///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Increasing base deficit complicating pregnancy - a surgical dilemma. Two case reports.

Abstract Number: 105
Abstract Type: Case Report/Case Series

Rajashekar Reddy Gowni MD(Anaesthesia), FRCA1 ; sajjid Kumar FRCA2; Khalid Hasan FRCA3; Joanna Budd FRCA4

Introduction

We report two cases of increasing base deficit complicating pregnancy in the third trimester. Both patients complained of abdominal pain and of being systemically unwell, with increasing base deficit at arterial blood gas analysis.

Case report 1

A 29 year old parturient at 38 weeks gestation presented with upper abdominal pain to the delivery suite. She complained of nausea, vomiting and increasing generalized weakness. On examination she was pyrexial (39.2⁰C), tachycardic and tachypnoeic. An obstetric examination revealed a good fetal heart rate with no signs of labour. Sequential arterial blood gases revealed a base deficit ranging between 10.4 to 12.5mmol/L. Investigations revealed a haemoglobin of 9.0gram%, WCC of 17.8109/l and CRP of 296. A general surgical review combined with an abdominal ultrasound examination was inconclusive. A decision for exploratory laparotomy combined with caesarean delivery was taken. Laparotomy revealed a severely inflamed and partially necrotic gall bladder with pockets of pus in liver bed. Post-operative period was uneventful.

Case report 2

An 18 year old parturient at 34 weeks gestation was admitted with a complaint of right loin pain radiating to epigastrium. Her medical history included asthma and a BMI of 41. Initial obstetric examination revealed a good fetal heart rate and excluded early labour. Subsequently patient became increasingly unwell with vomiting and diffuse abdominal pain. Investigations revealed WCC 16.9109/L, CRP 50, uric acid 521mol/L, ALT 149 U/L, ketones(4+) at urine analysis and normal blood sugar. Renal ultrasound and KUB were normal. Sequential blood gas analysis revealed severe metabolic acidosis (BE -19.3 to -20.3 mmol/L) and a bicarbonate infusion was started. General surgical opinion was requested but was inconclusive. Urine and blood cultures were negative for bacterial growths. Differential diagnosis included starvation ketoacidosis1 but the presence of pyrexia with persistent vomiting and diffuse pain raised concerns of an intra-abdominal pathology. A decision for laparotomy with caesarean delivery was taken. The laparotomy was negative for intra-abdominal pathology. Post-operative period was uneventful with a base deficit was 0.5 mmol/L after 24 hours.

Discussion

While base deficit up to 15 mmol/l has been documented previously in asymptomatic parturients2, a high index of suspicion and thorough clinical evaluation is required in symptomatic patients. Acute abdominal pain due to intra-abdominal pathology in pregnancy can masquerade as labour pains and complicate diagnosis and management.

References

1. Nikolaos Burbos, Alice M. Shiner and Edward Morris. Severe metabolic acidosis as a cause of acute starvation in pregnancy. Arch Gynecol Obstet 2009; 279: 399-400 (in print).

2. D Thorp-Jones, S Yadthore, R E Collis. Acid-base balance in an obstetric population:establishing a normal range. Int J Obstet Anesth 2008; 17; supplement 1.

SOAP 2009