More Than What It First Appears to Be; Gastric Cancer Masquerading as Hyperemesis Gravidarum
Audio File
- Define the interdisciplinary needs of pregnancy complicated with stage four antral gastric cancer with an outlet obstruction.
- Describe how religion, culture, and grief can profoundly influence the effectiveness of palliative care.
- Describe how funding and insurance issues can influence care.
A 27 year old, gravida 4, para 3, married Hispanic non-English speaking mother presented on our unit at 15 weeks gestation with hyperemesis gravidarum. She was discharged one week later on antiemetics and readmitted again one week later after fainting. She had electrolyte abnormalities, EKG changes, and severe malnutrition. Despite a droperidol drip she had intractable vomiting. She was noticeably withdrawn and admitted to feeling depressed.
Case:
At 17 weeks of pregnancy an endoscopic ultrasound revealed a large mass in the antrum of the stomach with invasion into the liver and pancreas.
A multidisciplinary team was assembled including these disciplines: nursing, hematology/oncology, gastroenterology, surgical oncology, palliative care, a Roman Catholic priest, case manager, and a social worker. The patient and her family were informed about the prognosis and fetal effects of several different treatment options. Her chance of survival was less than 10% at one year. Tumor resection increased this to 25%, but required chemotherapy prior to surgery. Chemotherapy would not likely affect the baby, but she had a five percent chance of spontaneous abortion or intrauterine demise.
The patient expressed concerns about insurance coverage if she were to terminate her pregnancy. In California, all mothers are covered during pregnancy regardless of immigration status. The case manager informed her of another public assistance program (permanent residents under color of law, Prucol) that could offer her coverage, but involved the risk that through this process immigration authorities would be notified.
She and her husband were supported during a very difficult decision making process. In the end they decided to terminate the pregnancy and initiate cancer treatment.
Her pain and nausea proved to be difficult to treat. The team felt there was a strong spiritual component to this; as she was rarely seen without a Bible in her hands. The Catholic priest provided her with spiritual support on an ongoing basis.
She is currently undergoing chemotherapy, has good symptom management with an opiod patch, acetaminophen, an antiemetic, and a laxative. She has not yet had a resection, but does have a jejunostomy tube. She is an outpatient now; smiles more; and seems to be as well as possible given the circumstances. She continues to be followed by the palliative care team.
Conclusion:
Although the pregnancy was lost, the patient’s cultural and family values were supported. This case illustrates holistic and multifactoral care.
Keywords:
Pregnancy loss, cross cultural nursing, grief, pain management
