Hyperemesis Gravidarum: An Out of the Box Presentation, a Rare Case Report and Literature Review

Abstract

Infratentorial ependymoma presenting as hyperemesis gravidarum during pregnancy is not reported in the literature. The management of these rare infratentorial tumors during pregnancy poses a great challenge to the obstetrician, since the physiological and hormonal changes of pregnancy can exacerbate the symptoms of the tumor and pose varying risks to both the mother and the fetus. We report a case of an infratentorial ependymoma presenting as hyperemesis gravidarum at 24 weeks of gestation. A 36-year-old diabetic woman was admitted with persistent vomiting at 24 weeks of gestation with a provisional diagnosis of hyperemesis gravidarum. She had history of hyperemesis gravidarum throughout the antenatal period and was on regular follow-up by obstetrician and physician. She developed features of intracranial hypertension and bilateral abducent nerve palsy during hospital stay. An MRI scan of the brain revealed a tumor of the fourth ventricle causing obstructive hydrocephalus. An emergency ventriculoperitoneal shunt was done to relieve the intracranial pressure. Subsequently, she underwent a suboccipital craniotomy with complete removal of the tumor. Histopathology was consistent with ependymoma. During the postoperative period, she developed stridor and dyspnoea and was ventilated. Intrauterine death of the fetus was confirmed by ultrasonology as there was cessation of the fetal heart sound. A hysterotomy was done to remove the fetus as an induction of labor failed. She subsequently developed ventilator associated pneumonia and adult respiratory distress syndrome followed by septicemia and expired on the 12th postoperative day despite appropriate antibiotics and other supportive measures. To our knowledge, this is the first reported case of infratentorial ependymoma presenting during pregnancy. Intracranial tumors, especially infratentorial tumors during pregnancy, are associated with high maternal and fetal morbidity and mortality as they behave differently from supratentorial tumors. A definite protocol for the management of pregnant patients with infratentorial tumors is lacking as there are only few reported cases. Early detection and treatment plays an important role in the management of these tumors. J Clin Gynecol Obstet. 2014;3(4):143-146 doi: http://dx.doi.org/10.14740/jcgo287w