Upper Gastrointestinal Bleeding in Pregnancy: An Unexpected Cause.

Dear Editor,

Esophageal varices secondary to chronic portal vein thrombosis as a thromboembolic event in a postsplenectomy beta thalassemia trait pregnant patient is a rare event.[12]

We are reporting the case of a 22-year-old primigravida patient who presented to the emergency department with multiple episodes of hematemesis and in a life-threatening hemorrhagic shock owing to esophageal varices.

She was diagnosed with beta thalassemia trait at the age of 7 years and had undergone splenectomy for the same. Her vitals on presentation were unstable, with a mean arterial pressure (MAP) of 50 mmHg and tachycardia.

Laboratory evaluation showed a hemoglobin level of 4.9, while ultrasound of the abdomen and pelvis showed chronic portal vein thrombosis, spleen was not visualized and a heterogeneous mixed density lesion of size around 8 cm × 6 cm × 4 cm was present within the stomach lumen. A single live intrauterine pregnancy, 6 weeks, 6 days of maturity was also noted. The patient was started on intravenous (iv) pantoprazole 80 mg, followed by infusion at 8 mg/h, 250 ml bolus of iv fluid ringer's lactate was administered and 2 packed red blood cells were transfused. A MAP of 86 mmHg was achieved.

The gastroenterologist was consulted and injection Vitamin K 10 mg iv, injection tranexamic acid 1 g iv, injection octreotide 100 μg were given iv stat followed by 50 μg/h of octreotide infusion and injection ceftriaxone 1 g iv 12 hourly was advised. The patient was subsequently taken up for endoscopy after stabilization and was found to have 2 oesophageal varices [Figure 1]. The varices were glued with 1 ml cyanoacrylate injection.[3]

Figure 1

Gastroesophageal variceal bleed

Thromboembolic complications in beta thalassemia along with the hyper dynamic state in pregnancy predisposes the patient in a perilous situation for potential variceal bleed, owing to the low levels of Protein C, Protein S, enhanced platelet consumptions, and endothelial activation.[1245]

In developing nations such as India, availability of emergency endoscopy is often limited for immediate endoscopic variceal ligation. Hence, a multi-disciplinary team approach, knowledge about the plausible medical therapy in pregnancy, and the ethical judgment for weighing the risk makes an emergency physician's stance pivotal. The limited data available in such cases also highlight the need for further.

Research quality and ethics statement

The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.

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Conflicts of interest

There are no conflicts of interest.