontaneous abortion. She was diagnosed with celiac disease four years back and had dermatitis herpetiformis for which she was on the tab. cetirizine 10 mg once a day and tab. chlorpheniramine 4 mg twice a day. She did not have a history of any other chronic illness and no history of any surgery and exposure to anaesthesia.
On examination, the patient was conscious, oriented to time, place and person and vitally stable. She had pallor and lesions of dermatitis herpetiformis all over the body except face. Her weight was 40 kgs and her airway examination was unremarkable. On per abdominal examination, fundal height corresponded to 32 weeks with breech presentation. Foetal heart sounds could not be heard.
Her haemoglobin was 8.6 g/dL after which one unit packed cell volume was transfused which was uneventful. Her total leukocyte count was 22,500/mm3, serum calcium 7.2 mg/dL, and the rest of investigations including bleeding and clotting profile were within normal limits. For hypocalcaemia she was taking tablets of calcium carbonate 500 mg with vitamin D3 250 IU three times a day. Ultrasound examination showed a single foetus in breech presentation lying in the abdominal cavity with no myometrial outline visible surrounding foetus. Foetal movements and foetal heart sounds were not appreciated. The placenta was visualised anterior to foetus.
As the patient had to undergo laparotomy and the large volume of blood loss was anticipated and she also had dermatitis herpetiformis lesions on her back, a decision to proceed with general anaesthesia along with all preparations for massive blood transfusion and difficult airway management was taken. After taking informed and written high risk consent, the patient was shifted to the operation table.
Routine monitors ECG, non invasive blood pressure, and pulse oximeter were attached. Her baseline heart rate was 86 beats/min, blood pressure 130/80 mmHg and SpO2 was 99% on room air. Intravenous (i.v) access was secured with one 16 G cannula in the right hand and 18 G cannula in the left hand. Induction of anaesthesia was done with inj fentanyl 80 μg i.v, inj thiopentone 200 mg i.v. After checking for the ability to ventilate inj vecuronium 5 mg i.v was given and the airway was secured with a cuffed endotracheal tube of size 7 mm internal diameter. After induction of anaesthesia, ultrasound guided central venous cannulation was done in the right internal jugular vein. Radial artery cannulation was done in the left hand under all aseptic precautions after doing Allen’s test and invasive blood pressure monitoring was started. A nasopharyngeal temperature monitoring probe was placed. The patient was covered with forced air blanket to maintain normothermia during surgery. A midline vertical incision was made and a non macerated dead female foetus of 2.2 kg was delivered from the abdominal cavity after clamping the cord. The placenta was found to be adhered to omentum, descending colon and peritoneum. Placenta was separated from the underlying structures. Intraoperative blood loss was around 2 L. Along with crystalloids and colloids, three units of packed cell volumes and four units of fresh frozen plasma were transfused. Inj tranexamic acid 1 gm i.v was given. To maintain normal blood pressure, nor adrenaline infusion was required to be started at the rate of 0.05 μ/kg/min. Urine output was maintained at ≥0.5 mL/kg/hr during the intraoperative period. The temperature was maintained at around 37°C during surgery. The 10 mL of 10% calcium gluconate was given.
Towards the end of the surgery, noradrenaline support was stopped and the patient’s blood pressure was 100/60 mmHg off inotropes. Her blood gas analysis had pH 7.38, partial pressure of oxygen and carbon dioxide 141.7 and 36 mmHg, bicarbonates 24.3, base excess -2.3 and oxygen saturation was 98.5%. The patient was extubated after giving inj glycopyrrolate 0.4 mg i.v and inj neostigmine 2 mg i.v and shifted to high dependency unit for postoperative monitoring. In postoperative investigations patient’s haemoglobin was 7.5 gm/dL, serum calcium was 7.8 mg/dL and all other investigations were within normal limits. The patient’s vitals were stable. Calcium replacement was continued in postoperative period. She was shifted to ward on third postoperative day and discharged home on tenth postoperative day.
Abdominal pregnancy is a rare form of ectopic pregnancy, with incidence ranging from 1:1000 to 1:30,000, where implantation of fertilised ovum occurs in the abdominal cavity (1). Abdominal pregnancy can be primary or secondary. In primary abdominal pregnancy implantation of fertilised ovum occurs directly in the abdominal cavity but secondary abdominal pregnancy is usually a tubal pregnancy where after tubal rupture reimplantation occurs in the abdominal cavity (2). Various risk factors for abdominal pregnancy are previous ectopic pregnancy, advanced maternal age, endometriosis, multiparity, assisted reproductive techniques, pelvic inflammatory disease and tubal occlusion (3),(4),(5). Abdominal pregnancy needs to be diagnosed early to prevent maternal and foetal morbidity and mortality. But despite advances in technology, only one out of nine women who reached the hospital alive has preoperative diagnosis of abdominal pregnancy (6). In this case, also it was not diagnosed in previous scans. It was diagnosed very late at 36 weeks when the intrauterine of death of foetus had already occurred.
In the case of intra-abdominal pregnancy, placental implantation can occur at any site like a uterine wall, adnexa, omentum, small bowel, pouch of Douglas, liver and spleen (7). The placenta can separate at any time during the antenatal period leading to a massive haemorrhage. So, the most common cause of maternal and foetal mortality during the antenatal and intraoperative periods is massive haemorrhage (8). Placental removal is done if the blood supply to the placenta can be controlled. If the placenta is adhered to some vital structures and is required to be left in-situ, methotrexate is used to expedite the removal of residual trophoblastic tissue. But if the placenta is left in-situ, it may result in a lot of complications like disseminated intravascular coagulation, postpartum pre-eclampsia, intestinal obstruction, fistula formation, perforation, abscess formation and sepsis (9).
It is critical to establish adequate intravenous access in case massive blood transfusion is required intraoperatively. So, two wide bore peripheral cannulas were secured and central venous access along with invasive blood pressure monitoring was done before the start of surgery. Blood and blood products were cross matched and arranged. Tranexamic acid was also administered at the start of bleeding as it has been reported to decrease postpartum bleeding (10). Intraoperative embolisation of blood vessels supplying the placenta can be performed by intervention radiology whenever such facilities are available (11).
Celiac disease is a gluten sensitive enteropathy in which there is an inflammatory T-cell response in the small intestine leading to a decrease in surface area available for absorption (12). Signs and symptoms of this disease are mainly due to malabsorption. Most patients present with recurrent aphthos stomatitis, paraesthesia, skin disorder like dermatitis herpetiformis, infertility, poor development of bone structure, osteoporosis, lack of muscle co-ordination and malignancies (13). It is important to rule out hypoalbuminemia, hypocalcaemia, hypomagnesemia and vitamin K deficiency which may be present due to malabsorption. So appropriate laboratory investigations should be done and any deficiency should be corrected preoperatively. Hypomagnesemia should be given special attention as magnesium helps in the presynaptic release of acetylcholine (14). Vitamin K deficiency, if present, can cause prolongation of prothrombin time (14). But the patient was adherent to gluten 5free diet, so only calcium deficiency was present in her for which replacement was started preoperatively. She also had lesions of dermatitis herpetiformis all over her body except her face, for which she was on tab. cetirizine and tab. chlorpheniramine. In patients with dermatitis herpetiformis, for short-term relief from itching, dapsone can be prescribed; but this patient was not on dapsone therapy. Dapsone use may be associated with methemoglobinemia (15). Methaemoglobin interferes with pulse oximetry, oxygen saturation falls and plateaus at 85% as the level of methaemoglobin rises because pulse oximeter can only measure oxyhaemoglobin and reduced haemoglobin (16). Patients may have other associated autoimmune diseases with dermatitis herpetiformis like type 1 diabetes, hypothyroidism and pernicious anaemia (17). The index patient only had anaemia for which blood transfusion was done preoperatively. As lesions of dermatitis herpetiformis were also present over the back and a large volume of blood loss was anticipated, so subarachnoid block with epidural anaesthesia was not chosen. These patients are at increased risk of aspiration because of delayed gastric emptying so a long fasting period of eight hours for solids and ant aspiration prophylaxis was given before surgery (14). Due to growth retardation, difficult airway may be present. Hence the authors were prepared for management of unanticipated difficult airways. Airway examination was unremarkable in this patient.
The patient had celiac disease with abdominal pregnancy and IUFD. Abdominal pregnancy and celiac disease both are rare occurrences in themselves but in this patient both were present in the same patient making the anaesthetic management even more challenging. The patient was managed successfully by proper preanaesthetic check-ups to rule out any deficiencies, and complications due to celiac disease and IUFD. Massive haemorrhage intraoperatively was managed successfully by securing adequate i.v access, invasive blood pressure monitoring, crystalloids, colloids, blood products, tranexamic acid and inotropes.
DOI: 10.7860/JCDR/2022/56212.16665
Date of Submission: Mar 14, 2022
Date of Peer Review: Apr 08, 2022
Date of Acceptance: May 04, 2022
Date of Publishing: Jul 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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