Gastroparesis is common in type 1 diabetes and has also been described rarely in pregnancy. Hyperemesis gravidarum occurs in approximately 1% of pregnancies and very rarely necessitates preterm delivery. We describe a case of a 28 year old primigravida with severe, intractable abdominal pain and nausea in pregnancy on a background of an 11 year history of type 1 diabetes. Her symptoms started at 7 weeks gestation and persisted until delivery at 33 weeks. She first sought medical attention at 14 weeks and from that time she had 8 admissions to hospital, requiring a total of 80 days admission and more than 60% of the remainder of her pregnancy was spent in hospital.
She was extensively investigated including assessing for a renal, gastrointestinal, endocrine, immunologic or thrombotic cause of her symptoms, as well as 3 abdominal ultrasounds, abdominal MRI and gastroscopy. She received total parenteral nutrition on two separate occasions with significant improvement of her symptoms when she was nil by mouth. Her symptoms were otherwise intractable and did not respond to large doses of opioid analgesia, anti-emetics, anti-histamines and protein pump inhibitors. Oral steroid therapy was partially successful however was complicated by poor glycaemic control. Throughout pregnancy her BSLs were labile with repeated episodes of both hypo- and hyperglycaemia and starvation ketosis despite management with insulin/dextrose infusion with hourly titration. Pregnancy was also complicated by pre-eclampsia with hypertension, proteinuria and a placental infarction seen on histopathology.
The decision was made for early delivery at 33 weeks and a healthy male neonate was delivered with birth weight of 1977g (38th percentile) and Apgar scores of 8 at one minute and 9 at five minutes. Her symptoms completely resolved following delivery and she was discharged day 5 post-partum with plans for gastric motility studies as an outpatient.
This case represents a diagnostic and management dilemma in multifactorial severe gastrointestinal symptoms in a type 1 diabetic, pre-eclamptic primigravida.